SLO 2 – Support the ED team by answering clinical questions and making safe decisions

EM clinicians need to be expert decision makers. This Specialty Learning Outcome incorporates an understanding of the key steps in diagnostic reasoning, how clinicians make decisions and the factors that have a negative or positive impact on this fundamental skill. The trainee will develop an understanding of how to recognise and mitigate against cognitive errors that can cause harm and threaten patient safety. Good clinical knowledge remains key and the trainee will be able to apply the core principles of evidence based medicine to everyday clinical problems. This will extend to understanding how safe plans can be formulated, including deciding to discharge patients.

Domain 1: Professional values and behaviours

Domain 2: Professional skills:

  • communication and interpersonal skills
  • dealing with complexity and uncertainty
  • clinical skills (history taking, diagnosis and medical management; consent; humane interventions; prescribing medicines safely; using medical devices safely; infection control and communicable disease)

Domain 3: Professional knowledge 

  • professional requirements
  • national legislation
  • the health service and healthcare systems in the four countries

Domain 4: Capabilities in health promotion and illness prevention

Domain 5: Capabilities in leadership and teamworking

Domain 6: Capabilities in patient safety and quality improvement

  • patient safety

Key ACCS capabilities

At completion of ACCS a trainee will:

  • Understand how to  apply clinical guidelines
  • Understand how to use diagnostic tests in ruling out key pathology, and be able to describe a safe management plan, including discharge where appropriate, knowing when help is required.
  • Be aware of the human factors at play in clinical decision making and their impact on patient safety

Key EM capabilities

At completion of Intermediate training a trainee will be:

  • able to support the pre-hospital, medical, nursing and administrative team in answering clinical questions and in making safe decisions for discharge, with appropriate advice for management beyond the ED. 
  • aware of when it is appropriate to review patients remotely or directly

with Supervisor ‘on call’ from home for queries, able to provide directions via phone and able to attend the bedside if required to provide direct supervision

At completion of higher training a trainee will be:

  • able to support the pre-hospital, medical, nursing and administrative team in answering clinical questions and in making safe decisions for discharge, with appropriate advice for management beyond the ED. 
  • aware of when it is appropriate to review patients remotely or directly and able to teach these principles to others.

and would be able to manage with no supervisor involvement

ACCS descriptors

  • Proficient in ECG and plain film interpretation, as relevant to acute care
  • Aware of the cognitive psychology of decision making
  • Understand basic diagnostic test methodology
  • Understand the fundamentals of decision rule design
  • Aware of the strengths and limitations of using guidelines e.g. NICE
  • Demonstrate capabilities in dealing with complexity and uncertainty
  • Share decision making by informing patients, prioritising patient’s wishes, and respecting their beliefs, concerns and expectations

Intermediate & Higher Descriptors 

All ACCS descriptors apply in intermediate and Higher training 

  • Aware of the human factors at play in clinical decision making and their impact on patient safety
  • Aware of key steps in diagnostic reasoning include
    • Cognitive processing and dual process theory – “how we make decisions”
    • The anchor and adjust heuristic
    • Factors that affect our decision making
    • How to use diagnostic tests effectively
    • How to make therapeutic decisions effectively for the benefit of individual patients
  • Be competent in ECG, clinical image and biochemical assay interpretation 
  • Understand diagnostic test methodology
  • Be able to recognise and describe strategies to reduce the incidence of cognitive error
    • To include metacognition and cognitive debiasing techniques
  • Be able to describe strategies for dealing with uncertainty. To include 
    • The use of pre and post-test probabilities 
    • Bayesian analysis 
    • Risk stratification or decision rule design
    • Use of guidelines
  • The Emergency Physician should always demonstrate appropriate professional values and behaviours, supporting colleagues, respecting difference of opinion, and working as a collaborative member of a team
  • Able to provide effective feedback on clinical reasoning and decision making 

Trainees will be required to record evidence of grounding in the theoretical underpinnings of clinical reasoning. Resources include:

  • RCEM learning material
  • Local and regional teaching to cover this SLO
  • To include simulation/ human factors training on decision making

Core trainees will have the opportunity to receive focussed feedback in this Speciality Learning Outcome with any patients they review. Formative assessment should focus on trainee commitment to a decision that can be probed and opportunities to explore reasoning, or the use of diagnostic tests and guidelines. WPBA is also an opportunity to test background learning in cognitive decision making at this stage, and trainees will be expected to reflect on this following clinical encounters where decision making has been explored.

Evidence to inform decisions include:

  • CbD
  • ESLE
  • FEG
  • RCEM App
  • ACAT
  • MCR (AM)
  • Mini-CEX
  • MSF

Intermediate trainees will continue to receive feedback on decision making in more complex situations. They will also be observed and receive feedback in answering questions on the shop floor, in preparation for this role in HST. They will come to a conclusion in this situation. These encounters need not be extensive, but sampling a number of encounters is likely to yield a better view of capability.

Evidence to inform decisions include:

  • CbD
  • ESLE
  • FEG
  • RCEM App
  • ACAT
  • MCR (AM)
  • Mini-CEX
  • MSF

At the end of training there should be a profound understanding of diagnostic reasoning, its application to the Emergency Medicine setting and an ability to communicate key principles to others in training.

Markers of excellence would include a profound and detailed understanding of diagnostics and clinical reasoning that can be effectively communicated and a readiness to adapt and develop these skills.

HSTs should continue to seek feedback in this domain as they develop through training, and encounters with particular challenge recorded and reflected upon

Evidence to inform decisions include:

  • CbD
  • ESLE
  • FEG
  • RCEM App
  • ACAT
  • MCR (AM)
  • Mini-CEX
  • MSF

Entrustment Decisions

End of core training level 2b :

Trainees will not need to be entrusted to answer clinical questions at the end of ACCS

They will need to be entrusted to ask questions based on sound underpinnings, i.e demonstrate an understanding of key principles such as  diagnostic methodology, cognitive bias,  how decision rules and guidelines work and are best used

End of intermediate training level 3: 

ST3 Level 3:

At the time commencing HST (ST4) clinicians must be able to practice without direct supervision in this activity. Throughout Higher Specialty Training the trainee will be expected to support the Emergency Department and wider healthcare team in answering clinical questions, with support available from a consultant by phone. They must have awareness of their limitations and a faculty entrustment statement at this stage should attest to their readiness for this

End of HST Level 4:

At the end of training there should be a profound understanding of diagnostic reasoning, its application to the Emergency Medicine setting and an ability to communicate key principles to others in training.

Markers of excellence would include a profound and detailed understanding of diagnostics and clinical reasoning that can be effectively communicated and a readiness to adapt and develop these skills.

RCEM examinations

MRCEM 
SBA
OSCE
FRCEM
SBA
MSO

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