Thinking, physiology and medical education


Category : Medical Rants

I have written this many times. Medical students and residents want their educators to model the thought process. Yesterday I spent some time with a colleague discussing this concept. We agreed that data are retrievable, but using data is the key to good doctoring.

Medical education, at least in the first two years of medical school, does not focus enough on the thought process. Jerome Kassirer in a very important paper proposed that we actually teach clinical reasoning throughout medical school. He emphasizes that we should focus our efforts on understanding actual case presentations –

The theory proposes that memory of clinical medicine and clinical reasoning strategies is enhanced when errors in information, judgment, and reasoning are immediately pointed out and discussed. Rather than using cases artificially constructed from memory, real cases are greatly preferred because they often reflect the false leads, the polymorphisms of actual clinical material, and the misleading test results encountered in everyday practice.

As educators we should strive for understanding rather than memorization. Clearly in medicine we do have to memorize many facts, but that process goes much more smoothly if we have a cognitive framework on which to hang our data. If we understand, we can categorize our differential diagnoses and thereby use that process to narrow our diagnostic possibilities. For example, when we have a patient with anemia, the thoughtful physician first asks if the anemia is a production problem, a destruction problem or a blood loss problem. If it is a production problem, then we must ask if there is a nutrient deficiency or a primary bone marrow deficiency. As we match the physiology and pathophysiology to the patient’s presentation we can construct a logical storyline to understand how and why the patient is presenting at this time with this finding.

While I do not have data, many learners tell me that this style of teaching has become less common. Since our research showed that learners want understanding learned when their teachers make their thought processes explicit, we should work hard to emphasize this point.

If you are a clinical educator, ask yourself if you focus on lists or the reason for the lists. If you are a learner (and actually we all are) are you more attracted to teaching that focuses on helping you understand rather that listing factors.

Of course, I have created a straw-man argument with which almost no one would disagree. Please share any reflections you have of this teaching style.

Comments (3)

I strongly endorse the approach you proposed of guided discussion around clinical reasoning. I encourage widening the lens during a discussion to include patient context, and think it’s useful to do this as a matter of habit when discussing cases with medical students and residents. For instance, if a patient’s chronic condition, e.g. diabetes, is increasingly hard to control is that a biomedical problem (e.g. increasing peripheral insulin resistance) or a contextual problem (e.g. worsening vision resulting in errors in self administration of insulin)? Just as there are pathophysiological differentials for clinical presentations, so too are there contextual differentials.

We’ve identified 12 broad “domains of context” to consider when a patient’s clinical presentation may be attributed to a life change: competing responsibilities, social support, access to care, financial situation, skills/abilities/knowledge, emotional state, cultural perspective/spiritual beliefs, attitude towards illness, relationship with healthcare provider/system, resources, and health behavior. Clinical reasoning should consider both “under the skin” and “outside the skin” (ie contextual) factors in every clinical presentation.

The contextual problems we focus on these days – 1) are all diagnosis covered with right terminology for insurance to cover payment ( our hospital even called a consultant to teach this) 2) are all notes dated and timed 3) are medical residents complying with duty hours 4) predicting where patient will be discharged 5) will the patient be read tired in 31 days ( well if we can treat the right problem on the first time, possibly not) etc etc….

I sincerely hope the wheel of medicine will turn in my lifetime so that we can focus on ththe real biomedical and contextual problems as stated above.”……..seems like patients are for health care rather than health care for patients.


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