Clinical Decision-Making Case: Seizing the Diagnosis: Eclampsia
Correspondence should be addressed to Samuel Parnell, MD at samuel.parnell@utsouthwestern.edu
DOI: https://doi.org/10.21980/J8.52338
ABSTRACT:
Audience: This practice certifying exam case is intended for emergency medicine residents.
Introduction: The American Board of Emergency Medicine (ABEM) certification process is currently undergoing a significant transformation, with the new ABEM Certifying Exam replacing the long-standing ABEM Oral Exam, which has been in place since 1980.1 The Certifying Exam will utilize a new exam format to evaluate different competencies compared to the Oral Exam, including high-stakes communication, managing difficult conversations, patient-centered communication, clinical decision-making, team management, leadership, procedural skills, ultrasound skills, reassessment, troubleshooting, task switching, and prioritization.1 This shift has understandably generated a degree of apprehension among Emergency Medicine (EM) residents preparing for their board exams. The new exam emphasizes several new cases and scenarios, including Clinical Decision-Making (CDM) cases. These structured discussions require residents to articulate their thought processes and justify their clinical choices while navigating simulated Emergency Department (ED) encounters with undifferentiated patients.1
Although the CDM cases are similar in length (15 minutes) and format to the Structured Interview cases from the prior Oral Exam (structured discussion eliciting the steps necessary to diagnose and treat a patient with an undifferentiated presentation), ABEM has established new scoring criteria and objectives for the CDM cases.2 Therefore, to effectively prepare residents for this evolving assessment landscape, relevant and challenging example CDM case scenarios are essential. This CDM case focuses on eclampsia, defined as seizures occurring in a woman with pre-eclampsia or gestational hypertension during the peripartum period. This condition is a relatively rare, yet critical, emergency at the intersection of obstetrics and neurology that carries significant maternal and fetal risk and demands prompt recognition and decisive management. This case aligns directly with the exam’s emphasis on high-acuity, low-occurrence presentations and provides a realistic and challenging opportunity to hone crucial clinical decision-making skills. It ensures that residents are not only well-prepared for the high-stakes Certifying Exam but are also capable of effectively managing this critical obstetric emergency in actual clinical practice.
Educational Objectives: By the end of this Mock Certifying Exam session, learners should be able to: 1) demonstrate familiarity with the Clinical Decision-Making case format and structure, 2) elicit relevant historical information and connect that information to the diagnosis of eclampsia, 3) describe and interpret physical exam findings and their significance in establishing a pertinent differential diagnosis, which includes eclampsia, 4) initiate appropriate diagnostic testing, interpret results accurately, and formulate a stabilization and treatment plan for a patient with eclamptic seizures, and 5) reassess the patient’s condition, modify the management plan as needed, provide relevant anticipatory guidance for disposition, and articulate the clinical decision-making rationale at each stage of the encounter.
Educational Methods: This educational intervention employed a simulated ABEM Certifying Examination case. The initial case, focusing on the critical presentation of eclampsia, was developed collaboratively by a team of Emergency Medicine education faculty at a large, urban, three-year EM residency program. The structure and format were modeled after examples of the new CDM cases provided on the ABEM website. The CDM format involves a dynamic patient encounter in which the learner progresses through different phases of care, making diagnostic and therapeutic decisions and justifying their rationale to an examiner.1
A pilot phase was conducted to ensure realism, educational value, and appropriate timing for the examination format. Four recent graduates of the EM residency program participated in this pilot: two fellows (in Emergency Medical Services and Medical Education, respectively) and two actively practicing attending physicians in community Emergency Department settings. These individuals engaged with the case as if they were taking the actual Certifying Examination, providing detailed feedback on the clarity of the scenario, the appropriateness of the clinical challenges presented, and the overall flow and timing of the case. Based on the insights gained from pilot testing, the case underwent refinement and adjustments to optimize its effectiveness as an assessment and learning tool.
The finalized eclampsia CDM case was then implemented in a testing phase involving eighteen PGY-3 (Post Graduate Year-3) EM residents. These residents participated in a simulated certifying examination experience, with two faculty members acting as examiners for each resident physician in individual exam rooms, closely resembling the actual testing environment.1 The examiners sat across a table from the examinee, and a separate screen was utilized to display the case stimuli and task sheet during the case. The case sessions were limited to a maximum of 15 minutes. While this CDM case was incorporated into a Mock Certifying Exam session with multiple other cases and scenarios, it could also be employed in isolation using a virtual or in-person format. Following the Mock Certifying Exam, a group debrief was conducted in-person. This session provided collective feedback to resident examinees and faculty examiners regarding the eclampsia case, the CDM case format, and key clinical learning points.
Research Methods: Following each simulated case encounter, faculty examiners evaluated resident performance using a standardized scoresheet. The scoresheet, derived from ABEM Certifying Exam Score Guidelines, assessed nine domains: focused history, physical exam interpretation, differential diagnosis, diagnostics, patient stabilization, reassessment, disposition, clinical reasoning, and pathophysiology.2
These nine domains were collated into the standard JETem scoring rubric, which includes 25 points spread among categories associated with the CDM format. In addition to the faculty assessment, residents anonymously completed a two-question post-case evaluation. This evaluation employed a 5-point Likert scale (1 = poor, 5 = excellent) to assess the overall quality of the case, characterized by how well the session met educational objectives and resident expectations, and the degree to which the case enhanced understanding of the certifying exam format (1 = strongly disagree, 5 = strongly agree).
Results: In total, 18 residents completed the case, and 17/18 residents (94.4%) completed the post-case evaluation. All residents identified eclampsia as one of the top three relevant differential diagnoses, administered intravenous magnesium as part of the treatment, and appropriately admitted the patient. However, antihypertensive medications were the most overlooked treatment modality.
The mean quality rating of the case was 4.94/5, and 100% of resident respondents rated the overall quality of the case as “very good” or “excellent” on a 5-point Likert scale. Furthermore, 100% of respondents agreed or strongly agreed that the case enhanced their understanding of the certifying exam format.
Discussion: The implementation of this CDM case proved highly effective in preparing EM residents for the complexities of clinical practice and the new challenge of understanding the Certifying Exam CDM format. The case was exceptionally well received, with a mean quality rating of 4.94 out of 5, and 100% of resident respondents rating its overall quality as “very good” or “excellent.” Furthermore, 100% of examinees agreed or strongly agreed that the case significantly enhanced their understanding of the certifying exam format, underscoring its utility as a preparatory tool for the newly formatted ABEM Certifying Exam.
From its implementation, we learned that high-fidelity mock cases, particularly those involving critical scenarios like eclampsia, are invaluable for assessing and refining clinical decision-making skills. Eclampsia is a high-yield case due to its critical nature, requiring a wide differential diagnosis for seizures, a deep understanding of pathophysiology, and the rapid initiation of diagnostic workup and treatment to mitigate significant morbidity and mortality. This type of simulation-based training provides a safe but realistic testing environment for residents to gain experience with rare or high-acuity situations they may not frequently encounter in clinical practice.
The main takeaway from this experience is the critical importance of proactive, targeted preparation for the evolving ABEM Certifying Exam. The overwhelmingly positive resident feedback and performance scores demonstrate that such simulated experiences are highly effective in enhancing understanding of the exam format. By providing a realistic, low-stakes environment for decision-making and targeted feedback, these mock cases directly contribute to residents’ preparedness for board certification and, more importantly, for safe, high-quality independent practice in emergency medicine.
Topics: Clinical decision-making case, eclampsia, seizure, post-partum, certifying exam, ABEM.
