The Pediatric Milestones are now being used to guide the ongoing evaluation of trainees in all rotations. Certainly the most important Milestones vary from rotation to rotation. In the Pediatric Emergency Department (as in many others) making sure that you obtain the right history is key to assuring that you can develop an appropriate differential diagnosis and plan.
This post in the Art of Medicine series delves into what we, as evaluators are looking for when we assess residents in terms of how they gather the essential information from their patients and their families in an accurate manner.
In general, early learners, like interns, rely on basic pathophysiology and use analytic reasoning to generate mental maps to try to link their history and the exam. This history can be too extensive and convoluted due to the lack of a filter for which information is most critical. The limited experience of the novice learner may result in neglecting potentially important factors. Intermediate residents can link signs and symptoms in the current patient to ones they’ve seen in the past. They filter information into diagnosis lists and develop illness scripts. These scripts are unique to each individual and are based on recognizing patterns of signs and symptoms relying on the experience gained from previous encounters to build “mental scaffolding representing characteristic features of specific illnesses.” An example would be Strep pharyngitis. Early residents may jump to a diagnosis of strep if they see a patient with fever, throat pain, and oropharnygeal exudates. With more experience they will have also seen patients with headache, abdominal pain, malaise, tender anterior cervical nodes and palatal petechiae. Even more experienced learners may recognize Pastia’s lines and circumoral pallor and be able to differentiate strep from mono (and maybe even diphtheria…). Advanced trainees use well developed illness scripts to help recognize variations in disease within patients. Their well defined “instance scripts” help recognize subtle differentiating features between similar conditions. Essentially, they are functioning autonomously at a very high level.
If you are a supervisor, in order to effectively assess resident history gathering it is recommended that we suggest that you refrain from assuming that the resident is only using pattern recognition if they jump to a diagnosis quickly. Seek to understand their thought processes and you may find that they arrived at precisely the right diagnosis because of their advanced filtering skills. When you first work with a resident makes sure that you clearly specify how much history you want to hear. More is generally better until you get a sense of their history taking skills. As always, direct observation is a great way to assure that they are doing a good job. this may introduce a bit of the “Hawthorne effect” into matters – the resident may perform differently since you are in the room with them – so you can alternatively check yourself by taking a history form the family yourself.