On learning and teaching medicine


Category : Medical Rants

Last week the NEJM featured a wonderful article on clinical reasoning, written by Dr. Judy Bowen. For those who have subscription – Educational Strategies to Promote Clinical Diagnostic Reasoning

The teacher’s expectation of evidence of strong reasoning should vary according to the stage of training of the learner, but the learner’s developmental level is often related more to the extent of clinical experience with the case at hand than to the year of training. First-year residents, for example, may have clinical reasoning skills that are as advanced as those of senior residents when it comes to common clinical problems that they saw frequently as medical students. Thus, although the stage of training is somewhat helpful to the teacher in determining expectations of and roles for learners, specific questioning strategies are necessary to probe the understanding and elicit the uncertainties of learners at any level. Several different strategies can be used, but open-ended questions are especially useful for assessing the learner’s clinical reasoning ability. Using this or other similar frameworks, clinical teachers can evaluate a learner’s performance on the basis of the expected performance at different developmental levels.

retired doc brilliantly discusses the editorial to this article – There is no substitute for experience

This reminds me that in the old days (before my time) they used to say that the only problem with every other night call was that you missed half the cases!! retired doc emphasizes the important point that we cannot develop clinical reasoning without seeing enough patients.

Basically experts have to know their subject matter. Here is a key quote from his editorial:

“The process of pattern recognition, so characteristic of an expert’s approach, is a product of extensive experience with patients overlaid on a formal knowledge background.”

He continues:

“…trying to teach or evaluate clinical problem solving or clinical reasoning skills is quixotic. Knowledge counts.”

It is all about practice and experience and previously I wondered what the consequences are/will be of the time shortened internal medicine training program. Will the novice internists leave their training programs with the expertise needed to qualify as even a rookie expert?

Many educators worry that we have become so worried about competencies and work hours that residents may not see enough patients to take the steps towards gaining expertise. I worry about these issues, and do not have any obvious solutions.

Bravo to Dr. Bowen for writing this important article!

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Comments (2)

Laura Landro has another interesting column in her Informed Patient series in today’s (11/29) wall street journal about the new Isabel decision support system in testing at kaiser and the VA. This web based system was developed by a father after his young daughter was misdiagnosed. If you and your readers have a subscription, the article provides more information to this important discussion of decision support and the critical reasoning skill development in the teaching/practice evolution. In some of my work I have actually heard attendings ask students if the diagnosis has been “Isabelled.”

Over the years I have tried two other diagnsotic programs…the first was PCbased and the other was Mac friendly. They were marginal programs at best…but I am sure as with all things, newer software will improve. I do note that the WSJ article spent a great amount of writing reviewing the source of any potential errors in patient care. The common theme among all these errors has to do with the lack of time to do the job right.

More time to carefully think, consider, educate and follow up would certainly improve outcomes. Diagnostic software may eventually help but if the more time were allowed , clnical medicine would most certainly be improved.

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