Background: Early development of clinical reasoning and problem-solving competencies are essential in generating individualized, outcome-based, and cost-effective patient care plans (Nat Acad Press 2015). However, few medical schools and residency programs have an explicit curriculum in clinical reasoning (Graber et al., 2012). A recent survey of internal medicine clerkship directors found medical students receive limited training in this area (Rencic J et al., 2017). SNAPPS, an oral presentation framework to verbalize the rational for clinical decisions, is known to enhance clinical reasoning learning in the outpatient setting, but can be easily modified for the inpatient environment. It also provides a structure for educators to assess reasoning skills and provide feedback (Wolpaw T et al., 2009 and Pascoe JM et al., 2015).
Purpose: To develop a clinical reasoning curriculum for interns on a hospital medicine service. Our aim was (a) to educate interns on clinical reasoning concepts (problem representation, illness scripts, differential diagnosis formation, and cognitive bias), and (b) to adopt an oral presentation framework to promote direct observation and feedback on clinical reasoning.
Description: In July 2017, we implemented a three-part clinical reasoning curriculum on the hospitalist service (internal medicine interns on 3-week admitting rotations supervised by hospitalists) at a large academic medical center: 1) Independent learner review of cases and online videos to emphasize the role of problem representation and illness scripts. 2) A modified SNAPPS (mSNAPPS) tool to optimize oral presentation and improve feedback on clinical reasoning. 3) Real-time identification and reflection on cognitive bias using a provided summary sheet. Interns were oriented to the new curriculum and hospitalists attended a faculty development session prior to initiation. Interns were given weekly in-person evaluations based on a “Clinical Reasoning Feedback Card”. The curriculum was evaluated by learners at rotation-end using a Likert scale. Preliminary data, based on hospitalist direct observation, reveals 93% of interns presented using mSNAPPS, 86% used both analytic and non-analytic reasoning to generate a differential diagnosis, and 93% considered how diagnostic testing would change management. The majority of interns felt the curriculum improved their clinical reasoning skills. When compared to the previous year (July 2016-June 2017), early data reveals a trend towards interns identifying as a more integral member of the team with regard to clinical decision making and patient care (8.5 vs 7.4 p=.086; 1=strongly disagree, 9=strongly agree).
Conclusions: The implementation of a clinical reasoning curriculum on an intern admitting rotation supervised by hospitalists is promising. Independent learner review of cases reinforced by direct observation and feedback using mSNAPPS is a novel and likely effective means of teaching clinical reasoning early in residency training.