Models for enhancing competency-based training and contextual clinical decision making


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Schemes for facilitating competency-based training, diagnostic labeling and immediate therapeutic interventions.

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Models for enhancing competency-based training and contextual clinical decision making

  1. 1. Frameworks for education Models for enhancing competency-based training and contextual clinical decision making Imad Hassan, Department of Medicine, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia New models of teaching and resident staff training are needed SUMMARY Background: In the era of quality care, competency and outcomebased education, new models of teaching and resident staff training are greatly needed. These should be based on adult learning principles and allow for highquality, patient-centred, evidence-based care. Context: Three areas that need restructuring with specific conceptual frameworks to allow for seamless competency-based training, and also to assist in putting the decision-making process in context, are: case or topic presentation; diagnostic labelling; and immediate interventions for front-line caregivers. Innovation: Three models are proposed: the competencystructured presentation (CSP) model; the bedside clinical diagnosis, etiological cause and severity score diagnostic labelling (BESD) model; and the symptomatic, supportive, specific, specialty and site of care (5S) model. Implications: The models listed above may assist in the following domains of patient care. In a competency-structured presentation, the CSP model formalises case presentations and discussions in a competency-based structure, thereby supporting the 392 Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 development of a competencyfocused thought process for patient care. The BESD and 5S models improve the understanding of patient problems within the appropriate context, and thus assists in achieving the following quality outcomes. The BESD model promotes better diagnostic labelling, thereby assisting in implementing individualised, evidencebased interventions. The 5S model promotes the cognitive conceptualisation of medical management, which will aid a more comprehensive, patient-centred, multidisciplinary care input, thereby reducing process errors and improving outcomes.
  2. 2. INTRODUCTION Q uality of care and competency-based training are two intimately linked concepts.1 Quality of care The Institute of Medicine has defined quality of care as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’.2 Six outcomes are emphasised: patient safety; patient centredness; effectiveness; efficiency; timeliness; and equity. These are geared towards the prevention or reduction of the six ‘D’s of patient care outcome: death; disease; disability; discomfort; dissatisfaction; and destitution (cost of care). Evidently, health care systems, and especially the staff, must be specifically empowered with all the knowledge and skills necessary to attain these outcomes. Competency-based training Unfortunately, old-style resident training is unlikely to equip the trainees with all the necessary skills for such a comprehensive look at patient care. New ‘resident competencies’ beyond simple clinical skill building are clearly necessary. Unavoidably, new structures and processes for resident staff training, particularly in the active clinical decision process, need to be put in place to achieve these outcomes. The move by medical training bodies in America, Europe and elsewhere to restructure their accreditation programmes is a direct consequence of this.3–5 In all of these programmes, outcome-based, competency-directed training frameworks were emphasised. The CanMeds framework (Table S1) is an excellent example of such a programme.3,4 It explicitly states that for a practising physician to be fully New ‘resident competencies’ beyond simple clinical skill building are clearly necessary competent, he or she must be proficient in seven domains of knowledge and skill. These socalled meta-competencies include competencies as a medical expert, communicator, collaborator, scholar, advocate, manager and professional. However, details of generic concepts to allow for a seamless incorporation of these competencies into everyday practice are not always explicitly outlined. Novel, friendly strategies to train and empower front-line staff, reduce inefficiencies in the care process and improve patient outcomes are needed. The three proposed models below may help in realising some of the aforementioned competencies by making them part of the routine in resident education, and in decision making when formulating a management plan for a specific patient. They may thus equip residents with strategies to manage patient complexities and uncertainties, reduce process errors and ultimately achieve the desired quality outcomes. The proposed models are primarily based on the author’s long experience in medical staff training in clinical care and in mechanisms to