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Theme trends of The "Hot Seat": An Online, Asynchronous, Clinical Reasoning Tool Focused on Diagnostic and Management Dilemmas
Haroon Shaukat1, Sonny Tat2, Pavan Zaveri1, Maybelle Kou3, Lenore Jarvis1. 1Emergency, Children's National Medical Center, Washington, District of Columbia, United States, 2UCSF, San Francisco, California, United States, 3Emergency, INOVA Fairfax Childrens Hospital, Fairfax, Virginia, United States

Purpose of Study To describe the themes of diagnostic and management dilemmas of an online asynchronous learning tool aimed at clinical reasoning skills for PEM providers over a 5-year period.

Methods Used A descriptive study whereby cases were organized into organ systems through their chief complaint. Poll questions were subdivided into imaging, lab, disposition, interpretation, and treatment dilemmas. A content analysis approach was used to investigate reader commentary and was rated using the Gricean Cooperative Principle scoring rubric to assess their participation as determined by the four maxims: quantity, quality, relevance, and manner. Commentary that included reference to a prior post either by name or topic was considered a direct response.
Summary of Results Greater than 100 cases have been published over a 5-year period by PEM fellows at 3 institutions. The site received over 36,000 page views by 7,800 visitors in 48 US states and globally. Overall, Hot Seat cases represented 7 organ systems including gastrointestinal, nephrology, neurology, pulmonary, cardiac, skin, and musculoskeletal. The top three organ systems were brain (27%), gastrointestinal (21%) and musculoskeletal (19%). Altered mental status, headache, abdominal pain, and extremity pain were recurrent chief complaints.

Poll questions were analyzed for diagnostic and management dilemmas. Imaging and laboratory workup were identified in 66% and 54%, respectively, of cases. Management dilemmas were similarly identified with disposition and treatment recurring in 61% and 51% of cases respectively. Only 14% of poll questions focused on interpretation dilemmas.

Grice's four conversational maxims were found in much of the commentary. Quantity and quality appeared most consistently to result in direct response to the posting.
Conclusions More than half of Hot Seat cases focused on diagnostic dilemmas including imaging and laboratory workup. Management dilemmas including disposition and treatment were also present in the majority of cases. To engage readers, posts focused on Grice's maxims of quantity and quality rather than relevance or manner.

Figure 1. The Gricean Cooperative Principle scoring rubric used to assess conversational participation as determined by the four maxims.

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