Teaching Clinical Reasoning
In The Apprenticeship Model
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Dennis Baker
Greg Turner
Lynn Romrell
* Stimulate discussion of clinical
reasoning in the context of curriculum
redesign
* Share ideas with those who design and
implement the 3rd and 4th years of our
medical education program.
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Describe the role of analytical reasoning
and pattern recognition in clinical decision
making.
Define cognitive bias and give examples of
the mental errors resulting from it.
Define framing and give examples of how
a physician’s framing of information can
lead to an uniformed patient decision
Describe strategies the clinical teacher can
use to facilitate the learner’s acquisition of
clinical reasoning skills
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Consistent with the U.S. national failure
pattern, 10% of our 2nd year students in the
past 2 years have failed USMLE step 1.
Additional students have trouble with the first
or second NBME shelf exams in the third year.
Many of them struggle with OSCE cases that
they represent a “mystery” diagnosis.
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Misdiagnosis is common: 15-20%
Most of the time (80%) these are
cognitive errors, not knowledge deficits
“Thinking about our thinking as physicians”
Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP
CurrMIT data:
 Clinical reasoning was coded as a topic
in 389 session (lectures, labs, small
groups, etc.)
 We do not know the amount of time
spent on the topic or even if it was a
major point of emphasis. We just know
the topic was covered.
COURSE
Clinical Anatomy/Embryology/Imaging
Clinical Microanatomy
Clinical Neuroscience
Clinical Physiology
Doctoring 101
Doctoring 102
Doctoring 103
Doctoring 201
Doctoring 202
Doctoring 3
Health Issues in Medicine 201
Medical Biochemistry and Genetics
Medicine and Behavior 201
Medicine and Behavior 202
Microbiology 201
Microbiology 202
Pathology 201
Pathology 202
Pharmacology 201
Pharmacology 202
Grand Total
SESSIONS
36
17
34
21
14
14
21
32
36
49
1
9
8
4
11
11
16
20
10
25
389
How can we
help students
develop
their clinical
reasoning
skills?
(Benamy, 1996)
A Developmental Competency
Experience and
Deliberate Practice
Doing something wrong repeatedly will
not improve the outcome.
The process by which clinicians collect
cues, process the information, come to
an understanding of a patient problem
or situation, plan and implement
interventions, evaluate outcomes, and
reflect on and learn from the experience.
Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al., 2001
Clinical Reasoning Concepts
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Diagnosis
Hypothesis generation
Context formulation
Test interpretation
Bayesian reasoning
Causal reasoning
Differential diagnosis
Assessing for adequacy
Working diagnosis
Cognitive Errors
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Treatment
Treatment under
uncertainty
Risk benefit analysis
Treatment thresholds
“Toss ups”
Therapeutic trial
Watchful Waiting
Analytical (Deliberate)
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Novice: Does Not Recognize the Pattern
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Expert: Case Does not Fit the Pattern
Non-Analytical (Pattern Recognition, Intuitive)
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Principles of logic and hypothesis
testing.
Journal Club
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Start with what we know.
Problem solving algorithms.
Head to Toe, Body Systems,
Pathophysiology, Acute vs Chronic,
Rule out Worst Case Scenario,
Exhaustive method, Deductive
(Covered in Doctoring 103)
Acad Emerg Med: November 2002, Vol 9, No.11
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YEAR 1
Doctoring 1
Anatomy
Neuroscience
Physiology
Biochemistry and
Genetics
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YEAR 2
Doctoring 2
Microbiology
Pharmacology
Pathology
Medicine and
Behavior
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Consciousness requires:
 Glucose
 Oxygen
 Adequate BP and blood flow to
deliver above
 Organized electrical activity in the
brain
Syncope results when any of these are
impaired
Bayesian Theory
 The predictive value of any diagnostic
test is proportional to the prevalence
of the disease in the population
tested.
 Describes uncertainty when potential
outcomes are not equally likely.
 As evidence is collected the
probability is altered.
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Physicians often need to make
decisions with incomplete information
We can always do “one more test.”
Odds vs. Stakes (Chest Pain, Rectal Bleed)
Cost vs. Benefit (Unexplained Wt Loss)
Defensive Medicine
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Make the Pattern Fit the Patient, not
the Patient Fit the Pattern. (18 month
old with lethargy and hyperglycemia)
Don’t stop looking until it fits.
Reconcile symptoms (palpitations,
lightheadedness) with findings (EKG,
blood glucose)
Decisions
are not simply
a result of
logic.
