Using “RIME” to Teach

Using “RIME” to Teach Paul E. Méndez MD FACP Assistant Dean for Clinical Curriculum Yvonne M. Diaz MD FACP Internal Medicine Assoc Program Director University of Miami Miller School of Medicine

Objectives Describe the elements of the “RIME” method of evaluation Use RIME to identify the level of the learner and create an action plan

RIME Reporter Interpreter Manager Educator Pangaro L, Acad Med, 1999

Observer Pre-reporter status Passively observes, but cannot meaningfully contribute to patient care activities Failing student

Reporter – CC2 to CC3 Accurately gathers history and performs basic physical examination Clearly organizes and communicates data, orally and written Able to recognize normal from abnormal and identify a new problem Reliable: day-to-day, punctual, follows-up Pangaro L, Acad Med, 1999

Reporter Resident – Let’s go see our next patient, Ms. Gonzalez. She’s our patient with breast cancer on chemotherapy who was admitted with neutropenic fever. How did she spend the night? Student – She had a fever of 38.5. [Pregnant pause – student with a deer-in-the-headlights look] Resident – What other information would be important in a patient with a fever. Student [a light goes off in his head] – She doesn’t really have any complaints. She denies any chills, sweats, cough, diarrhea, abdominal pain, or burning on urination. Her blood pressure was 126/78 with a pulse of 84. She was a little warm to the touch. Her lungs were clear. Her labs this morning show her white count dropped to 2.1K. Resident – What do you think is causing her fever? Student – She has no symptoms of a cold or UTI or other infection. I’m not sure – it could be lots of things.

Interpreter – CC3 to Intern Independent and critical thinking Prioritizes problems and Develops a Diff Dx Interprets follow-up test results • Higher level of knowledge • Skill in selecting data which support diagnosis • Applying test results to specific patients Pangaro L, Acad Med, 1999

Interpreter Resident – Let’s go see our next patient, Ms. Gonzalez. She’s our patient with breast cancer on chemotherapy who was admitted with neutropenic fever. How did she spend the night? Student – She had a fever of 38.5 last night. She’s feeling fine except for a cough. In addition to her fever, she has some tenderness around the site of her central line, though it’s not red or draining pus. The lungs are clear and the remainder of her exam was normal. As you mentioned, she’s neutropenic likely due to her chemo. Her white count is 2. 1K with an ANC < 500. As such, this is a neutropenic fever. I think a pneumonia or a line infection could account for her fever as well, since both of these are common complications that arise in hospitalized patients. Resident – How are you going to find out which it is? Student – We ordered a CXR this morning before rounds, but it’s not done yet. I guess we could draw blood cultures. Resident – Do you want to start her on antibiotics? Student – I guess so. Resident – Which would you choose? Student – Well, this would be a hospital-acquired pneumonia, so we need to consider pseudomonas and staph. And if it’s a line infection, staph or strep are the common culprits. So an antibiotic that would cover these, but I’m not sure which one.

Manager – Sub-I to Resident Actively and directly involved in pt care Decides when action needs to be taken • Takes more knowledge, confidence, and judgment Proposes and selects among different diagnostic and therapeutic options Tailors the plan to the particular patient Pangaro L, Acad Med, 1999

Manager Student – Ms. Gonzalez had a fever of 38.5 last night. She’s feeling fine except for a cough and some tenderness around the site of her central line, though it’s not red or draining pus. Otherwise her physical is unchanged from yesterday. Her white count is very low from her chemotherapy; it was 2.1K with an ANC < 500. I think a pneumonia or a line infection could account for her fever, both of these being common complications that arise in hospitalized patients. I would order a chest xray to rule out a pneumonia and blood cultures both peripherally and from her line to see if she has a line infection. I would start her on Cefipime. Resident – Good job. What organisms are you hoping to cover with the Cefipime? Student – Cefipime is used for neutropenic fevers. It has good broad spectrum coverage. Resident – True, but is it good for your other potential diagnoses? Will it cover pneumonia and line infections? Student – It should. Well, line infections are frequently due to Staph. Maybe we should use Vancomycin.

Educator – Resident / Attending Insight to define important questions and independently seeks the answers Self-directed learning Shares leadership in educating the team Driven to find evidence on which to base clinical practice and has the skill to know whether it will stand up to scrutiny Pangaro L, Acad Med, 1999

Educator Student – Ms. Gonzalez has a neutropenic fever likely from a line infection. After drawing cultures, ID recommended starting her on Cefepime. I questioned whether monotherapy was sufficient and looked it up. I found an article in Cancer from 2003 showing efficacy with monotherapy with Cefepime or Imipenen. They found a 75% response rate with Cefipime alone. However, they added Vanco if there was reason to suspect a gram-positive infection. The problem is that if we suspect Ms. Gonzalez has a line infection, maybe we should add Vanco. Should I call ID again? Resident – Let me see the article. But from what you tell me, it sure sounds like it.

