Practice for Real Life: Diversifying Cases in Educational Conferences

Case-based clinical-reasoning conferences, such as internal medicine morning report, typically have a familiar cadence. The case presenter initially describes a patient's symptoms and illness history and subsequently provides a one-time physical exam and one-time laboratory and radiographic information. Facilitators help coordinate audience discussion, which often focuses on differential diagnosis, whether interwoven throughout the presentation or occurring entirely after the case presentation is completed. The diagnosis is then revealed, and didactic teaching follows. Selected cases are often those encountered in the hospital or representing rare or "interesting" diagnoses.1Heppe DB Beard AS Cornia PB et al.A Multicenter VA Study of the Format and Content of Internal Medicine Morning Report.J Gen Intern Med. 2020; 35: 3591-3596Google Scholar This traditional approach has many strengths. First, it models the core clinical competency of gathering information from an unfamiliar patient and organizing it into a logical narrative of their illness experience and bedside findings. By starting with the clinical history, it emphasizes the primacy of history in diagnosis.2Balogh EP Miller BT Ball JR Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; Improving Diagnosis in Health Care. Washington (DC). National Academies Press (US), 2015Google Scholar By revealing laboratory and imaging data in the latter portion of the case description, it mirrors certain practice settings—such as ambulatory care or low-resource settings—where diagnostic testing can be requested but which might not be immediately available. Additionally, because a significant amount of time is spent on discussion about differential diagnosis, the session promotes development of a vital and challenging cognitive task. Concluding with a definite final diagnosis allows for clear teaching points related to specific disease entities. We believe that the use of cases that fit well within this framework should continue to occur because of their substantive educational value. However, exclusive use of this approach has many drawbacks, as it does not represent the full range of information flows and cognitive tasks that typically occur in modern clinical practice in resource-abundant settings. Here we explore these limitations and specifically propose that case-based educational conferences designed with the aim of teaching clinical reasoning be deliberately expanded to include additional types of teaching cases, outlined below. In modern medical practice, clinicians have often performed some degree of electronic health record (EHR) review prior to the patient interaction. In some instances, such review includes information such as the patient's past medical history and laboratory, imaging, and other diagnostic data. Thus, the clinician is likely to interview the patient differently than if they had no prior knowledge about their medical conditions or other completed diagnostic testing.3Drossman DA Chang L Deutsch JK et al.A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report.Gastroenterology. 2021; 161: 1670-1688.e7Google Scholar In many cases, this advanced knowledge can help the clinician perform the appropriate patient evaluation and begin clinical management more efficiently. In other instances, it might cause anchoring to certain data points or diagnoses, leading to premature diagnostic closure. Regardless of the net effect, representing this sequence in the educational setting is important. Situated-cognition theory suggests that clinical-reasoning tasks and abilities are highly contextual.4Rencic J Schuwirth LWT Gruppen LD Durning SJ. Clinical reasoning performance assessment: using situated cognition theory as a conceptual framework.Diagnosis (Berl). 2020; 7: 241-249Google Scholar Many clinical scenarios involve clinician, patient, and environmental factors that deviate significantly from the presumptions of the traditional case format. As an example, for a patient whose history is having been "found down" by another person, the availability and sequence of information as the clinician receives it are entirely different. Data flow and prioritization are also different when one receives a consultation for abnormal laboratory studies, arrives at a rapid response, or considers the management of an incidental radiographic finding. In many of these contexts, history is not the starting point (by necessity), but rather, is subsequently gathered in a hypothesis-driven, iterative manner with certain objective data already known. The traditional case presentation structure misses the opportunity to deliberately practice skills needed to evaluate and manage patients in these scenarios. Lastly, traditional case presentations almost always culminate in a neatly packaged, definitive diagnosis. This does not always occur in clinical practice, where uncertainty can persist whether the patient improves or deteriorates. Additionally, a single all-encapsulating diagnosis should not always be the expectation, as there are often multiple processes contributing to patients' symptoms or problems. Adopting such a frame of mind when evaluating actual patients could incorrectly narrow or overcomplicate the diagnostic evaluation. Some variability in case presentations during teaching conferences likely occurs spontaneously, driven by individuals' interest, creativity, and teaching intuitions.1Heppe DB Beard AS Cornia PB et al.A Multicenter VA Study of the Format and Content of Internal Medicine Morning Report.J Gen Intern Med. 2020; 35: 3591-3596Google Scholar,5Albert TJ Redinger J Starks H et al.Internal Medicine Residents' Perceptions of Morning Report: a Multicenter Survey.J Gen Intern Med. 2021; 36: 647-653Google Scholar Additionally, some examples exist of novel educational venues utilizing "non-traditional" case formats, such as discussions of abnormal laboratory