Illness Scripts Research Articles

Learning How to Build Illness Scripts

Learning How to Build Illness Scripts

Development and efficacy of a clinician-targeted refresher course for treating nonpneumonia respiratory tract infections.

BackgroundIn 2017, the Japanese government published an evidence‐based manual describing the appropriate use of antibiotics in outpatient settings to tackle the problem of antimicrobial resistance. To fill the evidence‐practice gap, we developed a clinician‐targeted course aimed at improving clinician skills in the daily clinical practice of treating acute respiratory tract infections (RTIs) based on the manual. The aim of this study was to evaluate the efficacy of the course.MethodsThis course consisted of lectures using illness scripts and checklists, as well as interactive communication skills training using role‐playing. We performed a vignette‐based evaluation of the changes in the knowledge and attitudes of the course participants toward prescribing antibiotics for nonpneumonia RTIs, using pre‐ and postcourse questionnaires. The questionnaires also included course feedback via the use of a 5‐point Likert scale.ResultsThirty‐eight clinicians were included in the analyses, and 90% of these participants had graduated ≥20 years ago. We found statistically significant reductions in the intention to prescribe antibiotics for four of the six nonpneumonia RTI vignettes: acute bronchitis (−47.2%; 95% confidence interval [CI] −66.3 to −28.1%), common cold (−16.2%; 95% CI −30.8 to −1.6%), acute pharyngitis (−27.0%; 95% CI −49.0 to −5.0%), and acute rhinosinusitis (−33.3%; 95% CI −53.3 to −13.3%). The course seemed to be satisfactory for experienced doctors who were the relevant target population of such a workshop.ConclusionsThe refresher course was helpful for reducing the participants’ intensions to prescribe antibiotics for nonpneumonia RTIs.

Identifying developmental features in students’ clinical reasoning to inform teaching*

Background: There is increasing evidence that students at different levels of training may benefit from different methods of learning clinical reasoning. Two of the common methods of teaching are the “whole – case” format and the “serial cue” approach. There is little empirical evidence to guide teachers as to which method to use and when to introduce them.Methods: We observed 23 students from different stages of training to examine how they were taking a history and how they were thinking whilst doing this. Each student interviewed a simulated patient who presented with a straightforward and a complex presentation. We inferred how students were reasoning from how they took a history and how they described their thinking while doing this.Results: Early in their training students can only take a generic history. Only later in training are they able to take a focused history, remember the information they have gathered, use it to seek further specific information, compare and contrast possibilities and analyze their data as they are collecting it.Conclusions: Early in their training students are unable to analyze data during history taking. When they have started developing illness scripts, they are able to benefit from the “serial cue” approach of teaching clinical reasoning.

Illness script development in pre-clinical education through case-based clinical reasoning training.

ObjectivesTo assess illness script richness and maturity in preclinical students after they attended a specifically structured instructional format, i.e., a case based clinical reasoning (CBCR) course. MethodsIn a within-subject experimental design, medical students who had finished the CBCR course participated in an illness script experiment. In the first session, richness and maturity of students’ illness scripts for diseases discussed during the CBCR course were compared to illness script richness and maturity for similar diseases not included in the course. In the second session, diagnostic performance was tested, to test for differences between CBCR cases and non-CBCR cases. Scores on the CBCR course exam were related to both experimental outcomes. ResultsThirty-two medical students participated. Illness script richness for CBCR diseases was almost 20% higher than for non-CBCR diseases, on average 14.47 (SD=3.25) versus 12.14 (SD=2.80), respectively (p<0.001). In addition, students provided more information on Enabling Conditions and less on Fault-related aspects of the disease. Diagnostic performance was better for the diseases discussed in the CBCR course, mean score 1.63 (SD=0.32) versus 1.15 (SD=0.29) for non-CBCR diseases (p<0.001). A significant correlation of exam results with recognition of CBCR cases was found (r=0.571, p<0.001), but not with illness script richness (r=–0.006, p=NS). ConclusionsThe CBCR-course fosters early development of clinical reasoning skills by increasing the illness script richness and diagnostic performance of pre-clinical students. However, these results are disease-specific and therefore we cannot conclude that students develop a more general clinical reasoning ability.

Applying Metacognition Through Patient Encounters and Illness Scripts to Create a Conceptual Framework for Basic Science Integration, Storage, and Retrieval.

