Clinical reasoning and naturalistic decision making


Category : Medical Rants

My colleagues and I have just published a clinical problem solving exercise in JGIM.  NSTEMI or Not: A 59-Year-Old Man with Chest Pain and Troponin Elevation

I believe that this presentation stresses an important concept in clinical reasoning, focusing more on how one achieves expertise than on how one makes errors.  I wrote the diagnostic reasoning portion reflecting on my colleague Dr. Gustavo Heudebert who wrote the clinician discussion.  We first discussed this patient in a live, unrehearsed case conference.  His written discussion reflects very closely his spontaneous discussion at our conference.

His reasoning is superb and the patient presentation represents a cautionary tale.  We believe the greatest strength of this presentation comes from an understanding of the skills he brought to the presentation.

Naturalistic decision making is a relatively new field on cognitive reasoning.  Its devotees work to better understand how experts perform, with an expectation that by understanding how experts achieve expertise then we can aspire to expertise ourselves.  A key factor in this movement is a reliance on experience for attaining expertise.  Knowledge alone is not sufficient, one must combine knowledge with experience.

I hope you enjoy the case and the discussion.

Comments (5)

Very cool case. Thanks for sharing. 

It's ALWAYS better to focus on the positives rather than the negatives, good to see this case is in line with this reasoning. 

Excellent-.Makes me what to write about phronesis again.

Thank you for putting together clnical and analytical reasoning; analytical reasoning from experts need both time and experience and I agree completely that it should be a major focus of physician training because that is one thinking lacking future generation of doctors. [Also, it is important to differentiate midlevels from real doctors]
Side note – A lot of Emergency rooms around the country would have checked a d-dimer in such a case and if elevated may have responded by getting CTA.

I love watching a master clinician in action.  However, can we really call these after the fact verbal case presentations an accurate reflection of "naturalistic decision making"?  They are always somewhat artificial.  The clinical data are framed nicely including sudden onset chest pain, and a diastolic murmur that would suggest aortic dissection to most reasonable clinicians.  But how would the same clinician perform in the real time din and chaos of the ER?  Would he hear that subtle murmur or would he be able to elicit the sudden onset  pain in a partially aphasic patient who has also had a stroke while trying to multitask and attend to multiple other sick patients while their pager is continually going off?  I teach trainees to take blood pressure in both arms in any acute chest pain presentation to the ER or in anyone with low pressure who doesn't have any other features of shock.  Maybe we should systematize chest pain evaluations in ER a la Gawande Cheescake Factory style – check BP in both arms by nurse at ER triage desk in all of them.  This might save the occasional life but might also lead to unnecessary CT scans in people with subclavian artery stenosis.  What do you think?

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