PERSPECTIVES Considering Cognition Current Challenges and Future Directions in Pulmonary and Critical Care Fellowship Training Peter F. Clardy1,2,4 and Richard M. Schwartzstein1,3,4 1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; 2Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; 3Center for Education, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and 4Harvard Medical School, Boston, Massachusetts

Abstract Fellowship training in pulmonary and critical care has evolved substantially over the past decade. Training programs are increasingly focused on a rigorous, multifaceted assessment of an individual trainee’s progress toward achieving specific curricular milestones, and their ability to independently manage a series of entrustable professional activities. This new system has provided programs with an enormous amount of detailed information related to the specific goals and outcomes of training. However, it has not addressed the unmet need for fellowship programs to systematically

assess and teach advanced clinical reasoning and judgment. Training programs must address these cognitive processes in a proactive and supportive way, and are challenged to develop novel approaches that encourage continuous self-evaluation. Only by addressing these critical deficiencies will programs enable trainees to progress beyond a level of clinical competence to one of true expertise. These efforts will also encourage physicians at all levels of training to embrace their commitment to lifelong learning. Keywords: competency-based education; education; medical; graduate; fellowships

(Received in original form January 26, 2015; accepted in final form March 10, 2015 ) Correspondence and requests for reprints should be addressed to Peter F. Clardy, M.D., Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, KsB-23, Boston, MA 02215. E-mail: [email protected] Ann Am Thorac Soc Vol 12, No 4, pp 474–479, Apr 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201501-054OT Internet address: www.atsjournals.org

Pulmonary and critical care fellowship training in the United States is in the midst of a period of unprecedented change. Program directors, faculty members, sponsoring institutions, and fellows themselves have been asked to fundamentally reconsider the goals and directions of subspecialty training. Much of this change has been driven by an ambitious new paradigm put forward by the Accreditation Council on Graduate Medical Education (ACGME), which is focused on a rigorous multifaceted assessment of an individual trainee’s progress toward achieving specific curricular milestones, and their ability to independently manage a series of entrustable professional activities (EPAs) (1–5). While this has been generally accepted as a necessary and important step forward in creating an educational environment that

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emphasizes the outcome, rather than the process, of training, this new paradigm has not addressed several issues of critical importance to the education of the next generation of pulmonary and critical care physicians. Specifically, there is a need to consider the ways in which training programs and medical educators explicitly address cognition, cognitive biases, and critical thinking. Educators need to understand how trainees think when they approach clinical problems, including the interplay between conscious and subconscious influences on thinking. At its best, critical thinking incorporates attributes of the thinker as well as the thought process: “the ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation)

and the disposition to be deliberate about thinking.lead to action that is logical and appropriate” (6). Stated differently, there is an unmet need to focus not only on what fellows know, but how they “think.” In other words, how do they reason through complex clinical scenarios? When faced with uncertainty, how does the fellow react? When the pieces of the clinical puzzle don’t fit, when patterns break down, how does he/she proceed?

Fellowship Training in 2015: Recent Changes and Ongoing Challenges The overarching goals of graduate medical education, as delineated by the ACGME, are

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PERSPECTIVES organized around six core competencies; some of these are intuitive (medical knowledge, patient care, professionalism, and interpersonal communication skills), whereas others are focused on the longitudinal development of skills for selfassessment and ongoing learning (practicebased learning and improvement) and the promotion of patient safety and quality improvement across an organization (systems-based practice). In 2013, the ACGME announced the initiation of a new system for the assessment and certification of graduate medical education training programs in the United States (1, 2). The Next Accreditation System (NAS) was developed in an effort to transition training programs from an emphasis on the methods (or process) of training to the end result of those methods on the outcome of clinical performance. In an effort to make the relatively abstract competencies more definitive and concrete, the NAS outlined a series of curricular milestones, each of which map to a specific core competency. These milestones delineate a range of performance levels, with specific descriptions of observable behavior, relevant to the core competency (3). Every training program is now required to have a core competency committee, which reviews evaluations compiled from a wide range of sources, and submits progress reports twice per year on every milestone for every trainee in an effort to monitor progress over time. Similarly, programs must assess the ability of every trainee to responsibly and independently perform a series of subspecialty-specific EPAs upon completion of their training (5). Examples of related competencies,

