Welcome to season 3, episode 7 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, John Eicken, and Teresa Chan) is pleased to welcome you to our online community of practice where we discuss difficult medical education cases each month. As usual, the community discussion will be reviewed using qualitative research methods to produce a curated summary that will be combined with two expert responses to create a functional teaching resource.

This month’s case dives into the truth omitting or fibbing resident. Why do some learners lie and how should staff respond?

[su_spoiler title=”MEdIC Series: The Concept” style=”fancy” icon=”caret”] Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan ( @TChanMD ) and Dr. Brent Thoma ( @Brent_Thoma ), theputs difficult medical education cases under a microscope. On thewe pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. guidelines ) and help the rest of us bring our teaching to the next level.[/su_spoiler]

by Dr. Teresa Chan

Caroline was struggling with one of her residents. As an assistant professor, her job included reviewing daily shift encounter cards for all of the off-service residents. Brian was an off-service resident who had been very keen to learn. He had, however, demonstrated significant knowledge deficits and multiple preceptors had expressed concern that he was not performing on par with his cohort. Caroline had met with Brian a few weeks ago to discuss her concerns, and they had created a tentative plan for remediation.

Fortunately, since their discussion Brian was reading more regularly, his attendance at teaching rounds was perfect, and his feedback from attendings was improving. However, Caroline still had the impression that there was something ‘off’.

“Dr. Caroline?” Brian approached Caroline timidly.

“Yep. Gimme a second...” Caroline said as she intently stared at her computer screen and waved Brian to sit down. She was typing down some final notes on the resuscitation they had just managed.

“No problem,” replied Brian, taking a seat.

“I just wanted to present the patient with chest pain that we were chatting about when the patient in cardiac arrest came in. He’s been waiting a long time, and he’s getting agitated.”

Caroline saved her progress on the note, and turned her attention to Brian. “Okay, tell me about your patient.”

Brian began telling her the story of Gerry. Gerry was a 56-year-old gentleman who had come in with retrosternal chest pain that had resolved a few hours ago. Brian explained that he had no cardiac risk factors, no personal history of coronary artery disease, and was a thin, fit-looking guy. His physical exam had been “non-contributory”.

“Has he ever used cocaine or other drugs?” probed Caroline.

“Ummm…no…no. I don’t believe so?” stuttered Brian.

“You don’t believe so? Did you ask him?”

“Well, no, I didn’t ask him… not directly… I kinda asked him about his social habits –you know smoking, drinking, cannabis– so I’m certain that if he had a problem with drugs he would have told me, right? Plus he looks like a pretty clean-cut guy. He is a banker after all…”

Caroline suppressed a sigh. She had repeatedly impressed upon Brian the importance of explicitly asking about social habits, including recreational drugs. “Alright, well, we can ask again when we see him together. Tell me, Brian, what’s your differential for Gerry’s chest pain?” she pushed.

“Well, my differential is the typical things: ACS, PE, pneumonia, aortic dissection.”

“When you examined Gerry, did you find a pulse differential?”

“Um…. no?”

“You don’t sound sure, Brian.”

“No.”

“Did you do bilateral blood pressures on him?”

“Well, no…”

“Did you ask if the chest pain was maximal at onset, radiating to the back, or ripping and tearing in quality?”

“I asked him how bad the pain was and he said it was really severe so I think it was maximal at onset.”

“If you did not perform a thorough physical exam or ask important questions about the type of chest pain he was experiencing then how do you know aortic dissection is part of your differential?” Caroline’s frustration was starting to show. She took a deep breath.

“What about risk stratification for the other items in your differential?”

“What do you mean?”

“What’s his risk of PE? ACS? You remember all the decision rule scores that we’ve talked about, like the HEART score for ACS or the Well’s score for PE?”

“Well, he is PERC negative so I didn’t do the Well’s score.”

“But he’s over 50 years of age, right? So he isn’t PERC negative.”

“Oh. Yeah. Sorry. So, I guess his Well’s score is 0.”

“You guess? Did you calculate it?”

Caroline was exasperated. She and Brian had discussed the PE and ACS risk stratification rules in depth during their most recent shift together. She had also suggested multiple resources for him to review and had emphasized the importance of obtaining a detailed history.

Brian seemed to still be deciding how he should answer Caroline’s question.

“I don’t want you to lie to me” Caroline prompted, trying to remain calm.

“Um…I’m not really lying; I just haven’t done the calculation…”

“Then that is what you should say rather than guessing. Maybe you should stop for a moment, and think before your present a case” Caroline said with a note of anger creeping into her voice. Seeing Brian’s defeated expression, Caroline immediately regretted her harsh words. Forcing a smile, she suggested he go back and try to clarify the history.

“Okay…” Brian mumbled, walking back towards Gerry’s room.