Early in my training one of my mentors introduced me to the R.I.M.E. model for setting clinical goals as a medical trainee. This model was developed by Dr. Louis Pangaro, MD, Chairman of Medicine at the Uniformed Services University and is used across the world to help students learn and grow. R.I.M.E stands for: Reporter, Interpreter, Manager, and Educator.
- Reporter- the learner is able to obtain and convey clinical data, but when asked for its significance, is often unable to parse out what is and is not important information.
- Interpreter- the learner is able to obtain and convey pertinent information as well as highlight the significance of the data.
- Manager- the learner does the above actions, but takes it a step further by making treatment suggestions and decisions based off of the data.
- Educator- the learner is able to obtain, convey, interpret, and act upon clinical data, as well as explain why they made the decisions they made to other people.
How will the R.I.M.E model help you on your clerkships?
Setting goals is a habit that all physicians should develop. Use the R.I.M.E. framework to help form that habit. At the start of your rotations, tell your attendings and residents that you are having trouble determining which physical exam findings and laboratory values to present. Explain to them that you would like to be functioning in the reporter phase of the R.I.M.E. model by the end of the rotation. At the halfway point, ask them if they have seen progress and where they feel you need to improve. Not only will this help them tailor your experience on the clerkship to fit your needs, they will see that you genuinely care about learning and growing as a doctor. Once you feel more comfortable in the reporter phase, push yourself to perform at the interpreter level.
For example, say you are pre-rounding on a patient admitted overnight with a fever and a swollen leg. Before you look for all the information, pause. What is your differential for this patient? Which pieces of data do you need to support or refute each of the diseases on your differential? If you suspect cellulitis with possible osteomyelitis, is the patient febrile, tachycardic, or hypotensive concerning for sepsis? Did the admitting team order blood cultures, a CBC, and an MRI? If you suspect a deep vein thrombosis, did the team obtain a D-dimer or ultrasound? Prioritize the data that changes the order of your differential diagnosis.
Once you have used your differential to hone in on the most relevant information, you can further organize the data into buckets. The way I do this is by circling any abnormal vitals, labs, microbiology data, or imaging findings. Say I order a basic metabolic panel and a complete blood count on a patient admitted for a possible GI bleed. The potassium, BUN, and creatinine are elevated and their hemoglobin is low. I also notice that their heart rate is elevated. I circle each of the abnormal values and add them to my problem list for the patient. So now, in addition to GI bleed, their problem list includes tachycardia, acute kidney injury, hyperkalemia, and anemia. How do you interpret this constellation of labs?
Think out loud
Being an interpreter means that you are not just listing off the labs and vitals. Try to make sense of them by reasoning out loud with the team. Ask, how could a patient with a GI bleed have changes in their heart rate and electrolytes? Do your best to give a reason. You may be wrong and that is OK! What matters is showing your team how you think. This also gives them a chance to provide feedback. The more you practice, the more you will learn and the more efficient you will be.
How will the R.I.M.E model help you for life?
Medicine is far too complex a field for any one person to know all there is to know. This is both humbling and liberating. What I love most about the R.I.M.E. model is that there is no “expert” level. The highest degree we can obtain is educator. This implies that no matter how far we progress in our training, the best we can do is share what we have learned along the way.
How are your clinical reasoning skills? What steps can you take to advance along the R.I.M.E. model?