The Rip Out on approaches to reduce diagnostic error in this issue of the Journal of Graduate Medical Education offers practical strategies for defining, teaching, and assessing critical thinking.1 Valuable by itself, this approach can be applied in greater detail to inform curricula, teaching strategies, and resident assessment, using a crosswalk between curricular Milestones2 and the Trowbridge3 12 concepts to avoid errors in clinical reasoning.
The detailed curricular Milestones developed by the internal medicine community in 2009 are not the reportable components of the Next Accreditation System currently being implemented by the Accreditation Council for Graduate Medical Education. They represent a very detailed framework of the attainment of competence and can be used to inform curricula and approaches to resident evaluation. Mapping the Trowbridge concepts against the Curricular Milestones identifies at least 28 milestones that capture the knowledge, skills, or attitudes relevant to teaching and assessing critical reasoning (box). Given the relevance of critical reasoning and avoiding diagnostic errors to the range of clinical specialties, the applicability of these concepts goes far beyond internal medicine.
The added detail provides a framework that identifies granular examples of specific knowledge, skills, and attitudes or behaviors for use in curriculum development and resident assessment. The concepts at the intersection of the Trowbridge more general concepts and the curricular milestones lend themselves to (1) the design of teaching vignettes, (2) drawing attention to particular aspects of these 28 milestones in discussions about the care of patients to avoid diagnostic errors, and (3) using these milestones to inform resident formative assessment, with the added benefit of enhancing the utility and richness of feedback to residents.
In summation, the detailed milestones related to critical thinking can serve as the foundation for a more detailed curriculum for critical thinking, as well as provide formative feedback to learners as they develop competence in this vitally important clinical skill.
Copyright: Accreditation Council for Graduate Medical Education 2013
Author Notes
William F. Iobst, MD, is Vice President of Academic Affairs at American Board of Internal Medicine; Robert Trowbridge, MD, is Director of Undergraduate Medical Education at the Maine Medical Center; and Ingrid Philibert, PhD, MBA, is Senior Vice President of Field Activities at the Accreditation Council for Graduate Medical Education.
Corresponding author: William F. Iobst, MD, American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106, wiobst@abim.org