Problem:Medical school curriculum continues to search for methods to develop a conceptual educational framework that promotes the storage, retrieval, transfer, and application of basic science to the human experience. To achieve this goal, we propose a metacognitive approach that integrates basic science with the humanistic and health system aspects of medical education.Intervention:During the week, via problem-based learning and lectures, first-year medical students were taught the basic science underlying a disease. Each Friday, a patient with the disease spoke to the class. Students then wrote illness scripts, which required them to metacognitively reflect not only on disease pathophysiology, complications, and treatments but also on the humanistic and health system issues revealed during the patient encounter. Evaluation of the intervention was conducted by measuring results on course exams and national board exams and analyzing free responses on the illness scripts and student course feedback. The course exams and National Board of Medical Examiners questions were divided into 3 categories: content covered in lecture, problem-based learning, or patient + illness script. Comparisons were made using Student t-test. Free responses were inductively analyzed using grounded theory methodology.Context:This curricular intervention was implemented during the first 13-week basic science course of medical school. The main objective of the course, Scientific Principles of Medicine, is to lay the scientific foundation for subsequent organ system courses. A total of 150 students were enrolled each year. We evaluated this intervention over 2 years, totaling 300 students.Outcome:Students scored significantly higher on illness script content compared to lecture content on the course exams (mean difference = 11.1, P = .006) and national board exams given in December (mean difference = 21.8, P = .0002) and June (mean difference = 12.7, P = .016). Themes extracted from students’ free responses included the following: relevance of basic science, humanistic themes of empathy, resilience, and the doctor-patient relationship, and systems themes of cost, barriers to care, and support systems.Lessons learned:A metacognitive approach to learning through the use of patient encounters and illness script reflections creates stronger conceptual frameworks for students to integrate, store, retain, and retrieve knowledge.

Anything but Shadowing! Early Clinical Reasoning in Emergency Department Improves Clinical Skills.

IntroductionTransitioning from the pre-clinical environment to clerkships poses a challenge to students and educators alike. Students along with faculty developed the Clinical Reasoning Elective (CRE) to provide pre-clinical students exposure to patients in the emergency department and the opportunity to build illness scripts and practice clinical skills with longitudinal mentorship in a low-stakes environment before entering clerkships. It is a voluntary program. Each year, the CRE has received overwhelming positive feedback from students. The objective of this study is to determine if the CRE improved students’ clinical skills and reported comfort in their skills.MethodsWe examined the relationships between students’ self-reported participation in the CRE and their individual scores on a comprehensive clinical assessment (CCA) at the end of the pre-clerkship period. A total of 178 students took the CCA exam in 2016. Of these, 113 participated in the CRE and 65 did not. Seven students who participated in CRE did not complete the exit survey and were omitted from analysis. We performed regression analysis and dichotomous (participants/nonparticipants) comparisons of means with t-tests. Survey of student reactions was collected.ResultsParticipants completed an average of 10 sessions over the course of the program (range=1–20). Involvement in the CRE was associated with significantly increased scores on Abdominal History; Pulmonary Physical Exam; Overall History-Taking; Overall Communication; and Overall Physical Exam (p<0.05). Nearly all students (97%) reported that the program offered opportunities to enhance clinical skills, increased their comfort with patients, and better prepared them for their clinical years.ConclusionThere were measurable improvements in clinical skills performance for students who participated in CRE. As many schools seek to incorporate early clinical exposure to their curricula, this program provides a successful framework to provide meaningful clinical exposure to real patients that also shows objective benefits to students’ clinical skills.

A Recognition Study Testing the Psychological Validity and Development of Illness Scripts

PurposeThis study investigates whether the recognition memory phenomena previously found for script-based stories also apply to illness scripts, the hypothesized mental structures expert physicians apply in medical diagnosis. In addition, the development of these scripts is investigated. MethodSecond and sixth year students and experienced family physicians participated; the influence of typicality of information (prototypical versus atypical statements), textual presence (verbatim or implicit), and delay (15min or 1 week) on recognition memory discrimination was investigated in a 3×2×2 ANOVA design and on recognition reaction times (RTs) in a 3×2×2×2 ANOVA design. ResultsThe expected developmental differences could not be replicated; all participants appear to dispose of illness script structures, which explains poorer memory discrimination for prototypical than atypical information. The results also show that at a longer delay, medical students and physicians are more inclined to infer unstated, but script-typical information. With regard to the RTs, the interaction between typicality and textual presence on RTs could be replicated: RTs for prototypical unstated items were longer than for any of the other types of information. Apart from this, RTs for different statements did not show a consistent pattern. DiscussionThe superior memory discrimination for script atypical, compared with script prototypical, information, and at immediate retention, compared to delayed retention supports theoretical notions as well as previous research on illness scripts as general event representations with actual case information “tagged” to these stored representations. This tagged information decays over time. In terms of script development, all participants appear to have their knowledge structured in illness scripts, even students who have little experience with the diseases included in the study.