milestones, and EPAs are provided in Table 1. As part of this transition, several long-standing traditions central to the management of an ACGME-certified training program were abandoned. Specifically, the preparation of detailed program information forms, which included information related to specific curricular experiences, patient populations, institutional and program-specific policies, affiliation agreements among institutions, call room availability, and access to electronic medical records, are no longer required. Similarly, high-stakes on-site visits by the ACGME to a specific training program are no longer mandated on a routine basis. In place of these methods, institutions, rather than specific training programs, are now visited routinely to assess the global learning environment and to understand the focus and commitment of the organization to the educational mission as part of the Clinical Learning Environment Review program (7). The result of all of these changes on the 141 ACGME-certified pulmonary and critical care medicine training programs in the United States, encompassing nearly 1,500 trainees, remains to be determined. Certainly, by lifting some of the documentation burden on the process of training, in favor of a more comprehensive assessment of the trajectory and outcome of each individual trainee, programs (and program directors) are better able to focus on specific unmet needs, and are likely better positioned to develop innovative approaches to both cognitive and procedural training. Despite this, there are substantial challenges created by this new system. For example, specific procedural training

requirements have not been addressed in a comprehensive manner, in spite of the dramatic evolution in the role of procedures and technology in the management of patients with pulmonary disease or critical illness over the past decade. Training opportunities and formal assessment of competence related to airway management, transbronchial needle aspiration, bedside ultrasound, pulmonary artery catheterization, and other procedures vary widely, and are not formally addressed by the ACGME (8–12). Similarly, formal development and assessment of trainee teaching skills, though feasible, has not been adopted as a requirement for training programs (13), and integration of some of the “nonintuitive” core competencies, including systems-based practice and performance-based learning and improvement, is generally lacking (14). Perhaps the greatest unmet need in fellowship training, however, is the teaching and assessment of advanced clinical reasoning and judgment. Thus, the greatest challenge for fellowship training programs is to address these cognitive processes in a proactive and supportive way, and to develop novel approaches that encourage continuous self-evaluation. While ambitious, this goal is central both to understanding the needs of our trainees, and to developing, within each of them, an appreciation for the importance of explicit and thoughtful awareness of the cognitive processes that underlie their clinical behaviors. In so doing, we will inform their ability to progress not only to a level of clinical competence, but to continue to evolve as exceptional physicians and life-long learners.

Table 1. Examples of core competencies, curricular milestones, and entrustable professional activities Core Competency

Curricular Milestone

Patient care

Develops and achieves comprehensive management plan for each patient

Interpersonal and communication skills

Communicates effectively with patients and families across a broad range of socioeconomic and cultural backgrounds Recognizes system error and advocates for system improvement

Systems-based practice

Entrustable Professional Activity Manage care of patients with acute complex pulmonary diseases across multiple care settings Facilitate family meetings, including advance directive and end-of-life decisions Improve the quality and safety of health care at both individual and systems levels

The progression from general core competencies to more discreet and observable curricular milestones, and ultimately to specific entrustable professional activities (EPAs), is outlined here. There are six core competencies, 23 curricular milestones, and 20 EPAs for fellows training in combined pulmonary and critical care programs. Assessment across all of the curricular milestones is conduced twice yearly for each fellow by a clinical competency committee and submitted for tracking purposes to the Accreditation Council on Graduate Medical Education. Programs must certify the ability of trainees to perform all relevant EPAs upon completion of training. Adapted by permission from References 3 and 5.

