Structured teaching and assessment

Evidence and best practice

Chart-stimulated recall has been used with practising professionals in medicine and allied health fields as a valid and reliable tool to identify strengths and weaknesses in clinical practice.2 The reliability and validity of CSR has been established in family medicine and other specialties, physical therapy, and occupational therapy.2–5 Given the success of using CSR to assess practising physicians and allied health professionals, the Accreditation Council for Graduate Medical Education has recommended that CSR be included in residency evaluation as well.6

The greatest advantage of CSR as an assessment tool is the immediacy of feedback. Learners (especially senior residents) are often being taught about events post encounter. Giving immediate, relevant, and meaningful feedback to residents about a specific, defined patient encounter results in deeper learning and enhanced understanding of the competencies being evaluated.7

Applying CSR tools to resident education for assessment for learning is a logical step. However, existing CSR tools are not created to teach or assess patient-centred care, nor do they integrate CanMEDS–family medicine (CanMEDS-FM) competencies.8 Redesigning a CSR tool to allow for assessment in these areas meets 3 needs: it makes CSR more appropriate for resident education; it establishes a tool to assess competencies that can be hard to document; and it aligns assessment with the competency-based focus suggested by both the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada.

We have adapted the Chart Audit Field Note and CSR Worksheet originally developed by the Physician Achievement Review program of the College of Physicians and Surgeons of Alberta,9 creating a worksheet with a learner focus (available on CFPlus*). Discussion questions are listed and are grouped by CanMEDS-FM roles. Our new CSR worksheet acts as both a structured teaching tool and as an assessment for learning tool. Preceptors have found this form to be an excellent resource to use during scheduled teaching sessions and a useful way to structure feedback for learners.

The questions on our CSR worksheet were developed from a patient-centred care perspective and with CanMEDS-FM roles in mind, helping to model and teach patient-centred care within the CanMEDS-FM competencies framework. An initial draft of this CSR worksheet was presented at faculty development workshops and was well received by generalist and specialist teachers alike. The original CSR worksheet, instructional video, and case example of CSR in action are available on the educational website www.practicalprof.ab.ca.

In using the CSR worksheet in our own teaching, we have found that it is useful for all levels of learners. Chart-stimulated recall is an especially helpful tool with which to challenge advanced learners. These learners are functioning at a high level and they often do not get useful feedback or receive much structured ambulatory teaching. The discussion questions in the CSR worksheet allow teachers to really challenge these learners. For residents experiencing difficulty, the CSR worksheet can expose knowledge gaps, evaluate clinical reasoning skills, and identify problems in reaching common ground with patients. In particular, the CSR worksheet is helpful with early closers—those who are overly confident, but do not have the expert knowledge base or pattern recognition skills of more seasoned physicians. These residents will often decide on a diagnosis before acquiring additional supporting evidence, then go down a path focusing only on the parts that fit. Learners who compare and contrast possibilities, despite any early suspicions, and take into account the patients’ ideas and expectations are less likely to be early closers, and will be better at hypothesis generation. As a result, these individuals will reach common ground with their patients more effectively, in terms of both identification and management of the problem.

Using the CSR tool

In keeping with best practices for feedback and learning,1,7 our CSR worksheet is structured in the following way:

• The learner is prepared for the exercise. The teacher informs the learner that a chart will be reviewed and the patient encounter will be discussed.

• The learner is told that this will be a teaching session and that the learner will receive feedback on the chart note and case review.

• A chart note (electronic or handwritten) is selected for review.

• Together, the teacher and the learner go over the chart note. Initial feedback is given based on the chart note itself and written in “Box A” on the form.

• Relevant discussion questions are selected from the list provided on the worksheet to help guide the discussion toward CanMEDS-FM roles and patient-centred care.

• Feedback on the case discussion is written in “Box B” on the form.

• The written feedback is given to the learner, and the CSR is added to their portfolio, learning file, or workbook.

Conclusion

The CSR worksheet can be adapted to your program or used to suit your personal needs. This family medicine–based form focuses on comprehensive, patient-centered care. The CSR form and video on the Practical Prof website can be helpful for faculty development sessions as a new teaching tool. Further study is being done on the usefulness of this tool as a part of a competency-based system and for use with residents experiencing difficulties.