A Novel Clinical Reasoning Coaching Program for the Medicine Learner in Need

Background: Clinical reasoning deficits are common among medical trainees. Assessment of clinical reasoning skills is challenging, and limited evidence is available to guide remediation practices. Objective: We identified graduate medical learners struggling with clinical reasoning within the University of Virginia (UVA) Department of Medicine (DOM) and referred them for structured remediation. Methods: In 2016, we implemented a three phase remediation program for struggling graduate medical learners. Learners were referred to a remediation specialist who performed a standardized global assessment and identified a primary clinical deficit in one of the following areas: medical knowledge, clinical reasoning, organization/efficiency, and professionalism. Those with a primary clinical reasoning deficit were referred to a clinical reasoning coach to participate in a novel remediation program comprised of a 10-step, case-based targeted assessment followed by coaching of the clinical reasoning deficit(s) along the following spectrum: hypothesis generation; data gathering; problem representation; illness script organization; and appropriate manipulation of the differential diagnosis. Learners then engaged in direct observation exercises with supervising faculty. Results: Remediation plans were implemented for twelve resident and fellow learners (5% of total learners) in the DOM. Clinical reasoning was the most commonly identified deficit (8/14 referred learners). Targeted assessment of these learners revealed deficits in the following domains of clinical reasoning: hypothesis generation (5/8), data gathering (2/8), problem representation (6/8), illness script knowledge and organization (2/8), and appropriate manipulation of the differential diagnosis (7/8). Following completion, all learners are currently in good standing in their respective programs. Conclusions: This three phase program employing global assessment of learner need, targeted assessment of clinical reasoning deficit, and direct observation utilizing dynamic coaching and feedback is an effective remediation strategy. The strength of our approach involves the targeted, granular assessment of clinical reasoning deficit and the ability to translate a skillset into practice with standardized direct observation. Based on a national survey of program directors (PD), it is common for internal medicine (IM) residents to struggle during training.(Yao, 2000) Accurate assessment of the primary area of struggle is critical, yet challenging.(Warburton, Goren and Dine, 2017) Insufficient medical knowledge,