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PERSPECTIVES Fellowship Training in the Future: a Changing Paradigm For most of the past century, the focus of medical training at all levels has been largely directed to the base of Bloom’s Taxonomy (Figure 1). Medical knowledge and the biological foundations of disease have been the core of our teaching since the days of Flexner. At a minimum, the ACGME competencies of medical knowledge and clinical care should encourage practitioners to understand (explain), rather than just remember (repeat back), the answer to a clinical problem; despite this aim, the nature of what most physicians do on a daily basis is frequently best characterized as pattern recognition. Similarly, the questions clinical teachers generally ask (e.g., what is the most common cause of X?) tend to reinforce the traditional notion that the goal of medical education is factual recall. Unfortunately, this focus on memorization, rather than deep understanding, no longer serves us well as clinicians or teachers. Physicians now function in an era in which technology puts literally millions of facts and expansive databases at our fingertips at a moment’s notice; consequently, the need for memorization of lists of differential diagnoses and medications has greatly diminished. To be sure, doctors must have recall of substantial core biomedical sciences; we cannot look up everything as we evaluate and care for patients. However, the emphasis in medical education at all levels must shift from transfer of content to the development of thinking skills, to move the learner toward the apex of Bloom’s taxonomy pyramid. There are clear benefits to shifting toward a system that focuses on understanding rather than remembering. As an example, a majority of medical errors involve a cognitive component, in contrast to an error due to a systems problem (e.g., a failure of a radiology report to be sent to the patient’s doctor). In most scenarios involving a cognitive error, the problem is not that the doctor did not “know” the missed answer; rather, he/she did not reason to it (15, 16). A practical example would include a missed diagnosis of gastrointestinal hemorrhage in a young, male, hypotensive patient admitted from the emergency department to the intensive care unit with a diagnosis of sepsis and volume depletion, but who has 476

Complex

Abstract Creating Evaluating

Analyzing

Applying

Understanding Simple

Concrete Remembering

Figure 1. Bloom’s Taxonomy, which shows the sequence of thinking skills from remembering (knowing something, being able to repeat it back) to understanding (being able to explain it to someone else), et cetera. The peak of thoughtful use of information is to be able to create new solutions to problems not previously encountered.

a hemoglobin of 12, which is overlooked as “near normal.” What led the critical care physicians to make that error? Why did they not see through the framing of the case as presented to them by the emergency department? Why didn’t the mental alarm ring when they saw a marginally low hemoglobin level in a clinical scenario for which one would have predicted an elevated value? To the extent that pulmonary and critical care physicians are engaged in the care of some of the sickest patients, many of whom have multisystem disease and complex physiological abnormalities, it is incumbent on fellowship training programs to address this issue. In addition, they must consider the value of a pedagogical approach that specifically emphasizes inductive reasoning based on foundational knowledge of physiological principles in support of the more traditional elements of clinical reasoning in the context of broader knowledge of general theories emanating from cognitive science about how we approach problems. Clinical Reasoning

How do we get from a set of facts in the patient’s history, physical exam, and laboratory data to an understanding of what is happening with the person under our care? Classically, clinical reasoning has been taught via the hypothetico-deductive model, and has incorporated elements of clinical epidemiology (prevalence of

disease) and test characteristics (sensitivity and specificity) (17, 18). This process ultimately involves elements of pattern recognition, decisions made on the basis of disease groupings (e.g., infections processes, neoplasm, etc.), and estimates of disease probabilities as they relate to the patient confronting the doctor at that moment. Reasoning from a few facts, one creates hypotheses in the form of a differential diagnosis and then deduces what one knows about the findings associated with each diagnosis (Figure 2) (19). The diagnosis that matches most closely with the patient is the correct answer. But what if one has only one or two diagnoses that come to mind? And what if the diagnoses that arise are colored by one of many cognitive biases, defined as predispositions to think in certain ways, which do not reach the level of consciousness, but may have great effect on decisions (20). The probability of a cognitive error (i.e., one that arises from the thinking or reasoning process rather than systems issues) rises (21). Nearly 4 decades ago, Tversky and Kahnemann (22, 23) began to describe the role that unconscious bias plays on the way we make decisions. Over this time, the dual processing model of thinking was further elaborated and used to help us understand many of the cognitive errors to which doctors are prone (24). This model, which notes the contributions of unconscious or

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F1

H1

F2

H2

F3

H3

F4

H4

F8 F5

F6

F9

F10

F7

Figure 2. Deductive thinking in clinical reasoning. The individual works from a small number of facts (F1) and creates hypotheses (H1–H4) in the form of a differential diagnosis. He/she then deduces what is known about these diseases (F2–F10) and aligns his/her patient’s data with these facts. The hypothesis with the best fit becomes the preferred diagnosis. Graphic adapted by permission from Reference 19.

intuitive thought, likely related to our brain’s natural proclivity to seek patterns in what we observe, as well as more deliberative, conscious, analytical processing, provides a basis for teaching fellows about “thinking” and for helping them develop the skills of metacognition. If a doctor is aware of his/her own thought processes, it may allow him/her to avoid the errors resulting from cognitive bias (recall the framing issue noted previously here). The development of metacognition, and the ability to utilize it to avoid errors in problem solving is an instrumental milestone in developing advanced reasoning abilities (6). Not only is this important for the clinical care that a clinician provides directly, but to the extent that, in the future, pulmonologists and intensivists will be increasingly supervising midlevel providers or distant intensive care units via telemedicine,

F1

F2

H1

F3

physicians will need to be even more astute at discerning framing issues and bias as cases are formulated by others and presented to us as neat packages. The hypothetico-deductive model of clinical reasoning may be particularly susceptible to cognitive bias; doctors are rewarded early in their clinical training for providing the fastest differential diagnosis. Inductive reasoning, working from a larger number of facts to create intermediate hypotheses that pertain to physiological and pathophysiological mechanisms rather than diagnoses, may enable one to avoid anchoring on a single diagnosis or prematurely closing off consideration of alternative explanations (Figure 3) (19, 21). Inductive reasoning has been missing from traditional approaches to clinical reasoning (6, 18), but we believe it should be part of a new construct for how doctors should approach clinical problems (Figure 4) (6).

F4

F5

H2

F6

F7

F8

H3

H4 Figure 3. Inductive thinking in clinical reasoning. One collects a range of facts (F1–F8) in the form of historical information and physical exam and laboratory data before generating intermediate hypotheses (H1–H3), which are related to mechanisms of disease rather than specific diagnoses. Additional data then allow one to move from mechanisms to a specific diagnosis (H4). Graphic adapted by permission from Reference 19.

Perspectives

Strategies such as concept or mechanism mapping (25–28) can be employed to reinforce core physiological concepts and to assist the fellow in making links between elements of the history, physical exam, and laboratory data. This is particularly helpful for the fellow who is having problems “putting the case together” or who is overly reliant on pattern recognition. Although the research agenda in pulmonary and critical care medicine has largely shifted from organ physiology to cellular biology and genetics, we must remember that a deep understanding of physiological principles provides the framework for learning in our specialty; linking new knowledge to existing frameworks is vitally important for acquisition and retention of new knowledge, and is instrumental to analytical reasoning and daily clinical care. Expertise and Clinical Reasoning

We all want our fellows to graduate and become “expert” in their field. Expertise is traditionally defined as knowledge plus experience, but studies suggest that there are two types of expertise—routine and adaptive (29)—and that the ability to reason inductively may be key to adaptive expertise. A routine medical expert has an extensive inventory of cases from which to draw upon and the ability to access that prior experience when seeing a new patient. Confronted with a new case, the doctor matches its features with other patients seen in the past and a diagnosis and/or treatment plan is established. If confronted with a clinical scenario not previously encountered, the routine expert is left without the tools to reason to an answer, or may force the situation to fit into a pattern previously encountered; his/her knowledge is described as “static” (29). In contrast, the adaptive medical expert has the ability to reason to solutions working from a deep understanding of core biomedical and pathophysiological principles. Working with fellows to attain this level of understanding is key. When assessing new patients, fellows should be pushed to reason inductively from basic mechanisms to ultimate diagnosis to achieve solutions to clinical problems and avoid the tendency to fall back upon previous cases. With this practice and skill, a fellow’s knowledge will be “dynamic,” and new solutions can be created for problems not previously encountered. 477

PERSPECTIVES New Competencies Hypothetico-deductive thinking Clinical epidemiology

Inductive reasoning Evidence-based medicine

Figure 4. Clinical reasoning: overlapping concepts. The use of hypothetico-deductive thinking or inductive reasoning is not mutually exclusive. These approaches, along with knowledge of clinical epidemiology and evidence-based medicine, are combined as a clinician approaches mastery within their area of expertise.

