A 72-year-old woman with a history of poorly controlled diabetes, coronary artery disease, and hypertension presents to the emergency department complaining of nausea and vomiting. As an emergency department resident, you elicit the history that the patient felt well until 24 hours ago, when she developed anorexia followed rapidly by bilious emesis. She describes mild upper abdominal discomfort but is unable to further localize the pain and reports no abnormal bowel movements, gastrointestinal bleeding, or chest pain.The patient is febrile (39°C) and appears uncomfortable. Her lungs are clear and cardiac examination reveals only a fourth heart sound. There is moderate epigastric tenderness and guarding throughout the abdomen but no rigidity. Pelvic and rectal examination results are unremarkable. Electrocardiography shows no changes suggestive of ischemia. Laboratory testing shows a leukocytosis of 17 500 ×10 3 /µL, serum transaminase levels twice the upper limit of normal, and a total bilirubin level of 3.2 mg/dL (54.7 µmol/L). In considering the differential diagnosis for the patient's presenting complaint and laboratory results, you wonder whether the suspicion of acute cholecystitis is high enough to warrant further testing. Why Is This Question Important?Acute cholecystitis accounts for 3% to 9% of hospital admissions for acute abdominal pain. [1][2][3][4] The majority of patients presenting with upper abdominal complaints are subsequently found to have a relatively benign cause of pain (eg, dys-Author Affiliations are listed at the end of this article.

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Feedback is considered an important means of improving learner performance, as evidenced by the number of articles outlining recommendations for feedback approaches. The literature on feedback for learners in medical education is broad, fairly recent, and generally describes new or altered curricular approaches that involve feedback for learners. High-quality, evidence-based recommendations for feedback are lacking. In addition to highlighting calls to reassess the concepts and complex nature of feedback interactions, the authors identify several areas that require further investigation.

No CT variables predicted severe in-hospital morbidity and mortality (death from pulmonary embolism, death from any cause, or cardiac arrest) in patients with PE. However, ventricular septal bowing and increased RV/LV diameter ratio were both strongly predictive of less severe morbidity, namely, subsequent ICU admission, and oligemia was associated with subsequent intubation and vasopressor use.

Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.

Clinical educators may help learners avoid diagnostic errors by employing several of the educational techniques described herein.

Background Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. Objectives To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians’ tolerance of medical uncertainty. Design Qualitative study using individual in-depth interviews. Participants Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1–3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine–pediatrics), at a single large US teaching hospital. Measurements Semistructured interviews explored participants’ strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. Results Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. Conclusions Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

The prevailing model of graduate medical education has long been one of according the trainee increasing gradations of responsibility over time. 1,2 This process remains widely endorsed 3,4 and, despite a lack of substantial empirical evidence supporting its effectiveness, has a strong theoretical basis. 5 It is clear that the degree and quality of the clinical supervision currently provided is highly variable. 2,6,7 In addition, recent developments have highlighted the need to reconsider the current paradigm of supervision. Evolution of the concept of patient safety, for example, has emphasized the importance of preventing medical errors and the need for close oversight of all medical trainees. 8,9 The 2008 report of an Institute of Medicine committee on resident duty hours strongly endorsed greater supervision of residents stating ''The committee found that closer supervision leads to fewer errors, lower patient mortality, and improved quality of care.'' 10 Finally, there has been increased scrutiny as to the specific form of clinical supervision provided, with the acknowledgment that such oversight may occur on several different levels 11 and that direct supervisory involvement in patient care may be the most critical element of effective clinical supervision. 12A logical response on the part of academic medical centers to these developments is to increase attending physician availability and supervision, including mandating 24-hour in-house coverage. As described previously, the potential benefits of a system of increased attending involvement include the prevention of medical errors, more efficient medical care, and decreased length of stay.10 In addition, increased attending presence could serve to counter the ''hidden curriculum,'' which substantially affects resident perceptions of supervision and may act as a barrier to requesting assistance, even when it is clearly necessary. 13,14Yet there are theoretical risks to such a system. Most important, there is the potential to undermine resident autonomy, 6,15 long thought to be integral to the learning process in graduate medical education and a central component of residency program requirements. AbstractBackground An increased emphasis on patient safety has led to calls for closer supervision of medical trainees.It is unclear what effect an increased degree of faculty presence will have on educational and clinical outcomes. The aim of this study was to evaluate resident and attending attitudes and preferences regarding overnight attending supervision.