Table 2.
Qualitative Analysis of Themes Addressed by > 50% of Residents: Frequencies, Quotes, and ACGME Core Competencies
| Theme | No. (%) of Residents Who Referenced Theme in Scenario (n = 13) | No. (%) of Clinical Scenarios Referencing Theme (n = 129) | Examples From Patient Logs | ACGME Core Competencies Addressed |
| Limited resources necessitating variation in approach to treatment or diagnosis | 13 (100) | 32 (25) | see Table 3 | PC, MK, SBP, PBLI, PROF, ICS |
| Dealing with diagnostic ambiguity | 11 (85) | 38 (29) | • “Our presumptive diagnosis was bacterial pyomyositis . . . although we had no way to make microbiologic confirmation.” • “6-year-old female with unknown cause of worsening neurologic status and eventual decerebrate posturing.” • “8-year-old male with remote history of malaria, admitted with substantial weakness, dehydration, ecchymotic eyes, anuria, and hypertension. Required dialysis. Never found a clear diagnosis. Became comatose, though later started to be awake and alert. Later died of unknown causes (anemia, infection?).” | PC, MK, SBP, PBLI |
| Relying on physical examination to make diagnosis clinically | 11 (85) | 23 (18) | • “There was a baby with multiple congenital anomalies including cleft lip and palate, cutis aplasia, microcephaly, hyper-telorism, low set ears, polydactyly, and limb anomalies all consistent with Trisomy 13.” • “I found myself struggling to want to make the clinical diagnosis of pneumonia without radiologic proof.” | PC, MK |
| Encountering severe presentation of common diseases | 11 (85) | 31 (24) | • “18 yo male with history of congenital heart disease (presumed TOF) with palliative PA banding at age 4, since lost to follow-up, now with 1 week RUQ tenderness and 2 months of progressive dyspnea on exertion. Exam with marked clubbing, acrocyanosis, sats 8% on room air, tender hepatomegaly, JVD, scleral icterus. Progressing to Eisenmenger's physiology. Echo with large bidirectional VSD. PA gradient 75, RV pressure 95mmHg).” | MK, SBP, PBLI |
| Seeing diseases which are rare everywhere | 9 (69) | 27 (21) | • “9 yo female with bloody ascites of unknown etiology.” • “I made a home visit for a family that was concerned about their child's right arm paralysis . . . I deduced that the patient had a ‘serious infection' when younger and most likely developed paralytic poliomyelitis.” | MK, SBP, PBLI |
| Seeing diseases common in elective setting, but rare in United States | 9 (69) | 24 (19) | • “I have never diagnosed [chicken pox] because of the vaccine in the US.” • “. . . ultimately determined to have typhoid fever after several days in the hospital.” | MK, SBP, PBLI |
| Dealing with death | 9 (69) | 19 (15) | • “The most significant pause I've had [involves] the young man who I worried had DKA. I never even wrote down his name . . . none of the labs had been done and the overnight resident had coded him without calling us. He died. I was rushed. I should have followed up on the labs more closely . . . I wish I had spent longer thinking about him.” • “14-year-old male suffocation . . . [he] was sent on an errand in the evening and did not return. He was found with sand in his ears, nose and mouth . . . This patient has stuck with me on a daily basis.” | SBP, PROF, ICS |
| Addressing differences in economic and political determinants | 8 (62) | 17 (13) | • “Less clinical but just as impactful—meeting several families that have needed to travel abroad for several stages of chemotherapy [treatment], and learning about the psychosocial stresses from living abroad away from the rest of the family and the financial burden of traveling.” • “The interesting part of these patients [were] the discussions about when and how to continue, or become more aggressive with treatment, taking into account the individual patient's familial, psychosocial, and economic considerations.” • “The most impactful cases were those that involved navigating the geopolitical, psychosocial, and economic issues that were barriers to our patient's ability to access health care.” | SBP, PROF, ICS |
| Relishing in a “clinical win” with a positive outcome | 7 (54) | 16 (12) | • “I was able to see her in the malnutrition clinic a couple of weeks after discharge and found her to be greatly improved.” • [The baby] “developed bilious emesis and I helped diagnosis her with an annular pancreas. She had a surgical repair and did incredibly well.” • “8-year-old female admitted with altered mental status, vomiting, and seizures after presumed environmental ingestion. She was intubated, lungs were suctioned, and she walked out of the hospital 3 days later.” • “13-year-old with Guillain-Barré syndrome . . . There are only 4 ICU beds for the whole hospital . . . so it takes a patient that has a good outcome and some convincing to get a peds patient in. Luckily he was taken, had a tracheostomy placed, and after 2 weeks was decannulated. Every day he would talk about ‘basking in the sun' and show us what muscles were getting stronger. Anytime I was having a hard moment, I would chat with him.” | PC, SBP |
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; PC, patient care; MK, medical knowledge; SBP, systems-based practice; PBLI, practice-based learning and improvement; PROF, professionalism; ICS, interpersonal and communication skills.