Clinical Exercise Testing —
Training activity: 4

Details

Review patient referrals for  patients referred for unexplained breathlessness and identify the most appropriate exercise protocol to answer the clinical question

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to accurately reviewing patient referrals specifically for unexplained breathlessness and then selecting the most appropriate exercise protocol that is specifically designed to answer the particular clinical question presented.
• Consider how the learning outcomes apply, specifically in relation to preparing patients, selecting assessments based on referral criteria, effective communication, and demonstrating a patient-centred approach.
• What does the accurate selection of the appropriate exercise protocol look like for a patient referred for unexplained breathlessness?
• Discuss with your training officer to gain clarity on the specific criteria used for protocol selection, common clinical questions associated with breathlessness referrals, and the expected format for documenting your rationale for protocol choice.

What is your prior experience of this activity?

• Think about what you already know about the indications for performing various field exercise tests and full cardiopulmonary exercise tests (CPETs), especially when assessing unexplained dyspnoea.
• Consider possible challenges you might face during the activity, such as interpreting ambiguous or incomplete referral information, challenges in differentiating between cardiac and respiratory causes of breathlessness purely from referral details, or the task of justifying your chosen protocol to a multidisciplinary team, and think about how you might handle them.
• Recognise the scope of your own practice for this activity i.e. know when a referral is too complex or presents an unusual case that requires input from senior colleagues before a protocol can be definitively selected, and from whom.
• Acknowledge how you feel about embarking on this training activity, reflecting on your feelings about the responsibility of clinical decision-making, your confidence in interpreting diverse referral information, or any potential uncertainty regarding complex diagnostic pathways.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop related to enhancing your skills in critical analysis of referral information, refining your clinical reasoning for protocol selection, and improving your ability to link patient symptoms effectively to appropriate diagnostic pathways.
• Identify specific insights you hope to gain regarding the diagnostic utility and specific applications of different exercise protocols in cases of unexplained breathlessness and appreciate the importance of precise protocol selection to ensure that the clinical question is accurately and efficiently answered.

What additional considerations do you need to make?

• Consult actions identified following previous experience where you had to select exercise protocols, especially for challenging or ambiguous cases involving unexplained symptoms.
• Identify important information you need to consider before embarking on the activity, such as consulting national and international clinical guidelines for exercise testing and interpretation, and familiarising yourself with any local protocols or pathways for managing patient referrals related to unexplained breathlessness.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate when analysing referral information or deciding on a protocol?
• Are you encountering situations such as:
  • The referral presenting ambiguous or conflicting clinical information e.g., dyspnoea but normal previous imaging results that makes identifying the primary clinical question difficult?
  • Identifying a previously unknown absolute contraindication e.g., recent unstable angina buried within the patient history that necessitates immediate revision of the planned protocol?
  • The clinical question relating to unexplained breathlessness being so complex that the required protocol e.g., highly specific CPET falls outside standard local operating capacity?
• Consider how this specific experience compared with previous experiences of reviewing referrals or selecting protocols.

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding appropriately to an ambiguous referral? Are you adapting or changing your approach to identifying the clinical question or selecting the protocol?
• Consider the steps you are taking in the moment, such as:
  • Immediately consulting national or institutional guidelines to justify protocol selection based on complex symptomology?
  • Seeking immediate advice from a senior colleague on the most appropriate diagnostic pathway for an ambiguous referral?
  • Adapting the phrasing of your proposed protocol justification to address conflicting clinical data?
• How are you feeling in that moment? For instance, did you find it difficult to adapt to incomplete information? Did it affect your confidence in choosing the most appropriate protocol?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice during this activity. For example, are you successfully identifying a clear protocol and justifying your rationale? Or are you needing support because the clinical complexity requires senior review to authorise a specialist pathway?
• Identify what you learned as a result of the unexpected development during this process. For example, are you mastering a more systematic approach for correlating symptoms with protocol indications or gaining insight into the hierarchy of diagnostic testing for dyspnoea?

On action

What happened?

• Begin by summarising the key points of reviewing the referral and selecting the exercise protocol.
• Consider specific events, actions, or interactions which felt important when analysing referral information or deciding on a protocol, including your own feelings during the experience.
• Include any ‘reflect-in-action’ moments where you had to adapt to ambiguous referral information or challenging clinical questions as they unfolded during the review, for instance, immediately consulting guidelines to choose a protocol appropriate for conflicting symptoms.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding interpreting complex referrals or selecting the most appropriate exercise protocol. What strengths did you demonstrate e.g., identifying the clinical question rapidly? What skills and/or knowledge gaps were evident e.g., understanding the nuances of different exercise protocols, or correlating specific symptoms to a relevant clinical question?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in efficiently identifying the clinical question or selecting protocols?
• Identify any challenges you experienced, such as incomplete referral documentation, conflicting information, or a particularly complex patient history, and how you reacted to these. How does this activity contribute to your diagnostic skills?
• Identify anything significant about the activity, such as needing to seek advice or clarification e.g., from a clinician regarding the clinical question or an experienced colleague about protocol suitability? Or did you need to escalate the referral if it seemed beyond your current scope to interpret effectively?
• Acknowledge any changes in your own feelings now you are looking back on the experience.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received related to reviewing patients’ referrals. What feedback have you received with regards to your ability to identify appropriate exercise protocols?
• What will you do differently next time you review a patient referral for unexplained breathlessness or select an exercise protocol? Has anything changed in terms of what you would do if you were faced with a similar situation again?
• Do you need to practise any aspect of the activity further, such as advanced referral analysis techniques or deepening your knowledge of specific exercise protocols?

Beyond action

Have you revisited the experiences?

• Have you reviewed the actions you identified in your previous reflections for this activity, specifically related to improving your practice in advanced referral analysis techniques or deepening your knowledge of specific exercise protocols?
• Have you completed the specific actions you previously identified? For example, if you planned to consult national or international guidelines for linking specific dyspnoea presentations to protocol indications, how did completing this review impact your subsequent ability to review ambiguous referrals and justify protocol choice?
• Engage in professional storytelling with peers, near peers, or colleagues about challenging referral interpretations or justifying protocol selection for complex cases. How has discussing these cases influenced your systematic approach to linking symptoms to diagnostic pathways?

How have these experiences impacted upon current practice?

• Consider how the accumulated learning from performing or reflecting on referral review and protocol selection will support you in preparing for observed ‘in-person’ assessments for the module, such as Case-Based Discussions that require making recommendations based on physiological data.
• How has your practice in interpreting physiological data developed and evolved over time? For example, can you identify instances in your current practice where the foundational knowledge gained from matching symptoms to protocols has informed decisions for interpreting complex data from other diagnostic modalities?
• What transferable skills e.g., diagnostic reasoning, critical appraisal, or pattern recognition did you develop through this activity, and how will this understanding help you evaluate and adopt new monitoring or diagnostic technologies in the future?

Relevant learning outcomes

#	Outcome
# 2	Outcome Prepare patients to undertake field and formal clinical exercise assessments.
# 3	Outcome Select the appropriate clinical exercise assessment based on referral criteria.
# 7	Outcome Employ effective communication skills and compassion with a range of patients enabling patients to understand their treatment pathway.
# 8	Outcome Demonstrate a patient centered approach to practice, considering communication with patients and relatives and the patient experience.