Editor’s Note: See Remediation Part 1: Aquifer Tools & Strategies for an overview of ways to use Aquifer cases for remediation and hidden gems within your subscription to support your students.
Whether you’re looking for materials to help learners develop clinical reasoning skills, new ways to structure coaching sessions, or ideas to diagnose gaps in skills or knowledge, Aquifer cases can support your remediation efforts.
In our webinar, “Using Aquifer to Support Struggling Learners,” our panel of educators from medical schools and physician assistant programs around the country shared their approaches to using Aquifer cases for remediation and addressing barriers to success in the following areas:
- Differential diagnosis (fixed or frozen, siloed, impractical)
- Focusing on pertinent information
- Medical knowledge gaps & exam performance
- Written and oral communication skills
- OSCE’s & clinical exam preparation
Some of their stories are shared below.
Faculty Stories and Structures for Remediation
Stop-Action Coaching Framework for Clinical Reasoning
Elizabeth Stuart, MD, MSEd, Director of Medical Student Education & Clinical Professor in the Department of Pediatrics at Stanford School of Medicine, structures clinical reasoning coaching around Aquifer cases.
She begins by selecting a “fresh” case that students have not seen before and compliments it worksheet she has developed with coaching prompts to capture student thought processes at key moments in the case. Students complete steps 1 and 2 (see image) of the worksheet before beginning the case and meeting the virtual patient, training them to start thinking ahead. “We imagine that doctors first gather a lot of data from the patient and then think about it–and students are taught that way–to learn the history first, and then learn clinical reasoning and the differential. The reality is that doctors don’t do that–first they think about what they need, then they gather the information, and then they think about it some more. This structure forces students to work through a case that way and formulate their thinking.”
After completing the first two prompts, students work up to a specified breakpoint in the case where they pause and write a summary statement and revised differential, then continue the rest of the case. Reviewing the worksheet in a one-on-one session facilitates stop-action coaching and allows her faculty to understand where the student was at each step of the process, and enables them to talk through each point with the student (“Why was this condition missing from your differential?”, “What information was missing?”). Elizabeth notes that this approach works best when coaches can identify a few cases that they know well and that have breakpoints that work for what they need. “The cases essentially become standardized patients that you know all the details of and can structure your coaching around.”
Remediating Exam and OSCE Performance with Targeted Case Assignments
At Pace University-Lenox Hill Hospital Physician Assistant Program, Kindred Harland Shulgin, MS, PA-C, Clinical Assistant Professor, pairs a careful analysis of her students’ exam performance with exam blueprints to create a focused remediation plan with Aquifer cases.
To support students who did not pass exams, Kindred begins by comparing individual student exam performance with the exam blueprint, and focuses on the most important areas. Once the problem areas are identified, she uses Aquifer’s Case Library (now known as the Content Library) to quickly search the cases to find the content that is most relevant and will have the biggest impact on the struggling students. She creates custom courses to assign cases to individual students, or groups of students struggling in similar challenging areas.
“When I’m choosing cases, I always look at the case synopsis, which shows the differential diagnosis associated with each case. Even if the final diagnosis doesn’t match up to something that they missed on the exam, the Aquifer cases are so thorough in terms of evaluating differentials that I think the case is still really helpful exercise–and the students do too,” says Kindred. “For students who don’t pass the end of rotation exams, I also meet with them and to review their summary statements, and talk about the cases. The students really get a lot out of the cases, I think it is more real for them because it is case-based and about a ‘real’ patient, which helps the information stick with them.”
The team at Pace also found the cases helpful for remediating students who failed the OSCE. For example, a few students failed a standardized patient with a history of asthma presenting with shortness of breath. Faculty found that students had a bias toward diagnosing acute asthma exacerbation instead of considering all of the PE risk factors in the case and a robust differential list. “It worked out perfectly–when I reviewed the Aquifer cases available on pulmonology, there was a case with a very similar scenario,” noted Kindred. “Students were required to complete the Aquifer case, watch their OSCE video, and write a reflection on what they did well, what they could have done better, what they would do now, and rewrite an assessment and plan. The quality of the assignments were great, students really showed that they internalized the mistakes they made and understood what they needed to do differently,”
One-On-One Reviews Focused on Oral Case Presentations with the Case Analysis Tool
“One of my favorite Aquifer resources is the Case Analysis Tool,” says Jensen Lewis, MSPAS, PA-C, Director of Didactic Curriculum at Case Western Reserve University Physician Assistant Program, “We use it to get into students’ brains to figure out where the disconnects are.” The Case Analysis Tool (CAT) worksheet accompanies the Aquifer cases and guides students through the clinical reasoning process. For remediation, Jensen uses the worksheet as a structure for one-on-one reviews with clinical advisors. Students complete a specific Aquifer case and the CAT, and then participate in an oral assessment, walking through each step of the case, talking through the process and the tough questions (“Why didn’t you think of PE?”, “Why this treatment?”, etc). The structure, and student notes recorded at each step in the process, allow faculty advisors to dive down into the details and reasons behind clinical decisions.
“We’ve found that going through the cases orally is a really powerful way to find the real issues. For example, a student might know how to treat a condition, but not how to make a diagnosis,” said Jensen. “We gain insight into where the fundamental problems are, which makes it easier to address those gaps.”
To learn more, watch or listen to Jensen Lewis, MSPAS, PA-C, present in our webinar ( jump to 35:30, 9 min presentation). For more details on how Case Western Reserve University uses the Case Analysis Tool, read our blog post from Sara Kraus, MMS, PA-C, “Case Analysis Tool: Feedback for Developing Clinical Reasoning Skills.”
Case Cut-Points with Timed Note Writing
In her role coaching students in clinical reasoning at the University of Washington, Sherilyn Smith, MD, helps to prepare students for the fast pace of clinical rotations–and clinical exams like USMLE Step 2-CS or OSCEs. After coaching students on ways to prepare for efficient clinical reasoning, and talking about agenda setting, Sherilyn assigns an Aquifer case unfamiliar to the student and asks them to complete it through a set breakpoint mid-way through the case. At that stopping point, students set a timer for 10 or 15 minutes to complete a written note. “This provides great practice for performing under pressure and focusing on the pertinent information in the case,” says Sherilyn, “The exercise forces them to think quickly and communicate clearly, but in a safe space.” Then Sherilyn reviews and gives feedback on what they wrote, looping back to discuss any problems that came up when going through the differential diagnosis, focusing on key points they forgot or information included that was not in the case.