Table 3.

Sample Strategies for Resident Clinical Teachers to Promote DR Teaching During Conversations on Inpatient Rounds

Component	Learner	Resident’s response
Problem representation	“This is a 45-year-old man living with HIV/AIDS (CD4 = 20) who presents with 4 weeks of escalating headaches and neck stiffness, found to have a lymphocytic pleocytosis, increased CSF protein, and low glucose on his LP.”	“Awesome summary! To push you a bit, how could you synthesize his symptoms and CSF parameters more concisely?” Instructional aim: Prompt learner to distill the patient’s symptoms to “chronic meningitis.”
Reasoning-focused assessment and plan	“I think the most likely causes of his headache is tuberculous meningitis. Another possible cause is S. pneumoniae, though this is less likely. I want to follow up the cultures and start rifampin, isoniazid, pyrazinamide, and ethambutol.”	“You’re absolutely right that TB can cause a chronic meningitis. My illness script for S. pneumoniae meningitis is an acute, rather than chronic, meningitis. I would suggest replacing pneumococcus with fungal pathogens, like Cryptococcus, on your chronic meningitis schema; Let’s add to his CSF a cryptococcal antigen, to test for Cryptococcus, and a Mycobacterium tuberculosis (TB) polymerase chain reaction, to test for TB. We can decide on treatment once these tests return.” Instructional aim: Refine illness scripts, expand diagnostic schemas, and anchor testing decisions to both
Day of discharge reflection	“Ok, for Mr. Smith, our patient with HIV-associated cryptococcal meningitis, is ready to discharge today. He’s going to SNF on fluconazole and will be leaving at 2 pm.”	Great! Let’s reflect on the diagnostic journey we experienced with Mr. Smith. What’s one thing you’ve learned that you’ll bring to the next time you see a patient with HIV and headaches? We can also think about how our conversations with his outpatient care team supported our clinical decisions Instructional aim: Prompt reflection on both content and context

Component

Learner

Resident’s response

Problem representation

“This is a 45-year-old man living with HIV/AIDS (CD4 = 20) who presents with 4 weeks of escalating headaches and neck stiffness, found to have a lymphocytic pleocytosis, increased CSF protein, and low glucose on his LP.”

“Awesome summary! To push you a bit, how could you synthesize his symptoms and CSF parameters more concisely?”

Instructional aim: Prompt learner to distill the patient’s symptoms to “chronic meningitis.”

Reasoning-focused assessment and plan

“I think the most likely causes of his headache is tuberculous meningitis. Another possible cause is S. pneumoniae, though this is less likely. I want to follow up the cultures and start rifampin, isoniazid, pyrazinamide, and ethambutol.”

“You’re absolutely right that TB can cause a chronic meningitis. My illness script for S. pneumoniae meningitis is an acute, rather than chronic, meningitis. I would suggest replacing pneumococcus with fungal pathogens, like Cryptococcus, on your chronic meningitis schema; Let’s add to his CSF a cryptococcal antigen, to test for Cryptococcus, and a Mycobacterium tuberculosis (TB) polymerase chain reaction, to test for TB. We can decide on treatment once these tests return.”

Instructional aim: Refine illness scripts, expand diagnostic schemas, and anchor testing decisions to both

Day of discharge reflection

“Ok, for Mr. Smith, our patient with HIV-associated cryptococcal meningitis, is ready to discharge today. He’s going to SNF on fluconazole and will be leaving at 2 pm.”

Great! Let’s reflect on the diagnostic journey we experienced with Mr. Smith. What’s one thing you’ve learned that you’ll bring to the next time you see a patient with HIV and headaches? We can also think about how our conversations with his outpatient care team supported our clinical decisions

Instructional aim: Prompt reflection on both content and context