A Clinical Reasoning Tool for Virtual Patients: Design-Based Research Study.

BackgroundClinical reasoning is a fundamental process medical students have to learn during and after medical school. Virtual patients (VP) are a technology-enhanced learning method to teach clinical reasoning. However, VP systems do not exploit their full potential concerning the clinical reasoning process; for example, most systems focus on the outcome and less on the process of clinical reasoning.ObjectivesKeeping our concept grounded in a former qualitative study, we aimed to design and implement a tool to enhance VPs with activities and feedback, which specifically foster the acquisition of clinical reasoning skills.MethodsWe designed the tool by translating elements of a conceptual clinical reasoning learning framework into software requirements. The resulting clinical reasoning tool enables learners to build their patient’s illness script as a concept map when they are working on a VP scenario. The student’s map is compared with the experts’ reasoning at each stage of the VP, which is technically enabled by using Medical Subject Headings, which is a comprehensive controlled vocabulary published by the US National Library of Medicine. The tool is implemented using Web technologies, has an open architecture that enables its integration into various systems through an open application program interface, and is available under a Massachusetts Institute of Technology license.ResultsWe conducted usability tests following a think-aloud protocol and a pilot field study with maps created by 64 medical students. The results show that learners interact with the tool but create less nodes and connections in the concept map than an expert. Further research and usability tests are required to analyze the reasons.ConclusionsThe presented tool is a versatile, systematically developed software component that specifically supports the clinical reasoning skills acquisition. It can be plugged into VP systems or used as stand-alone software in other teaching scenarios. The modular design allows an extension with new feedback mechanisms and learning analytics algorithms.

Diagnostic Accuracy: The Wellspring of EBVM Success, and How We Can Improve It

Therapy and prognosis are entailed by the diagnosis: the holistic success of the EBVM approach there­fore firmly and critically rests on diagnostic accuracy.Unfortunately, medical professionals do not appear to be very accurate with diagnoses. In human medi­cine, there is 30-50% discordance reported between doctors’ ante- (presumptive) and post-mortem (defin­itive) diagnoses, with no significant change in the last 100 years (Goldberg et al 2002). This is attenuated by attaching a degree of certainty – ‘very certain’ shows 16% discordance, ‘probable’ 33% and ‘uncertain’ 50% – and some body systems are more difficult (e.g. respiratory) than others (Shojania et al 2002; Sing­ton and Cottrell 2002).Veterinary surgeons do not perform much better, although it is a chronically under-researched area. The single study that exists – from a respected referral institution – shows discordance between ante- and post-mortem diagnoses of ranging from 15% (oncology) to 45% (ECC), with internal medicine (44%), neu­rology (35%), surgery (33%) and cardiology (21%) lying in between (Kent et al 2004). Incorrect diagnoses are therefore common; the potential for subsequent incorrect or harmful therapy and/or prognosis is great; the quality of interventional evidence is immaterial if the wrong disease is being treated.How can we do better? Human EBM shows that technology, big data and further evidence does not guar­antee improvement; these are unlikely realisations for EBVM in the near future in any case. The answer may lie in the fields of psychology and social science. Studies indicate that diagnostic success may rest largely with the individual: expert clinicians consistently perform better. But how?Experts are marked out by the use of ‘illness scripts’, which are mental knowledge networks against which the presenting patient – history, signs, clinical data – are checked and hypotheses entertained or refuted until (with the addition of more clinical data) a diagnosis is reached (Custers 2015). Experts rapidly ap­praise relevant data, embracing and exploring inconsistencies in the clinical picture, largely ignore patho­physiology and make far fewer errors than novices.It appears we would do well to harness and teach these skills – however, current problem-based learning methods fail to do so. To maximise the impact on clinical performance, it seems explicit recognition, teach­ing and integration of illness scripts and pathways to expertise are fundamental steps for EBVM. This would require a ground-shift change in veterinary teaching and professional development, but may well prove to be the greatest positive difference EBVM can make to the veterinary profession.

