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Clinical reasoning in resident case presentations

Context and setting We studied the expression of clinical reasoning of internal medicine senior residents and interns during case presentations in the out-patient setting. Compared with interns, we hypothesised that senior residents would present more efficiently and express more clinical reasoning during case presentations. We rated the level of thinking expressed by preceptors (teaching staff) and learners in patient case discussions using the 3-point Preceptor Thinking Promotion Scale and corresponding Learner Thinking-Behaviour Scale to identify whether conversations occur at the level of: (i) giving the facts of the case; (ii) explaining assessment or decisions, or (iii) exploring uncertainties or difficulties. Why the idea was necessary About one-third of rotations for internal medicine residents occur in the out-patient setting. Yet studies have shown that learners’ case discussions with ambulatory preceptors were brief, with little or no feedback. We explored: (i) the quality of housestaff case presentations in the out-patient setting, and (ii) the need to enhance residents’ expression of clinical reasoning in presentations. What was done Rheumatology preceptors (n = 4) and first(n = 4) and third-year (n = 5) residents assigned to their out-patient offices (n = 4) participated in this study. Resident–preceptor encounters were audiotaped in the out-patient setting across a 3-month period. Third-year residents were taped near the end of their 3-year-long continuity rotation. Firstyear residents were taped at the start of their internship year. Residents were asked to audiotape all patient presentations to their preceptors except those that occurred in the presence of patients. Audiotapes were assigned a number and blinded for level of the learner. We recorded 53 preceptor–resident encounters, of which 14 occurred with interns and 39 with senior residents. The tapes were coded in 3-minute segments and analysed using the validated scales described above. Evaluation of results and impact A total of 53 preceptor–resident interactions were analysed. Kappa coefficients revealed high levels of agreement between coders. Senior residents’ interactions lasted a mean of 5.5 minutes (95% confidence interval [CI] 4.7–6.4) and were on average 3.3 minutes shorter than interns’ interactions (mean 8.8 minutes, 95% CI 6.9–10.7) (F = 14.3; P < 0.001). There was no difference in mean scores on the Learner ThinkingBehaviour Scale between third-year residents (mean 1.17, 95% CI 1.10–1.24; P = 0.81) and interns (mean 1.19, 95% CI 1.08–1.30; P = 0.78). On average, 80% of presentation time was spent on conveying facts. A third of the interactions consisted only of factual exchanges. Preceptors focused largely on eliciting and clarifying the facts of the case and questioning the resident’s factual knowledge, regardless of whether the resident was beginning or finishing residency training. Based on these results, we identified a need for resident development in giving case presentations to preceptors that effectively communicate clinical reasoning as well as facts. We propose that SNAPPS (Summarise history and findings; Narrow the differential; Analyse the differential; Probe the preceptor about uncertainties; Plan management; Select case-related issues for self-study), a six-step learner-centred technique for case presentations to enhance the expression of clinical reasoning, be used as a template for resident case presentations to preceptors in the office setting.