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Our attempt to Simplify Complexity
Simple rules of thumb that lead to
predictably faulty judgments
Subconscious mental procedures for
processing information
Remains compelling even after one is
aware of it
Center for the Study of Intelligence, CIA, 1999
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Aggregate bias
Anchoring
Ascertainment bias
Availability
Confirmation bias
Fundamental
Attribution error
Gambler’s fallacy
Gender bias
Hindsight bias
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Illusory
Omission bias
Outcome bias
Overconfidence bias
Playing the odds
Premature Closure
Representativeness
Restraint
Visceral bias
Zebra retreat
Achieving Quality in Clinical Decision Making: Cognitive Strategies and
Detection of Bias by Pat Croskerry, MD, PhD
A willingness to diagnose based on
incomplete information when
relevant information is available.
The tendency to seek out and assign
more significance to evidence that
confirms a pattern and ignore or assign
much less significance to evidence that
does not.
1994 Iraq No Fly Zone
‾
Air Force F-15s
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Air Force AWAC Plane
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Army Blackhawk
Helicopters
Snook, Scott A. Friendly Fire: The Accidental Shootdown of U.S. Black Hawks Over
Northern Iraq. Princeton, NJ: Princeton University Press, 2000. (Winner of the
George R. Terry Book Award, Academy of Management, 2002.)
Army Black Hawk
Hind
68 year-old male with known coronary
artery disease presents with chest pain,
nausea and shortness of breath and a
complaint of “I’m having another heart
attack doc.”
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Tendency to rely too heavily on one
piece of information when making
decisions.
OR
Inappropriate reference point
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Causation
Association
Background Noise
Attention Women who have had breast
implants and are having health problems.
Do you have the following symptoms?
• Chronic Headaches & Fatigue
• Upper & Lower Back Pain
• Pain in your Breast
• Hair loss
• Joint Pains
• Swelling
• Muscle Pains
• Memory Loss
• Unexplained Rashes
Dear Mr. Frailich,
“Your winning the $110,000.00 Dow
Class Action claim for my wife, was a
tremendous boost to our morale after
my wife's suffering so many years
with the symptoms of implant toxicity.
We were also surprised to receive the
claim check much earlier than your
office predicted that we may.”
1/7/11 J.P. Grand Rapids, MI
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Silver Dollars and Umbilical Hernias
Antibiotics and viral infections
Bed Rest and Premature Labor
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Unavoidable Risk
Information Cascade
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Confirmation: Does everything fit?
Illusory: What is the real relationship?
Overconfidence:
Did you find everything?
Anchoring, Availability, Attribution:
What else could it be?
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Mental model that influences how we
present an issue to others.
Influence of risk-aversion on decision
making.
Opportunity or Threat?
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Chantix Representative
Long Term (1 year) quit rate with
Chantix is 270% that of placebo
Welbutrin Representative
Rate of serious Cardiovascular Events
with Chantix was 25% higher than
placebo
The Medical Letter on Drugs and Therapeutics •
August 22, 2011 (Issue 1371) p.65
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A method of introspection in which
one is expected to contemplate or
reflect on their own thinking to avoid
cognitive errors.
A check and balance between intuition
and analysis.
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Disease is a movie, you may only have
one scene.
Defensive Medicine is not Clinical
Reasoning.
How we think, is what we will teach.
Let the students hear you
“think out loud”.
“The role of the teacher is not to
transmit knowledge but to facilitate
learning, encourage spontaneity, and
engage in mutual inquiry.”
“The best time to learn anything is when
the material is immediately useful.”
“Deliberate Practice”
Teaching Clinical Reasoning: Case-Based and Coached
Jerome P. Kassirer, MD
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Multiple Patient Exposures
Beginning in the First Year
Deliberate Developmental Progression
Learner Driven
Expert Mentors
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Should we further develop a clinical
reasoning curriculum?
What would the developmental
progression look like?
Would the Doctoring courses form the
backbone?
How do we train/engage the clinical
faculty?
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“How Doctors Think”
Jerome Groopman
Lecture Series – The Art Of Critical Decision Making
Professor Michael Roberto
Lecture Series - What Are the Chances? Probability Made Clear
Michael Starbird, Ph.D.
“Thinking about our thinking as physicians”
ACP Internist and American College of Physicians, October 2011
Jerome Groopman, MD, FACP and Pamela Hartzband, MD, FACP
Wikipedia
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