The Use of Short, Animated, Patient-Centered Springboard Videos to Underscore the Clinical Relevance of Preclinical Medical Student Education.

Medical students often struggle to appreciate the clinical relevance of material taught in the preclinical years. The authors believe videos could be effectively used to interweave a patient's illness script with foundational basic science concepts. In collaboration with four other U.S. medical schools, educators at the Stanford University School of Medicine created 36 short, animated, patient-centered springboard videos (third-person, narrated accounts of authentic patient cases conveying foundational pathophysiology) in 2014. The videos were used to introduce students to 36 content modules, created as part of a microbiology, immunology, and infectious diseases curriculum. The videos were created with input from faculty content experts and in some cases medical students, and were piloted using a flipped classroom pedagogical approach in January 2015-June 2016. Student feedback from course evaluations and focus groups was analyzed using a mixed-methods approach. On the course evaluations, the majority of students rated the patient-centered videos positively, and the majority of comments on the videos were positive, highlighting both enhanced engagement and enhanced learning and retention. Comments from focus groups mirrored the course evaluation comments and highlighted different usage patterns for the videos. The authors will continue to gather and analyze data from schools using the videos as part of their core preclinical curriculum, and will produce similar videos for use in other areas of undergraduate medical education. These videos could support students' review of content taught previously and be repurposed for use in continuing and graduate medical education, as well as patient education.

Student Self-Efficacy of Learning Using Illness Scripts

Abstract Student self-efficacy of learning after using illness scripts is described as an innovative strategy to teach clinical reasoning in an online pathophysiology and pharmacology course for RN to BSN students. Using illness scripts, students cluster relevant clinical features together to develop a plan of care while developing pattern recognition and expertise. A demographic survey, the student self-efficacy scale, and open-ended questions were administered to a convenience sample of students enrolled in the course. A high self-efficacy of learning was found over all student self-efficacy scale items (M = 8.94, SD = 0.24).

Illness scripts

Illness scripts

Walking among doctors and patients. Stories and reflections.

The clinician - the doctor who treats sick people - should be able to establish a good human relationship with his or her patients and their family; should be able to reach a diagnosis even in patients with rare diseases, or atypical presentations - or should refer the patient to a senior colleague; and should be able to recommend the best treatment (or no treatment at all). And he - or she - should be able to draw these abilities from the "deliberate practice" according to Ericsson, i.e. from the combination of experience with reflection - not, or with much lesser strength, from the medical literature as suggested by Evidence-Based Medicine. The diagnosis is often an easy task, i.e. by pattern recognition or recognizing a frequent illness script - "fast thinking" in the vocabulary of Kahneman; or a difficult task, sometimes very difficult for rare diseases or atypical presentations - "slow thinking" of Kahneman. The decisions about the use of therapeutic interventions, whether for individuals or entire healthcare systems, should be based on the totality of the available evidence. The idea that evidence can be reliably or usefully placed in "hierarchies" is illusory, and the pedestal deserved to the RCT is inappropriate.

Influence of learner knowledge and case complexity on handover accuracy and cognitive load: results from a simulation study.

The handover represents a high-risk event in which errors are common and lead to patient harm. A better understanding of the cognitive mechanisms of handover errors is essential to improving handover education and practice. This paper reports on an experiment conducted to study the effects of learner knowledge, case complexity (i.e. cases with or without a clear diagnosis) and their interaction on handover accuracy and cognitive load. Participants were 52 Dutch medical students in Years 2 and 6. The experiment employed a repeated-measures design with two explanatory variables: case complexity (simple or complex) as the within-subject variable, and learner knowledge (as indicated by illness script maturity) as the between-subject covariate. The dependent variables were handover accuracy and cognitive load. Each participant performed a total of four simulated handovers involving two simple cases and two complex cases. Higher illness script maturity predicted increased handover accuracy (p<0.001) and lower cognitive load (p=0.007). Case complexity did not independently affect either outcome. For handover accuracy, there was no interaction between case complexity and illness script maturity. For cognitive load, there was an interaction effect between illness script maturity and case complexity, indicating that more mature illness scripts reduced cognitive load less in complex cases than in simple cases. Students with more mature illness scripts performed more accurate handovers and experienced lower cognitive load. For cognitive load, these effects were more pronounced in simple than complex cases. If replicated, these findings suggest that handover curricula and protocols should provide support that varies according to the knowledge of the trainee.

