Teaching medicine requires teaching thinking


Category : Medical Rants

Many readers know that I am a founding member of the Society to Improve Diagnosis in Medicine.  This society has staked out the position that we no longer focus enough on the diagnostic process in medicine.  Thus, we have too many diagnostic errors.

Some want to blame diagnostic errors on “systems problems”.  Certainly, poor systems can make diagnosis more challenging and more difficult, but we physicians have the ultimate responsibility to overcome obstacles and find the correct diagnosis.

Some quality gurus are paying attention.  For example, Bob Wachter will be speaking again at the Diagnostic Errors meeting and last year Peter Pronovost spoke.  One can not reliably judge a clinician’s quality without an assessment of diagnosis accuracy.

But diagnostic accuracy evades measurement.  How can we assess accuracy without knowing the diagnosis?  Many researchers are looking for proxies, or studying specific situations.

Diagnostic excellence requires careful thought, and persistence.  Not all diagnoses present in obvious ways.

Kopelman and Kassirer first introduced clinical problem solving exercises to print in the New England Journal of Medicine.  Several other journals now feature these exercises.  I would submit that reading these publications helps one understand the thought process involved in getting to the correct diagnosis.  As one who has participated in publishing several of these articles, I would argue that all students of clinical medicine should focus on studying these articles and having an experienced clinician lead a discussion of the processes.

During clinical rotations, our teachers must focus on teaching the thought process.  For example, you have a patient with a potassium of 2.5.  The intern writes for potassium replacement with 20 mEq in each liter of normal saline.  Too many attending physicians will tell the intern to change the IV fluids to a different concentration.  They are the micromanagers.  The best attending physicians use this as an opportunity to make certain that the intern, resident and medical students understand the degree of potassium deficit, the limits of IV replacement, and ask the question – why is the potassium so low?  That teaching physician gets the same result as the micro-manager, but everyone is happy because they now understand how to approach this problem.  They understand the correct treatment depends on understanding how why the potassium is low, as well as understand the physiologic details of replacement.

We must teach thinking. Great medicine does not come from following scripts.  Great medicine occurs when the clinician knows enough to either proceed or know that they need another physician to help.  Algorithms are not the answer.  Excellent thought processes are the answer.

Comments (3)

RE:Excellent thought processes
Doing the right thing is easy. Knowing what the right thing is, is hard to do.

Excellent post; if we just focus on above for next 20 years in training students/ residents and then give them time to practice with thought process intact, it will save more money and give better outcomes than anything else.

A very few young physicians understand natural progression of illness… When Every hypoxemia with an abnormal CxR gets a CT to rule out PE, it breaks my heart.

While I do not understand what Amidoc wrote, I agree with the point. We watch older friends pushed for more test, more appointments, and more treatments, all with no clear focus on outcomes other than the financial gain of those involved.

Sad is watching someone anxiously awaiting the results of a test or scan, as if this alone will change the outcome, or course, of an aggressive and terrible disease.

Pharma and corporate medicine has convinced the public that with a little more technology, or a little more money, we here in America can overcome any disease and some how prevent the inevitable.

Steve Lucas

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