1. Teaching Clinical Reasoning
Jennifer Jackson, MD
Wake Forest School of Medicine
Ronald Silvestri, MD
Harvard Medical School

2. Goals & Objectives Discuss clinical reasoning terminology
Describe cognitive models of clinical reasoning
Discuss instructional strategies for helping students develop their clinical reasoning skills throughout their curriculum
Take home to your institutions practical ideas for how to improve the teaching of clinical reasoning to your students

3. Why teach students about clinical reasoning?
Diagnostic errors are frequent.
Estimates: 10-15%
Common occurrence in all fields of medicine
Diagnostic errors have major consequences.
2nd leading cause of adverse events, among medical errors
Associated with higher morbidity than other medical error types

4. Why teach students about clinical reasoning?
Thinking about how we reason makes us more effective clinicians.
When clinicians are forced to rethink their instinctive responses in solving complex cases, they make fewer diagnostic errors.
Teaching novices strategies to avoid cognitive errors can shorten their road to attainment of expertise.

5. Clinical Reasoning Skills
The Lingo

6. Clinical Reasoning (“Clinical Cognition”)
“The range of strategies that clinicians use to generate, test, and verify diagnoses, to assess the benefits and risks of tests and treatments, and to judge the prognostic significance of the outcomes of these cognitive achievements”
- Kassirer 2010

7. Problem Representation
A physician’s evolving sense of the clinical picture; a way of describing a specific case in abstract terms (“one liner”)
e.g., full-term newborn with severe, acute respiratory distress
Components:
Patient demographics
Clinical features from the history and PE
Semantic qualifiers (severe vs. mild; acute vs. chronic; unilateral vs. bilateral)

8. Illness Script
A mental representation of the important elements of an illness
e.g., strep throat: acute, febrile illness with exudative tonsillitis
The same illness script may be linked to more than one problem representation (i.e., different clinical presentations of the same disease).
Developed by medical knowledge and refined through clinical experience

9. Illness Script Includes: Pathophysiology Who gets it
Key signs and symptoms
Duration/pattern of symptoms
Includes:
How the disease happens (pathophysiology)
Who gets it (demographics, risk factors, exposures)
Key signs and symptoms
Natural history (duration/pattern of symptoms)
Clinical Problem-Solving, Catherine Lucey, MD, UCSF (

10. Cognitive Models of Clinical Reasoning
Dual-processing theory: 2 distinct modes of thinking occur when clinicians reason:
Intuitive (non-analytic) reasoning:
“gut reaction”—impulsive, effortless, reflexive
Pattern recognition
Highly context dependent
Error prone
Analytical reasoning: slow, explicit, deliberate, purposeful effort to solve a problem
Hypothetico-deductive
Generally more reliable
“Looks like a duck”

11. Dual-Processing Theory
Eva, 2004
The clinical reasoning process is dynamic.
Intuitive and analytic reasoning modes interact with one another.
Clinicians “toggle” back and forth between the 2 modes in making decisions.

12. Dual-Processing Theory
Analytic mode can override the intuitive mode, and vice versa.
Repeated presentations to the analytic mode will eventually result in pattern recognition  default to the intuitive mode.
Novices tend to spend more time in the analytic mode, whereas experienced clinicians spend more time in the intuitive mode.

13. Hypothesis-Driven Data Gathering
During a patient encounter, expert clinicians
gather data based on their hypotheses
about the patient’s symptoms.
Focused history and review of systems
Hypothesis-driven physical exam
More effective in detecting PE findings and establishing a diagnosis than doing a survey exam without a diagnosis in mind
Differential diagnosis formation is iterative…

14. Hypothesis-Driven Data Gathering
Chief complaint, patient demographics
Initial problem representation
Scanning for illness scripts
Initial hypotheses
Before seeing patient
During patient encounter
Gather data
(history, PE, labs)
Working diagnosis
Analyze/
synthesize data,
refine the problem representation
Scanning for illness scripts, key features
Refine diagnostic hypotheses
(differential dx)

