Morgan Congdon1, Caitlin B Clancy2, Dorene F Balmer3, Hannah Anderson4, Naveen Muthu5, Christopher P Bonafide6, Irit R Rasooly7. 1. is Assistant Professor of Clinical Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania. 2. is Assistant Professor of Clinical Medicine, Perelman School of Medicine, University of Pennsylvania. 3. is Professor of Pediatrics and Director of Research on Pediatric Education, Division of General Pediatrics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania. 4. is Clinical Research Associate in Medical Education, Division of General Pediatrics, Children's Hospital of Philadelphia. 5. is Instructor of Clinical Informatics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania. 6. is Associate Professor of Pediatrics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania. 7. is Clinical Instructor of Pediatrics and Clinical Informatics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania.
Abstract
Background: Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described. Objective: To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning. Methods: We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework. Results: Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process. Conclusions: This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.
Background: Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described. Objective: To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning. Methods: We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework. Results: Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process. Conclusions: This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.
Authors: Jeffrey Chi; Maja Artandi; John Kugler; Errol Ozdalga; Poonam Hosamani; Elizabeth Koehler; Lars Osterberg; Junaid Zaman; Sonoo Thadaney; Andrew Elder; Abraham Verghese Journal: Am J Med Date: 2016-03-10 Impact factor: 4.965