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Assessing clinical reasoning skills following a virtual patient dizziness curriculum

  • Susrutha Kotwal ORCID logo EMAIL logo , Amteshwar Singh ORCID logo , Sean Tackett , Anand K. Bery , Rodney Omron , Daniel Gold , David E. Newman-Toker und Scott M. Wright
Veröffentlicht/Copyright: 12. Dezember 2023
Diagnosis
Aus der Zeitschrift Diagnosis Band 11 Heft 1

Abstract

Objectives

Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE).

Methods

All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated.

Results

Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04).

Conclusions

The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.

Keywords: clinical reasoning; OSCE; physical examination; simulation; virtual patients; diagnostic errors
Corresponding author: Susrutha Kotwal, MD, Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL Building East Tower, 2nd Floor CIMS Suite, Baltimore, MD 21224, USA, E-mail: , Twitter: @KotwalSusrutha
David E. Newman-Toker and Scott M. Wright contributed equally to this work and share senior authorship.

Acknowledgments

Dr. Wright is the Anne Gaines and G. Thomas Miller Professor of Medicine supported through the Johns Hopkins Center for Innovative Medicine and he is the Mary & David Gallo Scholar for Hopkins’ Initiative to Humanize Medicine. Dr. Newman-Toker is the David Robinson Professor of Vestibular Neurology and is supported, in part, through the Armstrong Institute Center for Diagnostic Excellence.

  1. Research ethics: The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Johns Hopkins Medicine Institutional Review. Board (JHM IRB). Number: IRB00167998. IRB Committee: IRB-X.

  2. Informed consent: Informed consent was obtained from all individuals included in this study.

  3. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. Susrutha Kotwal: I declare that I designed the study; had primary oversight over the data collection and analysis; designed the tables; authored the primary manuscript draft and all major revisions; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest. Amteshwar Singh: I declare that I assisted in study conduct and acquisition of data; edited the manuscript for scientific content; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest. Sean Tackett: I declare that I led all statistical analyses; edited the manuscript for scientific content; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest. Anand Bery: I declare that I assisted in study conduct and acquisition of data; edited the manuscript for scientific content; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest. Rodney Omron: I declare that I assisted in study design and study conduct; edited the manuscript for scientific content; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest. Daniel Gold: I declare that I assisted in study conception; edited the manuscript for scientific content; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest. David Newman Toker: I declare that I assisted in study design and data analysis; edited the manuscript for scientific content; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest other than what has been previously mentioned. Scott Wright: I declare that I assisted in study design; oversaw the study analysis; edited the manuscript for scientific content; and that I have seen and approved the final version. I agree to be accountable for all aspects of the work. I have no conflicts of interest.

  4. Competing interests: The authors state no conflict of interest.

  5. Research funding: The project was supported by a grant to the American Board of Medical Specialties Research and Education Foundation from the Gordon and Betty Moore Foundation. Dr. Newman-Toker’s effort was supported in part by a grant from the Agency for Healthcare Research and Quality (AHRQ, #R18 HS 029350). Dr. Newman-Toker conducts research related to diagnosis of dizziness, stroke, and diagnostic error. He serves as the principal investigator for multiple grants and contracts on these topics. Johns Hopkins has been loaned research equipment (video-oculography [VOG] systems) by two companies for use in Dr. Newman-Toker’s research; one of these companies has also provided funding for research on diagnostic algorithm development related to dizziness, inner ear diseases, and stroke. Dr. Newman-Toker has no other financial interest in these or any other companies. Dr. Newman-Toker is an inventor on a provisional patent (US PCT/US2020/070304) for smartphone-based stroke diagnosis in patients with dizziness. He gives frequent academic lectures on these topics and occasionally serves as a medico-legal consultant for both plaintiff and defense in cases related to dizziness, stroke, and diagnostic error.

  6. Data availability: The raw data can be obtained on request from the corresponding author.

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2023-0099).

Received: 2023-07-30
Accepted: 2023-11-09
Published Online: 2023-12-12

© 2023 Walter de Gruyter GmbH, Berlin/Boston

Artikel in diesem Heft

  1. Frontmatter
  2. Editorial
  3. The physical exam and telehealth: between past and future
  4. Review
  5. Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review
  6. Mini Reviews
  7. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare
  8. Tumor heterogeneity: how could we use it to achieve better clinical outcomes?
  9. Original Articles
  10. Factors influencing diagnostic accuracy among intensive care unit clinicians – an observational study
  11. Prevalence of atypical presentations among outpatients and associations with diagnostic error
  12. Preferred language and diagnostic errors in the pediatric emergency department
  13. Diurnal temperature variation and the implications for diagnosis and infectious disease screening: a population-based study
  14. What’s going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process
  15. Assessing clinical reasoning skills following a virtual patient dizziness curriculum
  16. Interleukin-6, tumor necrosis factor-α, and high-sensitivity C-reactive protein for optimal immunometabolic profiling of the lifestyle-related cardiorenal risk
  17. Effect of syringe underfilling on the quality of venous blood gas analysis
  18. Short Communications
  19. How do patients and care partners describe diagnostic uncertainty in an emergency department or urgent care setting?
  20. Enhancing clinical reasoning with Chat Generative Pre-trained Transformer: a practical guide
  21. Letters to the Editor
  22. How to overcome hurdles in holding mortality and morbidity conferences on diagnostic error cases in Japan
  23. Medical history-taking by highlighting the time course: PODCAST approach
  24. Journal Reputation Factor
  25. Case Report
  26. Pre-analytical errors in coagulation testing: a case series
  27. Acknowledgement
  28. Acknowledgement
https://doi.org/10.1515/dx-2023-0099
Schlagwörter für diesen Artikel
clinical reasoning; OSCE; physical examination; simulation; virtual patients; diagnostic errors

Artikel in diesem Heft

  1. Frontmatter
  2. Editorial
  3. The physical exam and telehealth: between past and future
  4. Review
  5. Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review
  6. Mini Reviews
  7. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare
  8. Tumor heterogeneity: how could we use it to achieve better clinical outcomes?
  9. Original Articles
  10. Factors influencing diagnostic accuracy among intensive care unit clinicians – an observational study
  11. Prevalence of atypical presentations among outpatients and associations with diagnostic error
  12. Preferred language and diagnostic errors in the pediatric emergency department
  13. Diurnal temperature variation and the implications for diagnosis and infectious disease screening: a population-based study
  14. What’s going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process
  15. Assessing clinical reasoning skills following a virtual patient dizziness curriculum
  16. Interleukin-6, tumor necrosis factor-α, and high-sensitivity C-reactive protein for optimal immunometabolic profiling of the lifestyle-related cardiorenal risk
  17. Effect of syringe underfilling on the quality of venous blood gas analysis
  18. Short Communications
  19. How do patients and care partners describe diagnostic uncertainty in an emergency department or urgent care setting?
  20. Enhancing clinical reasoning with Chat Generative Pre-trained Transformer: a practical guide
  21. Letters to the Editor
  22. How to overcome hurdles in holding mortality and morbidity conferences on diagnostic error cases in Japan
  23. Medical history-taking by highlighting the time course: PODCAST approach
  24. Journal Reputation Factor
  25. Case Report
  26. Pre-analytical errors in coagulation testing: a case series
  27. Acknowledgement
  28. Acknowledgement
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