enhance the implementation of evidencebased medicine. A COMPETENCYSTRUCTURED PRESENTATION (CSP) MODEL, USING THE CANMEDS FRAMEWORK Classically, and for educational purposes, both undergraduates and postgraduates present clinical topics in a narrative or case-based style. In both of these, classic headings that are used include definitions, etiology, epidemiology, clinical presentation, differential diagnosis, investigations, therapy and prognosis etc. This form of presentation does not explicitly emphasise the new domains of knowledge or skills necessary for quality of care, as outlined above, or empower the trainees with all the competencies outlined by CanMeds, or similar bodies, for comprehensive, outcome-based training and patient care. A proposed scheme for topic presentation is outlined below. Topic headings are now deliberately portrayed under competency headings. Presumably, this conceptual framework or map would assist in realising a more competency-directed clinical training and decision-making process, and in drafting a comprehensive, high-quality management plan for every patient. Practical, patientcentred care actions and interventions may thus be incorporated in the clinical decision process. Table S2, available online, depicts the presentation outlines for two common medical topics, namely stroke and bronchial asthma. It compiles all the necessary knowledge and skills under the CanMeds competencybased educational framework. Once completed, the exercise would have emphasised to the trainees and residents all of the concepts that are conducive for comprehensive, multidisciplinary, quality care. It is vital to highlight here that active training in relevant practical skills is an essential component of the exercise: e.g. training residents in Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 393
  3. 3. Failure to consider the precipitant or cause will inevitably result in deficient care inhaler technique or in peak flow meter recording, in the example of bronchial asthma, which are skills not normally included in old-style lectures. CONCEPTUAL FRAMEWORK FOR COMPREHENSIVE GUIDELINE-FRIENDLY DIAGNOSTIC LABELLING: THE BEDSIDE CLINICAL DIAGNOSIS, ETIOLOGY, SEVERITY DIAGNOSTIC (BESD) MODEL So often, when residents are asked for their clinical diagnosis, an incomplete and clearly seriously deficient label is given. In my opinion this hinders proper, comprehensive, guideline-based, therapeutic interventions, with an unmistakable negative impact on the quality of care. For example, labelling a patient with an exacerbation of bronchial asthma or heart failure, as such, without explicitly including the probable precipitant and degree of severity (and therefore the necessity for admission to hospital or an intensive care ward) will hinder appropriate guideline-directed immediate care, and also any additional interventions needed to reduce the duration of stay, the cost of care and the future use of the health care system. With this in mind, residents must be trained on unequivocally including the following three essential elements in any diagnostic label given to any one patient: the bedside clinical diagnosis; the etiological or precipitating cause; and the severity score or grade. Table 1 Table 1. The bedside clinical diagnosis, etiological cause and severity score diagnostic labelling (BESD) model: comprehensive, guideline-friendly diagnostic labelling Case scenario 1 A 64-year-old hypertensive and diabetic patient presenting with breathlessness. Clinically in pulmonary oedema, with gallop and crackles up to his upper chest posterioly and blood pressure of 80 ⁄ 60 mmHg. Electrocardiogram and cardiac enzymes confimed an acute ST -elevation myocardial infarction. Bedside clinical diagnosis Etiological diagnosis or precipitant Severity Acute left heart failure and pulmonary oedema Acute myocardial infarction Killip class 4* Case scenario 2 A 24-year-old patient with type-I diabetes presented with abdominal pain, nausea, vomiting and fever. He has stopped taking his insulin. Urine confirmed the presence of ketonuria and uncountable pus cells. Plasma glucose, 630 mg ⁄ dl; ABG revealed a pH of 7.3; bicarbonate 18; anion gap 11. Bedside clinical diagnosis Etiological diagnosis or precipitant Severity Diabetic ketoacidosis Urinary tract infection Insulin therapy non-compliance Mild DKA** *Killip class 1, no crepitations; class 2, less than 50 per cent creps; class 3, more than 50 per cent crepitations; class 4, cardiogenic shock. **According to the severity scoring of the American Diabetes Association. ABG = artierial blood gases, DKA = diabetic ketoacidosis 394 Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 gives two examples. In addition to the clinical diagnosis, a failure to consider the precipitant or cause will inevitably result in deficient care and a poorer outcome. Moreover, the appropriate evidence-based interventions for optimising the outcome will be different for acute coronary syndrome or diabetic ketoacidosis,6,7 with regard to the sites of care and recommended interventions, e.g. admission to the