Clinical Decision-Making Case: Pulmonary Embolism
Correspondence should be addressed to Lubna Ahmad Saffarini, MD, MSHPE at James.Lee@sutterhealth.org
DOI: https://doi.org/10.21980/J8.52339
ABSTRACT:
Audience: Emergency medicine residents and medical students on emergency medicine rotations.
Introduction: Pulmonary embolism (PE) is a common diagnosis with an annual incidence of approximately one in 1000 persons.1,2,3 There is a wide variety of clinical presentations, ranging from the asymptomatic patient to shock and cardiac arrest. Most patients have chest pain and shortness of breath (SOB), but PE may also present with mild or nonspecific symptoms, such as dizziness, cough, wheezing, syncope and hemoptysis. These patients have risk for clinical decompensation.4,5 It is therefore critical to maintain a high level of suspicion because misdiagnosis is common. There are risks attributable to the diagnostic evaluation and treatment, including radiation exposure, contrast reactions and complications related to anticoagulant therapy. Work up requires an understanding of clinical pretest probability, diagnostic algorithms such as the modified Wells scoring system and the revised Geneva scoring system, the pulmonary embolism rule-out criteria (PERC), and interpretation of D-dimer testing and diagnostic imaging.6,7 Management requires anticoagulation, but for the unstable patient may also require respiratory and hemodynamic support, systemic or catheter-directed thrombolysis, catheter or surgical embolectomy, or extracorporeal membrane oxygenation (ECMO) if available. Understanding the diagnostic evaluation and management of pulmonary embolism is essential for the practicing emergency medicine physician.
Educational Objectives: By the end of the clinical decision-making case, the learner will: 1) gain familiarity with clinical decision-making (CDM) case format to be used in the new American Board of Emergency Medicine (ABEM) certification examination starting in 2026, 2) demonstrate the ability to obtain a focused history and physical examination and develop appropriate differential diagnoses for chest pain and dyspnea, 3) demonstrate understanding of clinical decisions rules to estimate the pre-test probability for pulmonary embolism and the application of rules to guide appropriate diagnostic testing, 4) recognize high clinical suspicion for pulmonary embolism and indication for empirical treatment, 5) recognize the unstable patient and provide appropriate hemodynamic and respiratory support, 6) understand indications for thrombolytic therapy or embolectomy in unstable pulmonary embolism, 7) demonstrate communication skills with patients and specialists across the health care spectrum, and 8) arrange appropriate disposition for the unstable patient with a pulmonary embolism.
Educational Methods: This session is based on the clinical decision-making (CDM) case format introduced by ABEM to be used in the oral certification examination starting in 2026.8 The materials were modeled after the samples provided in the instructional videos on the ABEM Qualifying Exam Part 2 released in December 2024. Slides were provided to the instructor concerning clinical presentation, differential diagnosis, and management for the debrief following the session. This case was tested using 18 resident volunteers ranging from PGY 1-2 in an Accreditation Council for Graduate Medical Education (ACGME) accredited emergency medicine residency program. This was our first mock board session using the CDM format.
Research Methods: Prior to the session, the learner was asked to complete a pre-survey to see if the learner had previously reviewed the ABEM instructional video demonstrating a CDM case. Immediate feedback was then solicited both from the learners and from the evaluators following the debriefing session. Residents were asked to evaluate the educational value of the case using a 1-5 Likert scale (5 being excellent). Evaluators were asked to score the residents by designating whether the learner was able to provide the correct responses concerning required appropriate historical information, physical examination findings, diagnostic testing needed, differential diagnoses, interpretation of diagnostic results, reaching the correct diagnosis, management and disposition of the patient and coordinating transition of care. The examiner would mark the evaluation form with either a yes or no for each response.
Results: Eighteen residents (nine PGY1 residents and nine PGY2 residents) completed the case. We were a new residency program at the time and did not yet have any PGY3 residents. The average score was 28.9 out of 29 points. The pre-survey revealed that only two of the nine EM PGY1 and four of the nine EM PGY2 had reviewed the ABEM video. Eighteen residents completed the post-survey which was done immediately after the simulation. The learners rated the educational value of the case 4.9/5 (5.0/5 for PGY1, 4.9/5 for PGY2). Fifteen residents (8/9 PGY1, 7/9 PGY2) stated that the case increased their understanding of key concepts about the disease process “somewhat,” while three responded that they have had similar patients and did not learn anything new. Thirteen residents (8/9 PGY1, 5/9 PGY2) said that the experience made them more comfortable with the new testing process but that they needed more practice, while only two residents (both PGY2) responded that they were very comfortable with the process.
Discussion: The objective of this oral boards case was two-fold: to give residents experience with the new CDM case format of the ABEM certifying exam and to reinforce the work-up and management of pulmonary embolism.
This simulation was an effective educational tool for residents to gain familiarity with the CDM case portion of the ABEM certifying exam. Only a minority (6/18, 33%) of the residents were familiar with the new testing format prior to the case. This session was the first mock oral board session using a CDM case. Post survey results revealed that 72% of the residents (13/18) said that the experience made them more comfortable with the new testing method but that they needed more practice, while only two residents (11%) stated that they were very comfortable with the process.
This was also a learning opportunity for the examiner in this new CDM case format. The evaluation form used a dichotomous yes/no format which likely contributed to excessive prompting which inflated scoring. This may not accurately reflect the experience at the certifying exam. In response, more specific criteria regarding the degree of prompting and timing of case were added to the script. Repetition of testing in this format should be helpful for residents and educators as preparation for the ABEM certifying exam.
The initial evaluation of pulmonary embolism is a topic with which most residents are comfortable. Residents scored well on testing, suggesting an understanding of the work-up for chest pain and routine management for pulmonary embolism. They had less familiarity with management of the high-acuity, unstable presentation.
This case was not tested on medical students, but we anticipate that this would be an appropriate learning experience for the medical student on an emergency medicine rotation, without need for modification.
This case was designed to introduce residents to the CDM case format. There is limited existing training material for the new oral board exam, and we feel this simulation case is valuable for residents to gain familiarity with the new ABEM certifying exam format through a comfortable topic and a “low pressure” setting.
Topics: Clinical decision-making case, pulmonary embolism, shortness of breath, dyspnea.
