Situation Awareness in Clinical Practice.

This tool devised by Margaret Frere, John Tepper, Markus Fischer, Kieran Kennedy, Thomas Kropmans Medical Informatics and Medical Education, School of Medicine, National University of Ireland, Galway, Ireland, is being used to assess situational awareness in clinical practice and in the OSCE stations in examinations. Situational awareness is sadly missing among the candidates who appear in the FCPS 2 in Medicine. I am sure it is also missing in other subjects. The reason it is missing is because the trainee doctors still think of history taking as a stilted magic formula based on certain set questions to which the candidate must have answers or they will fail. It appears totally irrelevant that those questions do not help in reaching a clinically sensible diagnosis. All the experienced examiners ask questions which does assess this situation awareness even if they do not call it “situation awareness”. Most of us call it a sensible or relevant or focused history taking and physical examination, synthesis of diagnosis and making a plan for the treatment and follow-up. Now remember the world of Medical Education is talking about situational awareness.  Lack of situation awareness (SA) is an important factor leading to poor clinical decision‑making and medical errors. Improving SA through training and testing in simulation could potentially reduce errors, and ultimately lead to fewer deaths

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What is situational awareness? It is knowing what is going on in a clinical situation or what is causing the problem. What is this situational awareness tool?

  • Level one. Perception. This has the following components: history taking, physical examination, diagnostic results and information gathering. (Most FCPS 2 candidates do not manage to go beyond this portion, hence can only be assessed for this portion. As they have not done or been assessed for the rest of the examination information it is not surprising that they fail. I have seen a candidate sit down, take out paper and pen and proceed to ask questions for 20 minutes. I had to remind him that he still needed to do the physical examination. The next candidate took a history for 25 minutes and when he was given the reminder that there were only five more minutes looked very surprised and angry as well).
  • Level 2. Comprehension. This has the following components: reasoning, sense making, pattern recognition, information interpretation, detecting an abnormality and making a diagnosis. This is the portion the examiner starts asking questions about. This is when the candidates are unpleasantly surprised because they have not been thinking about  the information they have gathered, certainly they have applied no logic to it. I will give you examples later.
  • Level 3. Projection. The components are: devising a treatment plan, seek further information, generate further investigations, project on to future plans.  The treatment our candidates make a very skimpy plan like for hypertension they will say I will give ACE-I, beta blockers or a diuretic.  Which ACE-I, how much, when will I increase the dosage or add another drug. Why was the choice made? What if another drug was used? What side effects will you look for?

What are perception, comprehension and projection? 

Perception involves recognizing cues relevant to the environment situation, comprehension requires integrating cues from Level 1, and projection involves extrapolating information from Level 1 and 2 and analyzing how this information may impact future events. A high degree of SA is crucial for health‑care students who will be required to make decisions in complex, unpredictable, and demanding situations. 

Let me explain with examples. In a patient who has clinical anemia or gives symptoms of tiredness and fatigability inability to cope with work that they were accustomed to do and you find an enlarged spleen the clues to look for in the history are any reason for the anemia, associated jaundice, possible weight loss (a clue that most students miss), evidence of GI hemorrhage or bleeding tendency and accompanying signs of hyperactivity of other organs associated with reticuloendothelial system like lymph node enlargement or hepatomegaly, or signs of chronic liver disease. This also becomes part of pattern recognition. You do not have to ask for diarrhoea, constipation, cough, sputum production, headaches or fits and you do not need to look for clubbing, Osler’s nodes, cyanosis, signs of heart failure or neuropathy. You are expected to do a full GPE and systemic examination because you may pick up a clue that will set you off in another direction but the likelihood becomes less probable. In an examination which has time limitation it is better to pick up the positive findings even if you do not have time for everything. For example in a case of Parkinson’s if you do not have time to examine the liver and spleen or look for shifting dulness you are unlikely to fail but if you have not done a thorough neurological examination including gait and cerebellar signs and cranial nerves (remember occulomotor crisis and multisystem disorder) you will fail. Similarly in SLE or dermatomyositis and myositis examine the skin and joints first, because it will be unforgivable if you have missed involvement of the joints or skin or motor system, in psoriasis again examine the nails, scalp, joints carefully. When you are studying write down the list of questions you need to ask for each disease or major symptom then you will not have to rack your brains (with the examiners watching) about what to ask next. The most “prevalent” way of failing the exam is to repeat questions or to waste time saying things like (Okay then tell me if or acha to phir yay butaiy ke phir kia hua). Ask direct relevant questions.