Coronary Care Unit and a strategy of immediate interventional revascularisation, for the patient with the acute coronary syndrome. A CONCEPTUAL FRAMEWORK FOR PATIENTCENTRED, COMPREHENSIVE, IMMEDIATE THERAPEUTIC INTERVENTIONS: THE 5S MODEL Similar to the discussion above for diagnostic labelling, when asked about treatment, residents have a tendency to jump to specific therapeutic interventions, without paying much attention to important, patientcentred inputs. Such interventions may at times be as important as the disease-specific therapeutic interventions themselves. Apart from the latter, there are at least four other therapeutically indispensable interventions that the decisionmaking process must incorporate as part and parcel of the management plan. These include: symptomatic care; supportive care; specialty ⁄ subspecialty involvement; and decisions on the most appropriate site of care. Symptomatic treatment is important, as it directly alleviates patient discomfort. Regrettably, action to relieve symptoms is not commonly initiated by medical staff. An excellent example is the use of analgesics in the acute-care setting: socalled oligoanalgesia.8 Supportive care to reverse physiological complications before damage
  4. 4. becomes irreversible, and until the precipitant is brought under control by its specific intervention, may be life saving. Guidelines unambiguously dictate the sites of care for specific disease severity scores, e.g. patients with community-acquired pneumonia with a CURB-65 (Confusion, Urea, Respiratory rate, Blood pressure-65 age in years) score of three or more must be managed in intensive care, as opposed to the general ward.9 Similarly, specific high-severity indices for patients with acute asthma exacerbation entail the need for higher levels of care.10 Likewise, guidelines recommend early specialty or subspecialty referral for specific acute illnesses, e.g. gastroenterology and endoscopy referral for patients with haematemesis and specific severity scores, etc. Cognitive conceptual deficiencies in the decision making of junior staff have been shown to be an important cause for poor outcome in the acute care setting.11 Training residents on routinely, conceptually constructing or outlining their management plan along the 5S framework may thus assist them in recognising several of the goals of quality care. Two examples depicting the utility of the 5S framework for front-line caregivers in the acute setting are presented in Table 2. It is gratifyingly evident that the BESD and 5S conceptual models incorporate all seven domains of the CanMeds competency skills. In my opinion, the successful application of these models hinges on a resident who is highly skilled in most, if not all, of the aforementioned competencies. For example, skillful diagnostic reasoning and severity assessment requires a competent ‘medical expert’, subspecialty referral envisages collaborative care, with the communicator, advocate and professional roles being indispensable for comprehensive, patient-centred care. Figure 1 depicts the interrelationship of the BESD, 5S and CSP models, especially in the acute care setting. TESTING THE BESD AND 5S MODELS In an exercise to test the usefulness of the above models, 21 year1 residents and interns were randomly presented with one of two case scenarios. One was of a 64-year-old patient with acute myocardial infarction (as presented in Table 1) and the other of a 70-year-old man with community-acquired pneumonia (as presented in Table 2). Trainees were requested to outline their likely diagnosis and their immediate therapeutic interventions on an answer sheet. Once completed, the same case scenario was resubmitted to the trainee, but this time the answer sheet was restructured to conform with the above two models. The two answer sheets were then compared with regards to the explicit inclusion of the various domains of case diagnosis and management, as outlined in the two models. Apart from the symptomatic, supportive and specific therapeutic inputs, which were relatively comparable Guidelines unambiguously dictate the sites of care for specific disease severity scores Table 2. Two examples depicting the utility of the symptomatic, supportive, specific, specialty and site of care (5S) model for guiding therapy for front-line caregivers in the acute setting Case scenario 1 A 70-year-old, smoker presenting with fever, pleuritic chest pain and breathlessness. Clinically, confused, temperature 39.6°C, systolic blood pressure 80 mmHg, respiratory rate 32 ⁄ minute and PaO2 on room air of 54 mmHg. Radiology confirmed a diagnosis of multilobar community-acquired pneumonia. Specific care Specialty ⁄ subspecialty care Symptomatic care Supportive care Analgesics Antipyretic Intensive care team Oxygen therapy Intravenous antibiotics that Intravenous fluids chosen are based on severity ⁄ referral Inotropes site of care: e.g. ceftriaxone and moxifloxacin, with additional antipseudomonal cover Site of care Intensive care unit, as the CURB-65 score is 4. Case scenario 2 A 17-year-old single, female with a painful sickle cell crisis. Clinically, drowsy, dehydrated and in pain. Haemoglobin 45 g ⁄ l. Chest X-ray revealed bilateral infiltrates. Symptomatic care Supportive care Analgesics Specific care Antibiotics Oxygen Exchange transfusion Hydration Simple transfusion Specialty ⁄ subspecialty Site of care care Haematologist Intensive care Pain service Intensive care Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 395