15. Metacognition
A method of introspection in which one contemplates or reflects on one’s own thinking; i.e., thinking about thinking
“It distinguishes…the thinking of experts from that of non-experts.”
- Croskerry 2003

16. Metacognition Effective metacognition involves:
Awareness of the learning process—knowing when a piece of information is important enough to commit to memory
Recognition of the limitations of memory
Ability to step back from the immediate problem at hand and appreciate the broader picture
Capacity for realistic self-critique and self-monitoring
Ability to actively select a strategy to deal with problems in decision-making—a deliberate cognitive intervention in the thinking process

17. Teaching Methods & Strategies
Coming…..
Clinical Reasoning Skills
Teaching Methods & Strategies

18. Small Group Discussion
Your curriculum revision subcommittee is charged with optimizing the teaching of clinical reasoning
1. What specific educational experiences and curricular changes would you propose & where?
2. Which of these changes are possible in the near term vs. intermediate term in your institution?
3. What are the obstacles to your students improving their clinical reasoning skillfulness?
Vascular
Infectious/Inflammatory
Neoplastic
Degenerative
Intoxication
Congenital/Hereditary
Autoimmune
Traumatic
Endocrine
Metabolic/Nutritional
Psychologic/Psychiatric 18

19. Large Group Discussion
Each table takes 5 minutes to report its proposed educational experiences, curricular changes, obstacles, etc.
Large group exchange of ideas

20. Teaching Methods & Strategies
Clinical Reasoning Skills
Teaching Methods & Strategies

21. Clinical Reasoning Starts at the Bedside
Sufficiently detailed & discriminating H&P
Think “What’s going on & what’s causing it” from the beginning of the HPI
Generate hypotheses as to potential causes of the problem
Test these hypotheses during H&P, seeking evidence of “clusters” of sx and signs pointing to various hypotheses amidst HTT exam
Allow hypotheses to be refined as new H&P data obtained
Use illness scripts, prior experience, or Dx props

22. Strategies for Teaching Clinical Reasoning
“VINDICATEM-P”: pathophysiology categories
Vascular
Infectious/Inflammatory
Neoplastic
Degenerative
Intoxication
Congenital/Hereditary
Autoimmune
Traumatic
Endocrine
Metabolic/Nutritional
Psychologic/Psychiatric
Vascular
Infectious/Inflammatory
Neoplastic
Degenerative
Intoxication
Congenital/Hereditary
Autoimmune
Traumatic
Endocrine
Metabolic/Nutritional
Psychologic/Psychiatric 22

23. Create a Pathophysiologic vs. Anatomic Grid to help in DDx
Ex: for Chest Pain think VINDICATEM for each site below
Skin
Ribs and muscle
Pleura
Pericardium
Myocardium
Endocardium
Lungs (bronchi, vessels, parenchyma)
Esophagus
Aorta
Spine and exiting nerves
Vascular
Infectious/Inflammatory
Neoplastic
Degenerative
Intoxication
Congenital/Hereditary
Autoimmune
Traumatic
Endocrine
Metabolic/Nutritional
Psychologic/Psychiatric

24. The Student First Has to Know about Problem Lists and Differential Dx
A “Problem” is any abnl sx, sign, illness, lab/imaging or constellation of them that makes clinico-pathophysiologic sense
A DDx is list of or paragraph of possible diagnoses or processes…
That explains a particular problem…
In this particular patient…
That includes data for & against each dx…
And is ordered according to likelihood

