Thread by @JenniferSpicer4

1/ *Case presentation of MSSA osteomyelitis*
...
Expert 1: Clearly we should treat w/ IV ceftriaxone
Expert 2: WHAT?! I would never use ceftriaxone to treat this
...
💭Trainee in the audience: What the heck should I be doing?

This week: teaching management reasoning effectively

2/ This week we will discuss how to teach management reasoning, also sometimes referred to as "therapeutic reasoning."

3/ Management reasoning is more complex than diagnostic reasoning because:

1⃣there's usually more than one "right" answer
2⃣many factors must be considered
3⃣a degree of uncertainty about the diagnosis or "best" choice almost always exists

4/ For example, this @AcadMedJournal paper shows that hospitalists and ID physicians consider many different factors when selecting antimicrobials

pubmed.ncbi.nlm.nih.gov/32379146/

5/ But that's a lot of information to teach all at once, so how can we make teaching this topic more approachable?

6/ One thing we can teach is a "management script" for common medical conditions, as described by @andrewparsonsMD @thilanMD & @JRencic in this @AcadMedJournal paper:

pubmed.ncbi.nlm.nih.gov/32349018/

Here are the components & an example of what that may look like for osteomyelitis.

7/ But once our learner’s master the management script, there's so much more we can teach.

And to me, this is the fun part about management reasoning.

8/ We can teach about testing and treatment thresholds.

For example:
*⃣When do we have enough data to initiate treatment?
*⃣What are the relative risks/benefits of additional testing prior to initiative treatment?
*⃣Will that test CHANGE our management or not?

9/ We can also teach about the variety of treatment options.

*⃣What options exist?
*⃣What are the risks/benefits of each?
*⃣How do patient characteristics impact selection? (e.g., medication interactions, allergies, etc.)
*⃣What are the limitations in the data that we have?

10/ We can teach about health systems by discussing how our context impacts decisions.

*⃣Are all options equally feasible in our context?
*⃣What resources do we have available?
*⃣How much does each option cost?

It's also important to discuss equity (& inequity) explicitly.

11/ Patient preferences are another important factor in management reasoning.

*⃣What are the patient's preferences regarding testing & treatment?

This is a great time to observe or role model discussions with patients.

12/ Finally, it's important to teach learners what to EXPECT once treatment is started.

*⃣What's the typical time course for a response to treatment?
*⃣How will we know if the patient is improving?
*⃣What are the potential complications that could arise?

13/ Management reasoning is fun to teach because there's always more to teach & learn.

This is always a great time to engage specialists to help all of us refine our own management scripts. I know I take every opportunity to talk to other teams.

14/ But it's important to recognize that management reasoning can be frustrating, especially for early learners, because there isn't one right answer.

Uncertainty is uncomfortable. And hard.

15/ Moreover, sometimes "style" drives decision-making, especially in evidence-sparse areas.

That's okay, but we should be upfront about this and explain our rationale.

Let's be good role models by avoiding absolutes and respecting others' opinions.

16/ In summary, here are some tools for teaching management reasoning.

Start with a management script for early learners, and then refine management reasoning by discussing more complex topics for more advanced learners.

17/ Join us next Tuesday when @GStetsonMD discussing asking effective questions to promote learning.

In the meantime, follow @MedEdTwagTeam, @YihanYangMD, & @ChrisDJacksonMD so that you don't miss any content!