  5. 5. The aim of [this integrated model]is to empower residents with applicable conceptual frameworks for quality care be a manifestation of a lack of an internalised cognitive conceptual framework for patient care. Proper Diagnostic Labeling CONCLUSION Clinical Diagnosis Etiological or Precipitating Cause Severity Score Immediate Airways/Circulation Checks Emergency Pa ent Interven ons Emergency & In-Pa ent Interven ons Medical Expert Symptomatic Care Communicator Professional Site of care PatientCentred Care Speciality/ Sub_specialty Referral Supportive care REFERENCES CompetencyBased Care Collaporator Scholar Specific care Manager Advocate Figure 1. The bedside clinical diagnosis, etiological cause and severity score diagnostic labelling (BESD), the symptomatic, supportive, specific, specialty and site of care (5S) and the competencystructured presentation (CSP) models for patient care R1 Residents & Interns (n = 21): Pre & Post Change in Management Decisions Post 120.0 Percentage Pre 71.4% 71.4% 80.0 90.5% 60.0 40.0 57.1% 57.1% 19.0% 0% 0.0 Clinical Etiologic Diagnosis Diagnosis 100% 57.1% 20.0 Severity Indication Site of Care 8.3% Special Referral Figure 2. Trainees pre- and post-change in management decisions before and after, albeit improved (85.7 versus 95.2%), all other domains significantly improved (Figure 2). This confirms that deficiencies in diagnostic labelling and in management decisions are not necessarily the result of a lack of knowledge, but are likely to 396 Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 1. Buckley JD, Joyce B, Garcia AJ, Jordan J, Scher E. Linking residency training effectiveness to clinical outcomes: a quality improvement approach. Jt Comm J Qual Patient Saf 2010;36:203–208. 2. Committee on the Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001. 3. Frank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach 2007;29:642–647. 140.0 100.0 This article proposes three simple inter-related models, the aim of which is to empower residents with applicable conceptual frameworks for quality care. Case or clinical topic discussions should be designed around a competency-structured presentation (the CSP model), diagnostic labelling needs to be comprehensive to support the application of evidence-based guideline recommendations (the BESD model) and initial, acute care decision processes should encompass all five domains of essential, patientcentred, therapeutic interventions (the 5S model). 4. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach 2007;29:648–654. 5. General Medical Council. Tomorrow’s Doctors. Recommendations on Undergraduate Medical Education. London: General Medical Council; 2009. 6. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC Jr. 2004 Writing Committee Members, Anbe DT, Kushner FG, Ornato JP, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 Focused Update of the ACC ⁄ AHA 2004 Guidelines for the Management of Patients With
  6. 6. ST-Elevation Myocardial Infarction: a report of the American College of Cardiology ⁄ American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC ⁄ AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2008;117:296–329. 7. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2009;32:1335–1343. 8. Motov SM, Khan AN. Problems and barriers of pain management in the emergency department: Are we ever going to get better? J Pain Res 2008;2:5–11. 9. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America ⁄ American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Diseases 2007;44:S27–S72. 10. Global Initiative for Asthma. GINA workshop report: global strategy for asthma management and prevention. guidelines-gina-report-global-strategy-for-asthma.html, Accessed November 2011. 11. Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. Qual Saf Health Care 2008;17:122–126. SUPPORTING INFORMATION version of this article at http: ⁄ ⁄ ⁄ doi ⁄ 10.1111/j.1743498X.2012.00584.x ⁄ suppinfo Table S1. The CanMeds competencies.3 Table S2. The competencystructured presentation (CSP) model: topic presentations; applying the CanMeds roles. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the author. Any queries (other than missing material) should be directed to the corresponding author for the article. Additional supporting information may be found in the online Corresponding author’s contact details: Imad Salah Ahmed Hassan, Department of Medicine 1443, King Abdulaziz Medical City, King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia. E-mail: Funding: None. Conflict of interest: None. Ethical approval: Not required. doi: 10.1111/j.1743-498X.2012.00584.x Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 397