25. Strategies for Teaching Clinical Reasoning: After the Bedside – Student Next Steps
Assemble data into coherent presentation
Step back, review, reflect, read & create Problem List
Focus on problem(s) needing diagnosis or cause
Create a DDx of each problem
Use pathophys. knowledge & prior clinical experience
Assess defining & discriminating features
Weigh sensitivity & specificity of various clinical findings
Consider pre-test probabilities
Write down further actions to narrow DDx (tests/Rx)
Vascular
Infectious/Inflammatory
Neoplastic
Degenerative
Intoxication
Congenital/Hereditary
Autoimmune
Traumatic
Endocrine
Metabolic/Nutritional
Psychologic/Psychiatric 25

26. Teaching Clinical Reasoning
Early meaningful mentored clinical exposure
Allow students to PRACTICE these skills on their own patient cases, and do it often!
Use current “unknown dx” cases and return to those cases where the dx finally made
Introduce the basic concepts of problem representations, illness scripts, and dual-processing.
Discuss possible cognitive errors that can occur (use real examples) and methods for avoiding them.

27. Strategies for Teaching Clinical Reasoning
CARD: variations of clinical presentation types
Common diseases
Atypical presentation of a disease
Rare diseases
“Don’t miss” diseases
Vascular
Infectious/Inflammatory
Neoplastic
Degenerative
Intoxication
Congenital/Hereditary
Autoimmune
Traumatic
Endocrine
Metabolic/Nutritional
Psychologic/Psychiatric

28. Strategies for Teaching Clinical Reasoning
SEA TOW - Avoiding Errors of Omission
Second Opinion…Do I need one?
Eureka Moment…Is this a pattern recognition dx?
Anti-evidence…Is there anything refuting the dx?
Thinking over my thinking…Have I done it?
Overconfident…Am I?
What else… could I be missing?
Williams,PA. Society for Medical Decision Making 2010
Vascular
Infectious/Inflammatory
Neoplastic
Degenerative
Intoxication
Congenital/Hereditary
Autoimmune
Traumatic
Endocrine
Metabolic/Nutritional
Psychologic/Psychiatric 28

29. Strategies for Teaching Clinical Reasoning
Get a commitment: “what do you think is going on in this case?”
Probe for supporting evidence: “What led you to that conclusion?”
Do a Wrap up for “adequacy” and “coherence” of case discussion
Teach 1-2 general rules that will apply to other situations
Reinforce what was done well
Correct mistakes

30. Strategies for Teaching Clinical Reasoning
Guidebook for Clerkship Directors, 4th Ed.
by Bruce Morgenstern
Lots of additional examples of clinical reasoning exercises for all levels of medical students

31. References
Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb 2011; 41:155–62.
Croskerry P. The importance of cognitive errors in diagnosis and strategies to prevent them. Acad Med 2003; 78:1–6.
Croskerry P. Cognitive and affective dispositions to respond. In: Croskerry P, Cosby KS, Schenkel S et al., editors. Patient safety in emergency medicine. Philadelphia: Lippincott Williams & Wilkins; p. 219–27.
Croskerry P. Cognitive Forcing Strategies in Clinical Decisionmaking. Annals of Emergency Medicine 2003;41(1):
Croskerry P, Abbass A, Wu A. Emotional Influences in Patient Safety. J Patient Saf 2010;6(4):1-7.
Hogarth RM. Educating intuition. Chicago: University of Chicago Press; 2001.
Elder L, Paul R. Critical thinking development: a stage theory with implications for instruction. Tomales, CA: Foundation for Critical Thinking; Available from:
Kassirer JP. Teaching Clinical Reasoning: Case-Based and Coached. Academic Medicine 2010;85(7):
Atkinson K, Ajjawi R, Cooling N. Promoting clinical reasoning in general practice trainees: role of the clinical teacher. The Clinical Teacher 2011; 8:
Rencic J. Twelve tips for teaching expertise in clinical reasoning. Med Teach 2011; 33:
Eva KW. What every teacher needs to know about clinical reasoning. Med Educ 2004; 39:

32. Wrap Up Take home points from today
How can or should DOCS as an organization advance the teaching of clinical reasoning?
Can we or should we try to do it alone? If not, who should our partners be?