Clinical Reasoning: Storing Stories to Narrow the Diagnosis

By Martina McGrath, MD
October 24, 2017

Accurate clinical reasoning is central to the art of medicine, and involves complex cognitive processes that most clinicians perform unconsciously. However, teaching these skills is an essential component of developing expert clinicians. In an era of rising healthcare costs, increased access to diagnostic testing and unlimited access to knowledge, the ability to sift through large amounts of data, synthesize a clinical presentation in a meaningful way and develop a logical differential diagnosis with a focused, rational plan of evaluation, is perhaps more important than ever.1

Skilled clinical reasoning follows a series of steps, beginning (as we were all taught in medical school) with history-taking and physical examination. As the clinician talks to the patient, she begins to develop an impression of the patient’s story, known as a mental abstraction.2 This mental abstraction guides further questioning and clinical examination. After acquiring the relevant data, the clinician must develop a concise one-line summary of the findings, a ‘problem representation,’ incorporating the most important features of the case, relevant negatives, and a differential diagnosis. The problem representation is an essential step in synthesizing the data to formulate a plan of diagnosis and treatment.

A specific patient presentation can trigger recall of a memory of a previous clinical encounter, along with its associated knowledge, which may include pathophysiology, treatment, complications, etc.

Helping trainees (particularly those early in their careers) to develop accurate problem representation allows them to accurately access their stored knowledge about a particular medical problem. If the presentation is not framed appropriately, the correct information cannot be accessed, leading to increased likelihood of unfocused reasoning and diagnostic errors. Teachers should encourage learners to develop a one-line summary and then explore that summary, using open questions such as “Why do you think that?” or “What features support/do not support that conclusion?” This approach informs the teaching physician of the trainees’ thinking process, and also encourages greater engagement by the trainee in clinical reasoning. It can be very instructive if the teacher then gives their own summary and reasons aloud, illustrating how the case links to their prior experience, and demonstrating effective clinical reasoning strategies.

Experienced clinicians mentally develop personal ‘illness scripts’, a repertoire of patient stories that connect prior clinical experiences with medical knowledge, and store them as accessible memories that guide diagnostic reasoning.2,3 A specific patient presentation can trigger recall of a memory of a previous clinical encounter, along with its associated knowledge, which may include pathophysiology, treatment, complications, etc. Possession of a broad range of illness scripts allows expert clinicians to rapidly formulate a diagnosis, but also recognize atypical presentations and break down complex cases into their component parts.

Encouraging the development of a trainee’s personal repertoire of illness scripts is central to clinical training. Repeated patient interactions, particularly early in a hospitalization before all testing is complete, are critical to developing this skill.4  Each experience feeds into the knowledge base behind illness scripts. Guided discussion with an experienced clinician helps to consolidate these mental connections, and provides very valuable insights. Also when rounding on admitted patients, critical reflection helps to consolidate illness scripts, and avoids cognitive errors due to failure to challenge that initial diagnostic label as more information becomes available later.

Those of us who have been fortunate enough to train with outstanding clinicians will recognize these approaches. Solving the puzzle and getting to the right treatment plan is one of the more rewarding aspects of being a medical professional, and should be a cherished skill to hand on to our future colleagues.


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References:

  1. Cooke S, Lemay JF. Transforming Medical Assessment: Integrating Uncertainty Into the Evaluation of Clinical Reasoning in Medical Education. Acad Med. 2017 Jun;92(6):746-751. doi: 10.1097/ACM.0000000000001559.
  2. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006 Nov 23;355(21):2217-25.
  3. Elstein AS, Schwartz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002;324:729-32.
  4. Simpkin AL, Vyas JM, Armstrong KA. Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training. Ann Intern Med 2017;167:507-8.

Head shot of Dr. Martina McGrathDr. Martina McGrath is an Instructor in Medicine at Harvard Medical School, and a member of the Renal Division, Department of Medicine, at Brigham and Women’s Hospital, both in Boston. Dr. McGrath is the Medical Editor for the Trends in Medicine blog.

 

*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

 

Effective Clinical Teaching on Rounds: Microskills Worth Practicing

By Martina M. McGrath, MD
May 24, 2017

On-the-job clinical teaching of students and physicians in training is a central aspect of medical education. For trainees, skilled teachers can become mentors and role models; often inspiring them choose a particular specialty and also having a formative influence on their clinical practice. For the teacher, it can be one of the most rewarding and enjoyable aspects of their practice. However, due to the frenetic nature of the clinical work environment with many competing demands, clinical teaching is frequently rushed, disjointed, and interrupted. Most of us would like to be better teachers, but how do we best make use of our limited time to impart some clinical pearls and support our trainees in their professional development?

Using a structured approach to teaching during a clinical encounter can maximize the learning opportunity without placing excessive burden on busy clinical teachers. Many approaches have been proposed but one of the more appealing ones, due to its simplicity, is The One minute preceptor: Microskills model of clinical teaching as proposed by Neher.1 This model distills a large body of learning theory into a manageable, five-step approach to a clinical teaching encounter:

Step 1: Get a commitment:  “What do you think is going on?”
Encouraging the trainee to commit to a diagnosis/plan of evaluation helps them to synthesize their thoughts and focus on the question at hand. Committing also helps them recognize their own learning needs, which encourages self-directed learning.

Step 2: Probe for supporting evidence: “Why do you think that?”
At this point, the temptation on the part of the teacher is to simply provide the correct answer or begin an explanation. However, encouraging active participation by the trainee will give them a much better learning experience. The aim is to encourage the trainee to reflect and work through the problem. This will in turn allow the teacher to provide more directed instruction related to the trainee’s level of knowledge and expertise.

Step 3: Teach general rules
Teaching is frequently more transferable and applicable when provided as general rules.1 An approach such as ‘when this happens, do this…’ can be very helpful. Having encouraged the trainee to work though the problem will allow the teacher to appropriately target this information to the trainee’s level.

Step 4: Reinforce what was done correctly
Feedback, which is specific to the task at hand and delivered in a timely manner, is an important way to reinforce learning. As many trainees are still developing their professional identities, reinforcing positive professional attributes also encourages their personal development.

Step 5: Correct Mistakes
Many teachers struggle to give negative feedback. Encouraging the trainee to reflect on his or her own performance is a nonconfrontational way to open the discussion of any errors that were made. Similarly, criticism should be of the approach rather than the individual (‘this aspect of the case could have been better dealt with by xx…’ as opposed to ‘you handled this case badly’).

Informal, opportunistic teaching is a central component of medical education. Applying an outline structure can improve the efficiency and effectiveness of a given teaching opportunity. By encouraging a discussion rather than a lecture, this type of approach can give educational benefit, and more enjoyment, for both the learner and the instructor.

References:

  1. Neher, et al. A Five-step “Microskills” Model of Clinical Teaching. Journal of the American Board of Family Practice. 5:419-424, 1992.

Developing Essential Skills in Clinical Research

This 1.25 credit CME course is designed for medical doctors who desire to pursue a career in clinical research in the US. The course will help you develop knowledge on key elements required to be an effective clinical investigator, understand what it takes to become a clinician-investigator, understand the importance of mentorship in your career trajectory, and develop specific skills in writing proposals, crafting scientific papers, and making effective presentations. Click on the title link to learn more.


Headshot of Dr. McGrathDr. Martina McGrath is an Instructor in Medicine at Harvard Medical School, and a member of the Renal Division, Department of Medicine, at Brigham and Women’s Hospital, both in Boston. Dr. McGrath is the Medical Editor for the Trends in Medicine blog.

 

 

*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.