The key to medical education – teaching students and residents how to think

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Category : Medical Rants

"I cannot teach anybody anything, I can only make them think."Socrates

Despite insurance company efforts to the contrary, despite politician proclamations, despite public reporting of performance scores, successful medicine depends more on establishing the proper diagnosis than on achieving performance goals.  For the past 10 days, I have rounded at the VA hospital.  I cared for no problems that performance flaws created.  I cared for no problems that we could solve through careful adherence to performance measures.

Most of our patients presented as diagnostic dilemmas.  We had to think.  Moreover, we had to think about thinking.

Several times I advanced a seemingly obvious hypothesis that turned out incorrect.  Fortunately, I always "hedged" my bets on the diagnosis, and continued the diagnostic process.

Today we looked at the VA algorithm for chest pain.  Astonishingly, that algorithm excludes a careful history and physical exam.  I looked at the poster with incredulity.  How can we skip the history and physical exam?

Of course we cannot.  If our only goal in caring for chest pain patient is to find acute coronary syndromes, we might succeed with the algorithm.  Acute coronary syndromes are not the only causes of dangerous and potentially fatal chest pain.  If we do not take a careful history and do a careful physical examination and keep our differential diagnosis wide, we will miss those other causes.

Keeping our differential diagnosis open requires continued thinking.  We work on retaking the history, performing the physical exam, and explaining the laboratory data and imaging studies.  All of these activities require thinking.

We cannot go to charts and easily measure thinking.  One cannot find the denominator or the numerator.  But when you think clearly and make the proper diagnosis, the patient often benefits.  

Students and residents seem eager to discuss the thought process.  They seem (at least to me) to revel in a clear explication of the diagnostic process.

From the informal feedback I get from students and residents, too often our peers overlook this important part of education.

Socrates understood that facts are easily learned, but using the facts to develop hypotheses to accept or rejection requires careful thinking.  I believe our patients desire careful, thoughtful physicians.  We have an obligation to produce them.  Society should demand them.

Comments (7)

Agree that the H and P have been devalued.  Of the two, I think 'H' has more value than 'P'.  Agree?

When you've lost H and P, the battle with the bureaucrats is over.
We lost. 

No one wants to pay anymore for the time that a careful history and physical require.  No one wants to pay anymore for the time it takes to think critically about a patient.  
No one wants to pay for the time it takes to develop clinicians who can think critically and do a thoughtful H&P.  

pcb,
I agree with you completely. It is society's loss.

How did we get here? Imposed on us or we played an active role to get here.

Sounds like a fun rotation. Way more fun than routine rounds on the chest pain unit." I'm envious. Great post, as always. 

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