TF1 A Tool for Faculty Preceptors to Guide Emergency Departments Learners in Constructing Focused Assessments of Common Presenting Complaints

Abstract

Patient management in the emergency department (ED) requires rapid evaluation and stabilization, efficient data collection, and timely risk stratification of life-threatening conditions. Heuristic models for thinking (eg, the ABCDE approach to trauma) are required to efficiently make decisions to resuscitate patients and narrow lists of differential diagnoses. Constructing and practicing such models of thinking is important in the development of the emergency medicine (EM) physician. Instructional modalities that encourage learners to develop systematic approaches to patient presentations, such as simulation, should be used early in their EM education. The goal of this project is to provide faculty preceptors in the ED with a tool to better support students and interns construct focused patient assessments for common presenting complaints. Primary: Provide structured evaluation of ED learners’ assessments of patients with common chief complaints. Secondary: In regards to common ED chief complaints, learners will list critical differential diagnoses, list necessary history and exam items to evaluate such diagnoses, complete a focused history and physical exam, and synthesize history and exam findings to formulate appropriate assessments and plans. “Chest pain” was selected as the chief complaint for an initial tool. A checklist was formed in table format, with rows consisting of history of present illness, review of systems, past and family medical history, and physical exam. Columns consisted of six critical diagnoses for chest pain: myocardial infarction, pulmonary embolism, aortic dissection, pneumothorax, cardiac tamponade, and esophagitis. Cells were populated with relevant history and exam findings, each with empty positive and negative checkboxes. A learner will evaluate an ED patient with chest pain and present to a faculty preceptor. The preceptor will use the checklist to document the learner’s positive and negative history and exam findings. The preceptor will provide feedback regarding the learner’s consideration of the critical differential diagnoses, what history and exam items are still required to complete an evaluation for these diagnoses, and whether the learner’s history and exam findings justify their assessment and plan. Learners are encouraged to re-examine the patient to complete the checklist, and discuss with the preceptor their additional findings and if and how their assessments and plans would change. The primary objective can be measured by asking preceptors if the tool helped them provide more structured feedback to learners and by asking learners to rate the quality of preceptor feedback. Secondary objectives can be measured by tracking learner checklist completion for subsequent assessments of ED chest pain patients or via preceptor evaluations of learners’ assessments over time, particularly whether they consider all critical diagnoses and demonstrate the ability to synthesize history and exam findings into an appropriate assessment and plan. This tool can be an effective adjunct in evaluating new learners' assessments of common ED chief complaints. This method provides more structured feedback from which learners are encouraged to develop their own systematic approaches to common patient presentations.