Background: Residents rotating in hospital medicine (HM) are challenged with gaining a broad clinical knowledge base and applying that knowledge in complex situations unique to the hospital. To address this challenge, HM curricula must focus on developing residents into adaptive experts with the meta-cognitive skills to navigate novel and ambiguous situations when routine clinical knowledge isn’t enough.

Purpose: Our overarching goal is to help residents rotating in HM develop skills to adapt and learn when faced with complex and ambiguous general medical problems. To accomplish this goal, we developed a curriculum founded on adaptive expertise, reflection, and life-long learning principles to teach residents the skills necessary to be adaptive experts in HM.

Description: Our curriculum includes a didactic component to provide residents with a foundation in the meta-cognitive skills of adaptive expertise. The didactic is delivered to residents on the first day of their four-week rotation. The curriculum also includes an experiential component where residents and attending supervisors are instructed to incorporate a ‘reflective pause’ into daily ward rounds. Clinical situations requiring adaptive expertise often arise unexpectedly and residents are rarely afforded time to process these situations and plan for their own learning. During the ‘reflective pause’, residents are given this time and specifically advised to identify a gap in their knowledge, set a goal for their learning, and identify the resources necessary to address their knowledge gap (1). We piloted our curriculum among first-year residents during their HM rotation and conducted focused observations of ward rounds to evaluate how they implemented the ‘reflective pause.’ Additionally, we triangulated our observations through post-round interviews with residents and supervisors. We observed that ambiguous clinical situations commonly arise on HM ward rounds, but time pressures and workflow demands can overwhelm residents’ cognitive capacity to engage as adaptive experts. The ‘reflective pause’ provided residents the necessary time to recognize clinical ambiguity, but some residents still struggled to clarify their knowledge gaps and plan the next steps for their learning. Residents benefited when they were coached through the ‘reflective pause’ by their supervising physician.

Conclusions: Ambiguous clinical situations are ubiquitous in HM, emphasizing the need for residents to develop adaptive expertise. The use of a ‘reflective pause’ gave residents the space they need to identify their knowledge gaps and plan for their own learning. However, we learned that residents struggle to identify when adaptive expertise is required. The next phase of our curriculum will focus on enhancing residents’ ability to recognize the need for adaptive expertise well as providing residents with skills to navigate adaptive clinical situations.