results.6Unremarkable Labs YouTube page. Accessed March 10, 2024. https://www.youtube.com/channel/UCVQ3Na5zXk5lpdUfPKhZ_EwGoogle Scholar However, we believe such expansion should be pursued more broadly and proactively. This can be done by implementing various case types that could enrich the value of clinical-reasoning educational conferences beyond the traditional format (Table 1). The table includes descriptions, examples, and unique learning objectives of each different case type.Table 1Summary of Distinct Case Types to Diversify Case-Based Clinical-Reasoning ExercisesCase TypeDescriptionExampleLearning ObjectivesTraditional caseRecounts chief symptom and detailed history, then physical examination, and select diagnostics; a single, definitive diagnosis existsA 73-year-old person presents with chest pain. The eventual diagnosis is Takotsubo cardiomyopathyDetail a chronologic account of a patient's symptoms and comprehensive historyConstruct a differential diagnosis rooted in effective history and examinationAbnormal labs or imagingAbnormal labs/imaging are the starting point of the caseA previously healthy and asymptomatic ambulatory patient is found to have a creatinine of 1.8 mg/dL, which was 1.1 mg/dL one year agoEvaluate common abnormal laboratory or imaging findingsGather history and exam findings iterativelyConsult questionA clinician is faced with a specific question from a colleagueA patient with hypertension and hypokalemia is found to have elevated 24-hour urine cortisol. Endocrinology is consulted to aid in further evaluation and managementRehearse how to conduct a focused review of the EMRAnalyze a specific symptom or abnormality in the context of a broader clinical scenario"Cold" casePatient is under the active care of the presenter; no diagnosis yet despite an initial evaluationA patient was admitted one day ago with 1 week of fevers; viral studies, urinalysis, chest X-ray are negative, while blood cultures and rickettsial serologies are pendingModify a differential diagnosis based on negative test resultsDiscuss ongoing diagnostic and therapeutic management in the setting of pending dataNo diagnosis despite initial common evaluationNo diagnosis despite appropriate diagnostic evaluation; in contrast to a cold case, the diagnosis is known at the time of presentation.A 37-year-old man continues to have severe abdominal pain and inability to eat or drink with no etiology found on basic labs, imaging, or upper endoscopyApply advanced (detailed) diagnostic frameworksUnderstand the sensitivity and specificity of common diagnostic testsReview rare illness scriptsComplex hospital courseA new problem develops (or new clinician takes over) during an already-complex hospital courseAn older patient was presumptively diagnosed with vasculitis and treated with immune suppression. After transfer out of intensive care, she develops worsening hypoxemiaEvaluate problems in the context of a complex hospital courseCritically reappraise impressions and decisions from other cliniciansMultifactorial caseA symptom or problem which is explained by multiple processesA woman with a gastric bypass develops subacute confusion. She recently began using opioids and stopped her other medications; her serum B12 level is 130 pg/mL, and ammonia is 70 μg/dLDetect multiple contributing processes to a health problem and consider relative contributions of eachAmbulatory caseCase evaluated mostly or entirely in the ambulatory settingA man reports fatigue and anorexia over several outpatient visits and is eventually diagnosed with adrenal insufficiencyUse clinical evolution over weeks, months, or years as a diagnostic toolDiscuss logistical barriers to outpatient evaluationManagement reasoningThe diagnosis is known, but significant therapeutic uncertainty existsA woman develops upper gastrointestinal bleeding two months after a drug-eluting stent is placed for acute coronary syndromeDescribe frameworks for treatment decision-makingConduct risk-benefit analysis of therapeutic interventionsRapid responseClinician responds to a deteriorating patient they do not know wellA 68-year-old man admitted for severe pancreatitis suddenly develops severe tachycardia and hypoxemiaReview the bedside approach to evaluating common rapid response scenariosPractice rapid decision-making with limited dataIncidental findingAn abnormal finding seems unrelated to the original reason for imaging or labsA middle-aged person undergoes a CT scan to evaluate for abdominal pain; an adrenal mass is noted incidentallyReview the evaluation of common "incidentalomas" Open table in a new tab We suggest that leaders and facilitators of case-based educational conferences consider formally updating their internal expectations around case selection and presentation format to broaden the types of cases used for such conferences. This guidance (including a "menu" similar to the Table 1) can be shared with case presenters, audience participants, and other stakeholders. Providing pedagogical justification for an expanded approach could also enhance stakeholder buy-in and implementation. Clinical-reasoning case conferences often focus on discussions about differential diagnosis and progress in a typical format, starting from the patient's history, proceeding to the physical exam, and ending with laboratory and imaging data. Substantial educational value remains in this traditional approach, since it does reflect certain types of modern-day clinical encounters and centers on the timeless, fundamental skills of history taking and physical examination. However, many workflows of present-day clinical practice deviate from this set of cognitive tasks. Preparing for different clinical contexts requires different educational frameworks and emphasis on different reasoning skills. Diversifying the types of cases used to teach clinical reasoning would better match the realities of modern clinical care, thereby allowing clinicians to "practice for real life."