Summary Statement Feedback

iInTIME has introduced a new feature allowing instructors to review student summary statements and provide them with formative feedback. Identifying, interpreting, and summarizing the key findings in a case is a fundamental clinical skill. This feature will be a valuable formative assessment tool that clerkship directors can use to gauge the student's clinical reasoning thought process.

Teaching clinical reasoning is an important goal of MedU virtual patient cases. One component of the current Diagnostic Network approach to teaching clinical reasoning is the summary statement. Most MedU cases ask the student to write a summary statement after the history and physical exam components. Currently, there is no way for the clerkship director or other faculty to see these responses or to provide feedback to students on this important component of a virtual patient case.  Integrating this feedback mechanism in the clerkship will allow you to give students the input they need to improve their clinical reasoning.

What is a summary statement?

A summary statement is a concise statement that highlights the most pertinent features in a case without omitting any significant points, and should contain the following three key components: the patient’s epidemiology, the temporal pattern, and a syndrome statement.

Why is the summary statement important?

Research shows that physicians who are able to provide a semantically rich summarization of a case are much more accurate in making a clinical diagnosis.

What are some important terms I should understand in thinking about clinical reasoning and summary statements?

  • Problem representation - a brief description of the patient’s illness in abstract terms, which may be used by the physician to compare with their illness script.
  • Illness script – the way clinicians store knowledge of illnesses, diseases and syndromes. An illness script is typically structured as predisposing conditions, pathophysiologic insult and clinical consequences. (An illness script is an individual clinician’s mental representation of an illness, and may vary.)
  • Semantic qualifier – paired, often opposing descriptors that can be used to compare and contrast diagnostic possibilities.

What constitutes a “good" summary statement?

  • A summary statement should be a concise statement that highlights the most pertinent features in a case without omitting any significant points
  • The summary statement should primarily be a problem representation, a brief description of the patient’s illness, which may be used by the physician to compare with their illness script.
  • The ideal summary statement provides the basis for developing a narrow differential diagnosis.
  • The summary statement should transform specific details into medical terms.
  • Summary statements should include semantic qualifiers - paired, opposing descriptors that can be used to compare and contrast diagnostic possibilities.


Sample Summary Statements

Good
This is a 28-year-old African American female with a prior history of diabetes who presents with acute onset of nausea, vomiting, diarrhea and blurred vision. On examination she appears severely dehydrated and is hypotensive, and laboratory evaluation reveals marked hyperglycemia, urinary ketones and an anion gap.

This summary statement presents patient epidemiology (28-year-old African American female with a prior history of diabetes), temporal pattern (acute onset), and a syndrome statement (the remainder of the findings that are listed). Medical terms are used to transform specific findings (hypotensive and dehydration), and semantic qualifiers are used (acute, severely, marked) to describe findings. After reading this summary statement, it would be easy to generate a narrow differential diagnosis.

Poor
Ms. Williams is a 28-year-old female who presents to the ED today with a chief complaint of 'dizziness'.  Three days ago, while at the beach with her family, she experienced diarrhea with no identifiable cause that resolved on its own.  Over the next 2 days, she had several episodes of vomiting, as well as increased thirst and frequent urination.  Today Ms. Williams was dizzy, especially upon standing and feels fatigued.  She also c/o blurry vision.  She denies fever or chills. Her vitals are BP 90/60, pulse 110, respiratory rate 18, pulse ox 98%.  She is an obese African American woman with a BMI of 35.  Her physical exam is remarkable for delayed capillary refill, dry mucous membranes, and acanthosis nigricans at the back of the neck.  Pertinent negatives include RRR of the heart with normal S1/S2, Lungs clear to auscultation bilaterally, and the absence of flank pain.

This summary statement, while accurate and thorough, includes a large number of facts, including many non-pertinent findings. Specific findings (e.g. detailed vital signs) are not transformed to create an abstract representation, and there is no use of sematic qualifiers. From reading this summary statement, it would be difficult to generate a narrow differential diagnosis.