Teaching Clinical Reasoning to Medical Students: A Case-Based Illness Script Worksheet Approach.

Clinical reasoning is a fundamental part of a physician's daily workflow. Yet it remains a challenging skill to develop formally, especially in preclerkship-level early learners. Traditionally, medical students learn clinical reasoning informally through experiential opportunities during their clerkship years. This occurs in contrast to the more structured, explicit learning of the basic sciences and physical diagnosis during the preclerkship years. To address this need, we present a flipped classroom case-based approach for developing clinical reasoning skills based on problem representation and the use of a structured illness script worksheet as a model. Students were given a short introduction via screencast to introduce clinical reasoning and related terminology such as problem representation and semantic qualifiers. They also received a case vignette and an illness script worksheet to prepare them for in-class discussion. Students used this worksheet to practice clinical reasoning in a small-group session that was held in our last organ system-based second-year course, prior to the start of the clerkships. In comparison to the traditional facilitator-led small-group sessions, where students would sequentially answer a set of defined content-based questions to explore a clinical case, 80% of students preferred the new framework that incorporates problem representation and the illness script worksheets. Faculty facilitators found the structure of the illness script worksheet helpful in leading a clinical reasoning small-group session. Based on the results of this pilot, we plan to systematically implement this clinical reasoning framework in our preclerkship curriculum.

The Case Files

The Case Files

Instructional Strategy: Administration of Injury Scripts

Context: Learning how to form accurate and efficient clinical examinations is a critical factor in becoming a competent athletic training practitioner, and instructional strategies differ for this complex task.Objective: To introduce an instructional strategy consistent with complex learning to encourage improved efficiency by minimizing intrinsic cognitive load and effectiveness by emphasizing the development of mental schemas. This strategy, called illness scripts in medicine, was adapted as injury scripts for athletic training.Background: Athletic training students are taught to learn a universal clinical reasoning process for conducting clinical examinations that consists of extensive collecting of patient data and matching these data to a hypothesis, referred to as a hypothetico-deductive approach. This process is burdensome to cognitive load storage capacity and delays development of expertise in diagnostic accuracy.Description: Injury scripts is a clinical reasoning strategy consistent with complex learning, where the evaluation of knowledge and skill competencies or key features of specific conditions are integrated in an incremental, simple-to-complex progression. This strategy will improve learning efficiency and effectiveness. The context in which cases are presented should emphasize real-life scenarios.Clinical Advantage(s): Improved efficiency of student learning and enhanced effectiveness in the professional preparation of knowledge and skills for injury evaluation.Conclusion(s): By integrating evaluation competencies or key features of specific conditions, they can be stored as injury scripts in long-term memory, saving space in working memory and ultimately minimizing intrinsic cognitive load. As students migrate through the curriculum, existing injury scripts will expand by consolidating additional information and effectively prepare them to be competent professionals in clinical examination and diagnosis. Students must also recognize that if specific data collected do not match a script, further analysis is needed to avoid diagnostic error.

Doctors’ experience of the contraceptive consultation: a qualitative study in Australia

BackgroundContraception is a field in which good doctor–patient communication is crucial and core to shared decision making. Despite the centrality of contraception to primary health care in Australia, little is...

Case-based clinical reasoning in feline medicine: 3: Use of heuristics and illness scripts.

This is Article 3 of a three-part series on clinical reasoning that encourages practitioners to explore and understand how they think and make case-based decisions. It is hoped that, in the process, they will learn to trust their intuition but, at the same time, put in place safeguards to diminish the impact of bias and misguided logic on their diagnostic decision-making. Article 1, published in the January 2016 issue of JFMS, discussed the relative merits and shortcomings of System 1 thinking (immediate and unconscious) and System 2 thinking (effortful and analytical). In Article 2, published in the March 2016 issue, ways of managing cognitive error, particularly the negative impact of bias, in making a diagnosis were examined. This final article explores the use of heuristics (mental short cuts) and illness scripts in diagnostic reasoning.

Clinical Reasoning Terms Included in Clinical Problem Solving Exercises?

Background Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown. Objective We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators. Methods A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013. Results The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators. Conclusions Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms.