AN EVIDENCED-BASED CURRICULUM FOR CLINICAL REASONING EDUCATION IN NOVICE STAGE LEARNERS: A NEUROLOGY STROKE CURRICULUM FOR PRECLINICAL PHYSICIAN ASSISTANT EDUCATION

Abstract

Introduction Preventable medical error represents a top 10 cause of mortality in the United States and misdiagnosis is the most common, costly and dangerous form of medical error. An estimated 80,000 people die every year because of misdiagnosis related harms. Although various approaches to the problem of misdiagnosis have been explored, research and expert consensus suggest that educational interventions are most likely to improve the problem of misdiagnosis. Specifically, improved educational models in clinical reasoning are thought to be the most effective approach to improving diagnostic capacity among healthcare teams. The majority of data and research on the problem of misdiagnosis focuses on physician performance. Other healthcare providers, like physician assistants, play a significant role in the modern healthcare system but less is known about the diagnostic performance of physician assistants. Although existing data suggest that physician assistants, like their physician counterparts, may be associated with diagnostic error, there is virtually no mention of diagnostic performance or preventable medical error in the literature. Methods Working from the premise that physician assistants would benefit from improvements in clinical reasoning training, the study set out to design a curriculum in diagnostic proficiency. Using the literature on best practices and evidence-based principles, an experimental curriculum in diagnostic proficiency was developed and delivered at a Midwestern physician assistant training program. The experimental curriculum focused on neurology with an emphasis on diagnosis of stroke. The rationale for this content emphasis is that neurology represents a significant source of misdiagnosis with stroke being a frequent cause of misdiagnosis related harm. The form of the study was a within-subjects comparison between trainee performance on material covered by the experimental curriculum (neurology, stroke) versus trainee performance on content covered by the institution’s conventional curricula. The effect of the experimental curriculum on the diagnostic capacity of the trainees was measured using case studies and illness script exercises. The study compared the trainee's performance on conditions covered by the experimental curriculum (anterior stroke and posterior stroke) against conditions covered by the institution’s existing curriculum (Henoch-Schönlein purpura and acute adrenal insufficiency). Additionally, student attitudes toward the curriculum of diagnostic proficiency were assessed using a series of survey questions. Results Trainee performance on the conditions covered by the experimental curriculum demonstrated a diagnostic accuracy of 88% (posterior circulation stroke case study) and 62% illness script repleteness (cardiogenic anterior stroke). Trainee performance on conditions not covered by the experimental curriculum (taught using the institutions current practices) demonstrated a diagnostic accuracy of 46% (Henoch-Schönlein purpura case study) and an illness script repleteness of 16% (acute adrenal crisis). Student attitudes toward the experimental curriculum were positive with qualitative analysis showing favorable student comments correlating with the evidence-based principles of the experimental curriculum.