Using RIME as a teaching tool Easy to understand Identify present level and the level one should be striving for Facilitates giving specific feedback, providing the “next step” (action plan)

Let’s Practice

Unknown Resident – Tell the team about our admission from yesterday, Mr. Perez. Student – Mr. Perez is a 67 y.o. male with a 70 pk-yr smoking history who presents with 2 day hx of lethargy and disorientation. His neurologic exam shows the lethargy and somnolence, but his strength and sensation appear intact with no focality. The remainder of his exam was normal. His labs were also all normal except for a sodium of 120. His CXR shows a 6cm mass in the right upper lobe. [Pregnant pause] Resident – OK, so give me a problem list. Student - Altered mental status, a lung mass in a heavy smoker, and hyponatremia. Resident - Why do you think he’s having the lethargy? Student – He mayhave had a stroke. But, the lung mass is probably a cancer from his smoking, and he may have a brain metastasis from the lung cancer. I’m not sure about the sodium though.

Unknown Student – So, in summary, Mr. Perez presents with a 2 day hx of lethargy and disorientation. He was found to have a sodium of 120 and a lung mass on his CXR. The differential includes SIADH, water intoxication, and hypothyroidism. Resident – Good. Which do you think is most likely? How are you going to find out which one of these it is? Student - In light of the smoking history and the lung mass, it is probably a lung cancer, and SIADH can be a complication of lung cancer, a paraneoplastic syndrome. I think we send urine lytes to make the diagnosis, I don’t think we send off ADH levels. This isn’t water intoxication as he hasn’t been drinking excessively as per his wife. To rule out hypothyroidism, we could check a TSH. Resident – How do we treat SIADH? Student – Oh boy, I’ve got to do some reading. I’m not sure.

Unknown Student – So, in summary, Mr. Perez presents with a 2 day hx of lethargy and disorientation, a sodium of 120, and a lung mass. I suspect his lung mass is a cancer, especially in light of his 70 pk-yr smoking history. The differential for hyponatremia includes hypothyroidism, water intoxication, maybe even from his IV’s. But I think it’s SIADH from his lung cancer. Resident – What did you do for him last night? Student – We got a urinary osmolarity and electrolytes on him which confirmed an osmolarity and sodium that was not as dilute as it should be in a patient with a sodium of 120, supporting the diagnosis of SIADH. We started him on water restriction, limiting his fluid intake. Resident – Good. What do you need to watch for? Student – We should raise his sodium very slowly, so we need to be monitoring his labs closely. We should watch his neuro exam and mental status closely, and if he deteriorates, we could consider 3% saline and transferring him to the unit.

Unknown Student – So, in summary, Mr. Perez presents with a 2 day hx of lethargy and disorientation due to a sodium of 120 from SIADH associated with his recently diagnosed lung mass. His urinary osmolarity and electrolytes confirm the diagnosis. So we started to restrict his fluid intake. Resident – Good job. How quickly should we raise the sodium? Student – On the one hand, he does have neuro manifestations, so we should try to raise it fast. But he doesn’t look that bad, and lethargy is not that severe of a neuro manifestation. And rapid increases in sodium can lead to osmotic demyelination. And 120 is not that low. I looked it up in UpToDate. For severe neurologic disturbances, they recommend increasing it by 2-4 mEq/L the first 2-4 hours, and no more than 10mEq/L over the first 24 hrs. So in this case, it should be less than that.

Unknown Student: Mr. Jones is our 45 yo male who was admitted with chest pain. He is without complaints today and has no changes on physical exam. His data also show no changes in his EKG, labs, or CXR. He has ruled out for MI and our plan is to discharge him home with possible outpatient stress.test. Resident - Why do you want to do this? Student - He has no more chest pain and I think that this is likely noncardiac, but he should get a stress test to risk stratify this. Resident - Why do a stress test at all? Student - Because that is what the guidelines say

Unknown Student - Ms. Jones is our 32 yo female with diabetes who was admitted with cellulitis. She notes improvement of her rash on the leg today and on Physical Exam, she has a decrease in warmth and erythema on the right leg on physical exam. The initial lesion was 4 cm but is now 2 cm in diameter. Her blood cultures are negative for 2 days. I would like to discharge her today on oral Clindamycin and Levaquin for 7 more days Resident - Why do you pick those antibiotics? Student - She was initially treated with Vancomycin and Timentin and Sanford says that this is a good combination that we can use for this disease. Resident - Are there any other antibiotic options for this patient? Student - Sanford also says that we can give Keflex.

“Active Learning Credo”Silberman, 1996 Active Learning 101 Strategies What I hear, I forget. What I hear & see, I remember a little. What I hear, see, & ask questions about or discuss with someone else, I begin to understand. What I hear, see, & do, I acquire as knowledge and skill. What I teach to another, I master.

Author Contact Information Paul E. Méndez, MD, FACP PMendez@med.miami.edu Yvonne M. Diaz, MD, FACP Ydiaz@med.miami.edu

Using “RIME” to Teach