Education Columns

Lawrence R. Fischetti,PhD, Oakwood Annapolis Hospital, Westland, MI; Michelle Diebold, MD; James Meza, MD, PhD, Wayne State University

Resident Assistance Committee
Although we invest a great deal of time in resident selection, prediction of residency success remains imperfect. Ten to 15% of our residents display deficiencies in the General Competencies. Moreover, difficulty assessing intern competencies can delay recognition to the second year. Prompted by these concerns, in 2005, the program organized a Resident Assistance Committee (RAC).

Composition of the RAC includes medical and behavioral science faculty and a chief resident. Faculty advisors participate in meetings upon invitation. The process begins with a letter from the program director listing specific, persisting concerns. The RAC chair convenes the committee, summarizes relevant information in the resident file, and with committee input, surveys faculty regarding resident performance in the General Competencies and identified areas. The RAC interviews the resident, program director, and other individuals with knowledge of the problem. The committee strives to maintain confidentiality and its aim of resident assistance—the committee does not make recommendations regarding disciplinary action.

Domains of Medical Practice
The Sadler and Hulgus description of the scientific and non-scientific domains of medicine informs the RAC’s work. Medical science, ie, medicine’s Epistemic aspect, incorporates knowledge of disease, diagnosis, and treatment, yet knowledge deficits account for a minority of RAC referrals. As an example of medicine’s Pragmatic aspect, Servis and Smith described a developmental framework for assessment of learner diagnostic skills. In the first stage, Reduced Knowledge learners’ fund of knowledge is limited, independent of context, and difficult to apply. In the second stage, learners reorganize medical facts into practical structures, ie, illness scripts, schemas, prototypes. Lacking these structures, Dispersed Knowledge learners display extensive book knowledge while offering overly broad differentials. In the third stage, learners begin a shift to pattern-recognition and pattern-comparison. Due to inaccurate or incomplete prototypes and inattention to essential facts, the Tunnel Vision learner jumps to a diagnosis.

Some years ago, we accepted an applicant who completed medical school despite the lack of a formal childhood education. The intern’s above average scores reflected a preference for book learning. During rounds, the intern’s diagnostic errors suggested a lack of illness scripts for common problems typical of Dispersed Knowledge learners. The intern’s rush to diagnosis suggested inaccurate or incomplete prototypes typical of Tunnel Vision learners. The RAC proposed faculty first emphasize complete and accurate clinical data gathering, followed by further guidance in evaluating differentials and selective reading tied to actual cases, resulting in the intern’s growing competence in diagnosis.

A few years later, the program director referred another intern demonstrating a lack of focus. The intern’s gift of humor kept us smiling yet raised concerns regarding professionalism, ie, medicine’s Ethical aspect. Faculty also wondered whether humor might hide a deficiency in medical knowledge. The intern responded defensively; the smiles and jokes all but disappeared. Over time, the intern’s focus improved along with evidence of developing knowledge and maturity. Months later during a recorded interview, a patient offered a humorous comment, and the intern responded in-kind. Faculty direction, modeling, and support helped the resident internalize appropriate guidelines for the therapeutic use of humor.

Conclusion
The RAC has enjoyed some hard-fought successes and a few disappointments. Mindful of Sadler and Hulgus, we maintain attention on patient problems. This awareness—incorporating medicine’s Epistemic, Pragmatic, and Ethical aspects—serves to humanize both education and practice and promote decision-making based on the “moral goals of the clinical encounter”² (p. 1318).

References

1. Swing SR. The ACGME Outcome Project: retrospective and prospective. Med Teach 2007;29:648-54.
2. Sadler JZ, Hulgus YF. Clinical problem solving and the biopsychosocial model. Am J Psychiatry 1992;149:1315-23.
3. Servis ME, Smith S. Diagnosing learner difficulties using a development framework for clinical teaching. Annals of Behavioral Science and Medical Education 2004;10:29-33.

For additional information on the assessment and remediation of diagnostic reasoning skills, see Servis and Smith (2004) and the following sources:

Bordage G, Zacks R. The structure of medical knowledge in the memories of medical students and general practitioners: categories and prototypes. Med Educ 1984;18:406-16.

Bordage G, Lemieux M. Semantic structures and diagnostic thinking of experts and novices. Acad Med 1991;66:S70-S72.

Lemieux M, Bordage G. Propositional versus structural semantic analyses of medical diagnostic thinking. Cognitive Science 1992;16:184-204.