Comprehension. This means to understand why the patient has complaints or certain signs and to put them together to know what abnormality exists or what disease is manifesting itself. It is not enough to say that the patient is breathless on exertion. You have taken the full history and examined the patient by now you should know why the patient is short of breath, ( please do not write the abbreviation of this as S.O.B because in the English idiom this means “son of a bitch” so again please avoid this otherwise your good information will be lost in the translation into offensive language), you got a history of exertional central chest pain suggestive of angina pectoris, there is occasional pedal edema; he is tired and wakes up breathless during sleep; he wakes up to pass urine at night; there are risk factors like smoking, obesity, hypertension and a positive family history so the patient has ischemic heart disease and should be investigated and treated along those lines. You have comprehended the reason for the breathlessness you do not need to discuss all the causes of breathlessness. Choose to guide the discussion towards IHD, its severity, how to confirm this, what treatment to give; medical versus cutaneous intervention versus open heart surgery. The examiner will only ask you about cardiomyopathy or pericardial effusion only if you appear confused or have done so well he wants to give you extra marks. If you have read up recent research trials mention those and discuss the controversies and complications in the treatment of this disease. Discuss cardiac transplant and 3D printing of internal organs. We very rarely reach this level of discussion, the candidate is stuck in the causes of breathlessness and is very unlikely to pass. So comprehension is understanding the pathology or disease which is causing the symptoms and the signs, which disease they are pointing to, what specific questions to ask and how to present this case.

Projection. Once you have taken a relevent history (perception) and examined the patient and found signs on which to base the diagnosis (perception) and you have made the diagnosis or a very short list of D/D and have presented the case (comprehension) then go on to project what you will do next. In some cases it is necessary to start treatment at once (e.g bronchial asthma, renal colic, severe dehydration, pneumonia, GI hemorrhage etc) so mention this, and then say I will do these tests after relieving the patient’s discomfort. In other situations it is necessary to  investigate, establish a diagnosis first because the D/D may be 2 diseases which are treated very differently or the treatment is dangerous like chemotherapy or surgery and you must have a definite diagnosis before you can commit the patient to a course of treatment which itself could prove fatal.

When you are preparing for the FCPS 2 exam concentrate on a group of symptoms or clinical findings which are likely to occur together like PUO with splenomegaly or joint pains with photosensitivity. Learn to recognise patterns.  Read the D/D of this pattern. Make a list of the questions to ask for each group of symptoms rather than individual symptoms so “tell me what brought you to the hospital and all the problems that had occurred before or after this symptom” Once the patient has given you all the information he thinks is relevant, ask leading questions to clarify the pattern of disease. Do the clinical examination knowing what it is you are looking for. Present your case with knowledge not wondering what the examiner is going to come up with. The examiner is limited by the information you give as they will examine you according to the current case. It is rare that you will be asked questions not pertaining to your case and then only if you are doing very well and the examiner wants to give you a chance to show off your knowledge in order to give you extra marks (believe me with good candidates this happens) or you are doing so poorly that the examiner changes the subject hoping that you get more than the 2 mandatory marks that are the minimum everyone gets.

Please remember that you are being assessed for your communication skills in taking the relevant history and picking up the positive and important negative findings (like the patient has anemia but no jaundice; the patient has enlarged lymph nodes but no splenomegaly; the patient has a tremor but no muscle stiffness or rigidity. A negative finding is only significant if you expected to find it and it is not there so the diagnosis changes). This is clinical pattern recognition. You then interpret the information showing that you know what is happening and why. You recognise the abnormality i.e. the BP is raised, the optic fundus shows grade 2 changes so the disease has been there for sometime and has already done damage to the vasculature; your ability to recognise or diagnose the disease. It is  your understanding of the disease or comprehension which is being assessed i.e. if the spleen is enlarged a. Is it recent or long-standing (soft or hard?)  b. Is it part of an infective process or a hemolytic process (accompanied by anemia and jaundice) or are the lymph nodes and liver enlarged or are there signs of chronic liver disease? c. Is the enlarged spleen causing any abnormality like portal hypertension or hypersplenism? All the candidates in the exam just say that the spleen is enlarged so many centimeters. No further information!!! No further marks. Next you are assessed for you ability to project this information into relevant investigations required, immediate treatment, further investigations, change in treatment based on these investigation, long-term follow-up and prognosis. Please remember there are no investigations called the “routine” investigations. The commonly done investigations are always done for a reason so if you are doing a CBC it is to look for anemia, a low platelet count or raised TLC or something like that. Please mention it. Also remember that the treatment means the generic name of the drug, dosage and duration along with the side effects to watch out for; alternate therapy with its benefits and side effects. Mention recent advances and research. Most candidates are very poor in answering this section.

Please prepare yourself according to the guide lines I have given you. I will write again on this subject.

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I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

One thought on “Situation Awareness in Clinical Practice.”

  1. I am really thankful to you madam God bless you, have a long life so that we can get benefit from your knowledge


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