Patient Presents With Hypotension and Bradycardia: A Novel Triplet Oral Board Approach

Mock oral examinations remain underutilized in undergraduate medical education despite their potential to strengthen clinical reasoning. Traditional formats typically present unrelated cases, which can predispose learners to diagnostic tunnel vision. This project evaluates whether presenting medical students with three near-identical oral board cases involving hypotension with bradycardia can improve their ability to generate differential diagnoses, distinguish overlapping clinical presentations, and initiate appropriate management. We hypothesized that this comparative approach would significantly improve diagnostic accuracy compared to baseline knowledge.

Fourth-year medical students enrolled in a clinical toxicology rotation participated in this quasi-experimental pretest-posttest study. Students first completed a baseline pretest assessment followed by three oral board cases involving a patient with altered mental status, hypotension, and bradycardia secondary to third-degree heart block, hypothermia, or beta-blocker/calcium-channel blocker overdose. Learners were evaluated via case-specific critical action checklists. Following the scenarios, learners participated in a structured debrief emphasizing comparative diagnostic reasoning and critical next steps of action. Students then completed a posttest assessment, which was analyzed via the Wilcoxon signed-rank test.

Twelve students (n=12) were enrolled and completed all phases of the study. Mean pretest scores were 62% (SD ± 21.4%) and mean posttest scores were 97% (SD ± 4.5%). A Wilcoxon signed-rank test demonstrated a statistically significant increase in performance (W=0.0, p=0.0005, two-tailed). Students demonstrated marked improvement in identifying differentiating clinical features and critical actions across the three scenarios.

Presenting multiple, subtly varied versions of the same clinical scenario is a feasible and effective strategy to strengthen diagnostic reasoning skills in medical school. This triplet-case approach has been successfully incorporated into the medical curriculum and expanded to other clinical presentations at our institution. While best suited for small-group instruction, this model is highly reproducible and applicable to educators both within and outside emergency medicine.