Mastery and Clinical Reasoning

A related concept to expertise is mastery, the continuous refinement of one’s knowledge and skills. As with adaptive expertise, mastery is dynamic; it requires one to reflect upon one’s performance on a regular basis to determine what was done well and what can be improved (30). Doctors who do not actively reflect on their practices stagnate, and may actually lose competence over time (Figure 5) (30). Knowing that biomedical knowledge is constantly growing at ever-increasing rates, medical educators need to encourage self-directed learners who can identify gaps in their own knowledge and devise ways to fill gaps as part of the core competency of practicebased learning and improvement. Unfortunately, doctors are notoriously poor at identifying and acting upon their own weaknesses, and continuing medical education does not consistently lead to changes in clinical performance (31).

How can we alter our teaching programs to explicitly emphasize and develop skills necessary for life-long learning? Classical morbidity and mortality conferences build upon this concept for teams, but they tend to address the most egregious errors and include only a small fraction of patients for whom we provide care. Self-assessments by fellows should be formalized and should occur on a regular, frequent basis. Furthermore, these assessments should include reflection on reasoning approaches as well as gaps in content knowledge. If these reports do not demonstrate insight and do not concur with observations of faculty members, remediation must occur not only on any particular deficiencies in knowledge, thinking skills, and performance, but on the ability to reflect, to be self-aware, and to be honest about who we are as doctors. Mastery will not be achieved in the absence of this well developed habit of mind.

Performance

Peak of career

Competence

Conclusions

0 10 Formal training

20

30

40

Years in practice Figure 5. Expertise and deliberative practice. Although the clinical performance of individuals increases after completion of formal training as they acquire experience, performance will begin to decline if the doctor does not engage in deliberative practice by carefully examining the care provided and seeking feedback on his/her work. Graphic adapted by permission from Reference 30.

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The Institute of Medicine has recently released a report on its vision of graduate medical education (32). Although the report takes a comprehensive look at graduate medical education, including its funding mechanism, it clearly calls on medical educators to produce graduates who are more attuned to the needs of American healthcare in the 21st century. In particular, the Institute of Medicine demands that we improve individual and population health while reducing the cost of care. To achieve this, we must broaden our approach to the traditional medical competencies of our fellows. Beyond the general goals of the performance-based learning and systemsbased practice competencies, programs need to provide explicit experiential opportunities for trainees in quality improvement and patient safety on a routine basis. Value added care, which goes far beyond considerations of cost to include a determination of patient values and desires with respect to side effects, complications, and false-positive and false-negative results, must become part of virtually every patient encounter; shared decision making requires that doctors seek to understand patient preferences (33–35). To achieve true patient-centered care, we must work more explicitly with our fellows on communication skills and strategies, and we must observe our fellows as they have difficult conversations with patients about options for diagnosis and treatment. All of this, however, will require extensive faculty development to ensure that our teachers have the knowledge and skills to help fellows achieve these competencies and the ability to reason inductively, with a firm understanding of the elements of clinical reasoning, cognitive bias, and metacognition.

Pulmonary and critical care fellowship training is poised at a critical juncture. Interest in our profession has never been greater, and both the size and quality of our applicant pool has increased steadily over the past decade. The ACGME has undergone a period of intense selfevaluation, and programs are now held to a much higher standard to demonstrate that the outcomes of their training, rather than

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PERSPECTIVES the specific clinical experiences, are effectively supporting learners in all of the core competencies, and are producing clinicians capable of shouldering the complex needs of our patients and society as a whole. Despite these recent changes, academic leaders must recognize that there are still substantial deficiencies in our current approach, and that explicit consideration of issues related to

understanding, rather than just remembering, will be of enormous benefit to future generations of pulmonary and critical care physicians. Much of what we have described here as part of the new paradigm for fellowship training will seem strange and foreign to our faculty members. Thus, to achieve our goals, we will need to commit collectively to the vision for the future and work together to fill the gaps for ourselves as

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Considering cognition. Current challenges and future directions in pulmonary and critical care fellowship training.

Fellowship training in pulmonary and critical care has evolved substantially over the past decade. Training programs are increasingly focused on a rig...
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