Table 1 a and b The original Milestone Patient Care 2 (a) and 3 (b)

a. PC2:Make informed diagnostic and therapeutic decisions that result in optimal clinical judgement

 Recalls and presents clinical facts in the history and physical in the order they were elicited without filtering, reorganization, or synthesis; demonstrates analytic reasoning through basic pathophysiology results in a list of all diagnoses considered rather than the development of working diagnostic considerations, making it difficult to develop a therapeutic plan

Focuses on features of the clinical presentation, making a unifying diagnosis elusive and leading to a continual search for new diagnostic possibilities; largely uses analytic reasoning through basic pathophysiology in diagnostic and therapeutic reasoning; often reorganizes clinical facts in the history and physical examination to help decide on clarifying tests to order rather than to develop and prioritize a differential diagnosis, often resulting in a myriad of tests and therapies and unclear management plans, since there is no unifying diagnosis

Abstracts and reorganizes elicited clinical findings in memory, using semantic qualifiers (such as paired opposites that are used to describe clinical information [e.g., acute and chronic]) to compare and contrast the diagnoses being considered when presenting or discussing a case; shows the emergence of pattern recognition in diagnostic and therapeutic reasoning that often results in a well-synthesized and organized assessment of the focused differential diagnosis and management plan

Reorganizes and stores clinical information (illness and instance scripts) that lead to early directed diagnostic hypothesis testing with subsequent history, physical examination, and tests used to confirm this initial schema; demonstrates well-established pattern recognition that leads to the ability to identify discriminating features between similar patients and to avoid premature closure; Selects therapies that are focused and based on a unifying diagnosis, resulting in an effective and efficient diagnostic work-up and management plan tailored to address the individual patient

Current literature does not distinguish between behaviors of proficient and expert practitioners. Expertise is not an expectation of GME training, as it requires deliberate practice over time

b. PC3: Develop and carry out management plans

 Develops and carries out management plans based on directives from others, either from the health care organization or the supervising physician; is unable to adjust plans based on individual patient differences or preferences; communication about the plan is unidirectional from the practitioner to the patient and family

Develops and carries out management plans based on one’s theoretical knowledge and/or directives from others; can adapt plans to the individual patient, but only within the framework of one’s own theoretical knowledge; is unable to focus on key information, so conclusions are often from arbitrary, poorly prioritized, and time-limited information gathering; develops management plans based on the framework of one’s own assumptions and values

Develops and carries out management plans based on both theoretical knowledge and some experience, especially in managing common problems; follows health care institution directives as a matter of habit and good practice rather than as an externally imposed sanction; is able to more effectively and efficiently focus on key information, but still may be limited by time and convenience; begins to incorporate patients’ assumptions and values into plans through more bidirectional communication

Develops and carries out management plans based most often on experience; effectively and efficiently focuses on key information to arrive at a plan; incorporates patients’ assumptions and values through bidirectional communication with little interference from personal biases

Develops and carries out management plans, even for complicated or rare situations, based primarily on experience that puts theoretical knowledge into context; rapidly focuses on key information to arrive at the plan and augments that with available information or seeks new information as needed; has insight into one’s own assumptions and values that allow one to filter them out and focus on the patient/family values in a bidirectional conversation about the management plan