Educational Strategies to Promote Clinical Reasoning
Gurpreet Dhaliwal, MD
December 2014
CLINICAL (EXPERIENTIAL KNOWLEDGE) STRATEGIES
I. Problem Representation
Practice problem representation. Teach learners to solve problems by defining them first.
This is the entry point to script selection and comparison. Practice using descriptive terms
that would be good Google search terms. Useful problem representations generally contain:




defining and discriminating features (from other diagnoses) of the illness
abstraction of key clinical details (e.g., prednisone 40mg daily 
“immuncompromised”)
medical terminology (“orthopnea”)
temporal (acute vs. chronic), qualitative (rest vs. exertional), or contextual (young
vs. old) features
Teacher provides an example of problem representation. The elimination of
redundant, irrelevant, or nonspecific findings (e.g., malaise) can be highlighted, or the
relative importance of the chosen features (e.g., dysphagia is more specific than dyspepsia)
can be emphasized.
II. Script Selection
Promote compare and contrast between two diseases rather than teaching about one
disease in isolation. Make learners define and discriminate between the leading
diagnoses. This will enhance understanding of “relevant” information, will form
connections between diseases, and will point out gaps in their illness scripts.
Probe for reasoning when a diagnosis is suggested. Activate what students already
know by asking them to describe the prototypical case (i.e., reveal their illness scripts) and
then ask how they compared and contrasted among the possible diagnoses and the
problem representation.
Teach by example (modeling). After providing a problem representation, model
comparing and contrasting of diseases (by revealing your illness scripts).
Encourage the use of pattern recognition in addition to analytical reasoning in making
diagnoses. This allows students and residents to start adapting the same highly effective
problem solving approach as practicing physicians, and research supports the promotion of
pattern recognition (it’s not dangerous).
Provide cognitive feedback. Point out cognitive pitfalls such as heuristics and biases in
learners’ analyses and how they can be avoided in the future. This makes reasoning, rather
than facts alone, a focus of assessment or feedback and shifts the focus of teaching from
what (knowledge) to why (reasoning).
III. Script (Knowledge) Development
Guide patient exposure…. The foundation of illness scripts should be common and
prototypical cases. Atypical or rare cases are sub-optimal initial exposures to a disease or
problem, as it takes a long time to recalibrate after first exposure (e.g., pheochromocytoma
as the anchor for a hypertension illness script). First impressions stick.
…but allow random patient exposure. For basic script building, “mixed practice,” where
problems are not pre-packaged as cardiac, gynecologic, or psychiatric, is optimal. Principle:
building knowledge in a (cognitive) environment that resembles the one where it will be
accessed later to optimize recall and transfer in new situations.
Connect material using concept maps. Concept maps are a visual representation of how
knowledge is organized and represented in memory. They can enhance understanding of
the relationships between concepts. (Example: “nodes” of anemia, renal failure, and lytic
bone lesions are all linked to “multiple myeloma,” but each concept has many other
linkages also.)
READING (FORMAL KNOWLEDGE) STRATEGIES
Less is more. Get the big picture first (form a scaffolding for the illness scripts) and then
fill in the blanks with more detailed reading and clinical experience. Excessive information
risks cognitive overload and minimizes retention.
Prioritize common diseases that need to be understood in real world practice rather than
the entire differential. Better to have a robust understanding (scripts) of the 4 most
common causes of shortness of breath than to be able to list the 30 causes in the textbook.
“Read on your patients.” Patient specific reading is more effective than general reading
because the knowledge is formed in the same context it needs to be accessed in the future –
with a patient and their issues in mind. Recent patient exposure = prime time to build the
illness script.
Never read about one condition alone. Encourage the habit of always learning about the
competing diagnosis (rather than just the patient diagnosis) and then comparing and
contrasting the distinguishing and discriminating features between diagnosis #1 and #2. In
real world practice, many diagnoses are made not in absolute terms but in comparison to
competing diagnoses. This reading habit replicates that cognitive process.