PAPER 13/PC/43
th
The Theme
The PDM theme is an extremely broad and arguably all pervasive theme in clinical undergraduate teaching, learning and practice. As such it is difficult to dissect out all the areas in which specific teaching, learning or assessment relating to the theme may occur.
There is a degree of overlap between this theme and others, particularly The
Consultation (the “Presentation” element in particular) and with Clinical
Pharmacology and Therapeutics (the “Management” element specifically). The current Theme Head has decided to focus on the Presentation and Diagnosis elements rather than management.
There is limited evidence to support any particular method of teaching that improves diagnostic thinking or reduces subsequent diagnostic error.
Learning outcomes 9g, 14i and 14j are very specific in contrast to the other outcomes within the theme.
Learning Outcomes
See Appendix 1.
Teaching and Learning
No overview of the specific teaching and learning opportunities that relate to this theme across the entire five-year curriculum exists and it would be a significant exercise of debatable value to undertake such a review. It would however be useful to know whether module leads utilize the current PDM LOs to systematically inform teaching or structure or blueprint assessments in their own modules.
The current Theme Head believes that a) consistency in approach to teaching relevant to this theme would be improved if a “core” list of presentations, diseases, investigations and treatments could be compiled and agreed. Students would then have a clear idea of the clinical material that they are expected to demonstrate competence in, and clinical teachers have a consistent framework on which to structure teaching and assessment in their modules.

b) Student understanding of the context and relevance of the theme would be improved if some basic additional lectures that focus on the theoretical aspects of clinical diagnostic thinking were included in the clinical curriculum.
Progress in these areas is outlined below. a) Core Presentations
In 2014, for the first time, a list of “Core Presentations” for the Edinburgh MBChB curriculum was produced. (See Appendix 2). It was difficult to engage all specialties in this exercise and at the time of writing this report feedback from specialties on the approach remains incomplete. The aim of the Core Presentation approach is to summarise the presentations that we expect an Edinburgh medical student to be familiar with by the end of Year 5 and express them in a common and consistent language.
By “familiar” we mean that students should know the a) key features in the history and physical examination that should be sought in any patient with each presentation b) common diseases that might cause each presentation c) typical investigations that might be appropriate in a patient with such a presentation d) typical treatments for each symptom itself (where appropriate) and the for the common diseases that might underlie such a presentation.
It is also hoped that, if widely accepted and adopted, Module Leads could use the list to ensure that key presentations in their specialty were addressed in the teaching provided within their own modules.
Finally an agreed list could be used to inform consistent and coordinated blueprinting of assessment content across Years 3,4 and 5.
If accepted, the method could be extended to create a list of “core” diseases, investigations, and treatments that students would also expected to be familiar with by the end of year 5. The inter-relationship between these is shown in schematic form in Appendix 3. b) Didactic teaching
Year 3 lecture
In February 2013 a single one-hour lecture on the principles of diagnostic thinking was introduced and delivered to the year. This includes information on common statistical expressions of diagnostic value (e.g. sensitivity and specificity) and the basic cognitive processes doctors employ in diagnostic thinking.
Year 4 lecture
In February 2014 a single one-hour lecture was introduced and delivered to the year.
This builds on the material presented in Year 3 and uses examples of misdiagnosis to

develop ideas relating to probability analysis, diagnostic algorithms, Bayesian thinking, and heuristics.
Assessment
No overview of the methods used across the five years of the curriculum to assess diagnostic thinking, clinical reasoning, knowledge of the causes of misdiagnosis, statistical methods used to express diagnostic reliability, or of the ability to apply theoretical knowledge relating to these principles to real clinical situations currently exists.
The Year 5 CPE assesses student’s ability to gather clinical information through history and physical examination and then synthesise that information to generate a diagnostic and initial management approach.
A number of LOs, including PDM LOs, are assessed in the newly modified Year 5
CPE and these are summarized in the table below.
The consultation
Presentation
Diagnosis and
Management
Clinical
Communication
Station 1
Physical
Examination
Yes
Yes
Yes
With Colleagues
EM-CARS
Pharmacology and
Therapeutics
Medical Ethics, Legal and Professional
Responsibilities
No
No
Yes
Station 2
Integrated
Acute Care
Yes
Yes
Station 3
History Taking
Yes
Yes
Total times outcome represented
(assessed)
3 (6)
3 (6)
Yes
With Patients and Colleagues
Yes
Sometimes
Yes
With patients and colleagues
Sometimes
Sometimes
3 (6)
1-2 (2-4)
0-3 (0-4)
Yes Yes 3 (6)
The Year 5 SiPP also assesses the ability to interpret basic clinical and investigative information, synthesise a diagnosis and select appropriate treatment.
In Year 4 the various modular examinations appear to assess a number of the PDM
LOs, and in Year 3 both the OSCE and OSCA exams appear to have a similar role.
It is not clear (to the author of this report) whether the blueprint for any of these examinations specifically includes a requirement to cover these LOS in any structured fashion.

