Council on Medical Student Education in Pediatrics


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COMSEP Meeting in Ottawa, ON

Platform Presentation:

Medical student clinical decision making in the precepted clinical encounter: a qualitative study

Pamela Fazzio,MD, Martin V. Pusic, MD, MA, Zeena Audi, BA, Andrew Mutnick, MD, Robert Best, MD, Lindsey Tilt, MD, Pediatrics, Columbia University Medical Center, New York, NY


Teaching models like the One Minute Preceptor and SNAPPS require learners to commit to clinical decisions. We developed a form-based process that, for a given patient, has trainees and attending physicians separately commit to diagnosis and management decisions.



We hypothesized that our process would improve learning by a) ensuring trainee commitment to their diagnosis and b) making transparent any discordance with the attending’s plan. Using focus group methodology, we sought to assess students’ and preceptors’ beliefs and attitudes on the utility of the process.



Intervention: We created a double-sided form with 7 decisions on each side: obtain blood, urine, lumbar puncture, imaging, place an IV, give antibiotics, and call a consult. Response choices were: definitely not, probably not, probably would, or definitely would. Medical students and preceptors each completed one side of the form independently and compared answers. Focus groups: We held 4 focus groups with 29 third-year medical students and 1 with 13 attendings and fellows. The focus groups were audio-recorded and transcribed. Three investigators coded the transcripts and categorized the codes.



Perceived benefits of our form-based process were that it prompted commitment, provided a framework for approaching clinical encounters, expanded differential diagnoses, and ensured the opportunity to present a plan. Perceived limitations were that not all decisions were represented and it was less helpful for simple and recurrent diagnoses. Barriers to its use included time constraints, fear of bothering preceptors, and student frustration when preceptors did not discuss the form. Students felt some anxiety over committing to answers and having discordance exposed, but recognized that the process promoted critical thinking and investment in the clinical encounter. Preceptors voiced difficulty teaching in the clinical setting: they have varying expectations of what students know at their training level, often lack formal training in education, and desire formal teaching methods.



Both medical students and preceptors reported that our decision-based forms often enhanced teaching in the Pediatric Emergency Department, though there were barriers to its use. The process laid bare for discussion many of the difficulties associated with clinical teaching and learning.