The assessments in which PDM LOs are likely to be assessed are tabulated below.
N PDM LO
14a Interpret and explain individual findings from the history, physical
14b examination, clinical observations and mental state examination, taking account of the patient’s perspective and relevant psychological, spiritual, religious, social and cultural factors.
Collate and interpret the findings from the history, physical examination,
8g and clinical observations to create an initial problem list.
Formulate a differential diagnosis for each of the problems on this list and demonstrate understanding of the causes of diagnostic error and the need to review and revise the differential diagnosis and problem list as further information becomes available.
8c Describe/explain the advantages and disadvantages of different investigative approaches to common clinical presentations and select an appropriate strategy for individual patients
14c Formulate, explain, and negotiate a plan of investigation based upon the clinical findings and best evidence, with the patient’s full understanding and informed consent, and respecting each patient’s right to refuse investigation.
14d List the common causes of abnormal investigations, appreciate the significance of abnormal or normal investigations in the context of core clinical presentations, and recognise common patterns of abnormality in core investigations.
14e Synthesise the information derived from investigations with that derived from the clinical assessment to create a refined problem list and differential diagnosis for each active problem and demonstrate understanding of the causes of diagnostic error.
14f Collate all available clinical evidence in a manner that can be coherently shared with clinical colleagues, and that permits the graduate, either alone or in consultation with seniors, to take clinical decisions, even in situations of uncertainty.
8e Select appropriate methods to treat or prevent common diseases, symptom complexes or presentations demonstrating an understanding of the scientific basis and evidence base for their use.
14g Formulate, explain, and negotiate a plan of management - including discharge from care when appropriate - based upon the clinical findings, results of investigation and best evidence, with the patient’s full understanding and informed consent, and respecting each patient’s right to refuse some or all treatments.
9g Select appropriate methods to treat or prevent dependence or other presentations of self-harm, and demonstrate an understanding of the scientific basis and evidence base for their use.
Where assessed for summative purposes
CPE
Year 3 OSCE
?Module Exams
Portfolio Cases
CPE
Year 3 OSCE
?Module Exams
Portfolio Cases
CPE
Year 3 OSCE
Module Exams
Portfolio Cases
CPE
Year 3 OSCE
Module Exams
Portfolio Cases
CPE
Year 3 OSCE
Year 3 OSCA
Module Exams
SiPP
Portfolio Cases
CPE
?Year 3 OSCA
Module Exams
SiPP
Portfolio Cases
Portfolio Cases
CPE
Year 3 OSCA
Module Exams
SiPP
SPA
Portfolio Cases
CPE
Module Exams
Portfolio Cases
SiPP
Portfolio Cases

14i Describe and recognise common presentations that may suggest abuse of children or vulnerable adults and describe the actions that must be taken to safeguard their welfare.
14j Describe/explain and recognise the common problems that occur for patients and their families at the end of life, select appropriate methods to treat or prevent common symptom complexes demonstrating an understanding of the scientific basis and evidence base for their use, and the legal framework of the management of death.
Portfolio Cases
Portfolio Cases
Of the “generic” PDM LOs ( as opposed to the specific LOs 9g, 14i, 14j) assessment is arguably the weakest for 14f, in that no summative assessment appears to be made of a student’s ability to create a written record from a consultation. Their unwritten collation of the findings from history and examination and subsequent presentation to examiners in the CPE may be felt to address this issue.
The central position in patient care and patient safety that these LOs appear to occupy should suggest that they are rigorously and intensely assessed. Although at face value the assessment of the PDM LOs appears reasonable in the table above, it is likely that some aspects of each LO are assessed in more depth than others ( for example knowledge of differential diagnosis, which is relatively easily assessed in a
KBA format, is more likely to be assessed in detail than the ability to communicate or negotiate a management plan.)
The relatively short duration of the year 5 CPE, which inevitably limits the content and range of assessment undertaken, may be seen as one modifiable factor that currently limits more intense or in-depth summative assessment of these LOS.
Furthermore the fact that the year 5 CPE does not include all clinical disciplines raises the possibility that the method and intensity of assessment of these LOs are inconsistent between the CPE and modular examinations outlined above.
Other issues
The PDM Theme currently has a module lead but no other support. In the next year an effort will be made to recruit clinical teachers with an interesting in developing the didactic programme, the core presentations ideas and/or other teaching methods to improve students clinical reasoning and diagnostic thinking.
Andrew Elder
May 2014.