Teaching Clinical Reasoning

Carlos Estrada, MD, MS cestrada@uab.edu

Martin Rodriguez, MD mrodri2@uab.edu

Starr Steinhilber, MD, MPH ssteinhilber@uabmc.edu

David McCollum, MD dmccollum@uabmc.edu

Tinsley Harrison Internal Medicine Residency Program

Learning Objectives

Identify key concepts of clinical reasoning,

diagnostic error, and biases

Illustrate educational strategies to promote

clinical reasoning

Outline

Introductions … 5 min

Clinical reasoning … 15 min

Small group exercise … 15 min

Diagnostic errors … 10 min

Conclusions … 10 min

Evaluation … 5 min

Clinical reasoning

Diagnostic reasoning

Considered by many to be the most critical of a physician’s skills

“It is every doctor’s measure of his own abilities; it is the most important ingredient in his professional self-image”*

* Nuland SB. How we die: reflections on life’s final chapter

Process of diagnostic reasoning

Synthesis of information generating a “problem representation”

Summary of the information that is available

Comparison with “illness scripts”

Information that has been acquired from similar patients, books, journals, talks

Problem representation

45 year old lady comes in with 4 weeks of abdominal distention. She reports that for the last 4-5 months she has lost 30 pounds. She has a family history of ovarian cancer in her mother at age 52. She reports no other past medical history, but has not seen a doctor in years. Exam is suggestive for ascites. An ultrasound confirms ascites and reveals a pelvic mass. Paracentesis reveals low SAAG

Middle age lady with subacute onset of low SAAG ascites, weight loss, family history of ovarian cancer, and pelvic mass

Illness scripts

This information is compared with illness scripts in our “internal library” of medical knowledge

Ovarian cancer: frequently presents with ascites, pelvic mass, family history occasionally seen, low SAAG

Cirrhosis: other stigmata of liver disease may be present, known to have liver disease, SAAG ≥ 1.1

A list of likely diagnoses is generated

Further data is obtained: more history, results, new tests

Semantic qualifiers

Descriptors that can be used to compare and contrast diagnostic considerations

45 year old (middle age), 4 weeks (subacute)

Other examples:

“Last night and started all of a sudden”: acute and abrupt

“I have had problems like this before”: recurrent

“It always happen on my left side”: unilateral

“The pain kept me up all night and was 10/10”: severe

Trainees should be encouraged to use such semantic qualifiers

Diagnostic reasoning, thinking about a patient?

Dual process theory: intuitive and analytical

Intuitive

Does not require attention or cognitive effort

Utilized daily

Analytical

Requires our attention, cognitive effort

Utilized in new situations, in challenging scenarios

Norman GR. Medical Education 2010; 44:94

Intuitive process

Rapid recognition of a pattern

First impressions

Use of previous experiences and knowledge

Minimal cognitive effort

Highly efficient

Susceptible to context and bias

Our brains developed this tool for efficient use of cognitive effort

Kassirer J. Acad Med 2010; 1118. Croskerry P. Acad Med 2009; 84:1022

Intuitive process

HIV-infected patient, comes in with 2 days of rash in palms, recently had unprotected sex

Someone with experience would recognize the pattern as secondary syphilis

Analytical process

Slower

Requires cognitive effort

Based on similar previous experiences or knowledge, logic

Usually activated when we encounter a new experience, atypical or complicated situation, when we don’t recognize a pattern

May be less susceptible to bias

Kassirer J. Acad Med 2010; 1118. Croskerry P. Acad Med 2009; 84:1022

Analytical process

HIV-infected patient, CD4 50, admitted with fever, esophagitis, weight loss, pancytopenia

Nonspecific presentation

Many diagnostic possibilities, broad differential diagnosis, coexistent pathologies

The patient is diagnosed with lymphoma and esophageal candidiasis utilizing the analytical process

Intuitive Analytical

Speed Rapid Slow

Cognitive effort Minimal Significant

Characteristics First impressions, pattern recognition

Activated in unfamiliar situations, complex or atypical

Requirements Based on previous knowledge and experiences

Based on knowledge, logic

Biases More susceptible to cognitive and contextual

biases

Less susceptible to biases

Intuitive vs. analytical process

Dynamics of these two processes

Intuitive vs. analytical processes

One process is not better than the other

Intuitive process

Efficient, frequently works well

Limitations to manage unfamiliar situations

Tendency to try to solve problems with known solutions instead of looking for new solutions

Analytical process

Allows more complete thought process

May be inefficient, excessive evaluation, “paralysis by analysis”

Kassirer J. Acad Med 2010; 1118. Croskerry P. Acad Med 2009; 84:1022. Croskerry P. Health Quart 2009; e171

Intuitive vs. analytical processes

Ideally clinical reasoning should use both processes in a dynamic way

Exclusive use of one of them is suboptimal

Experts develop the ability to slow down during clinical reasoning and use analytical process when needed

Kassirer J. Acad Med 2010; 1118. Croskerry P. Acad Med 2009; 84:1022. Croskerry P. Health Quart 2009; e171. Moulton CE, et

al. Acad Med 2007; 82(Sup 10): S109

Per

form

ance

Cognitive effort

Student Student or

resident

Resident Practicing

physician

Only a few

Intermediate level

Novice

Competent Expert

Master

Abilities

Analytic >

intuitive

Intuitive >

analytic

Diagnostic reasoning

Problem representation

Illness scripts

Semantic qualifiers

Dual process theory

Intuitive

Analytical

Small group exercise

Small Group Exercise

How would you teach clinical reasoning? How

would you introduce the concepts?

What is the ‘problem representation’ you would

expect to hear? What ‘semantic qualifiers’ could be

used?

What would you want to see in their Assessment &

Plan?

Small group exercise

Diagnostic errors in internal medicine

Very frequent

15% of internal medicine patients

Study in a hospital

Average number of errors was 6, usually multifactorial

Cognitive errors and health system problems

Mistakes in clinical reasoning

Synthesis and data acquisition

Lack of knowledge was rare

Graber ML, et al. Arch Inter Med 2005; 165:1493

Cognitive biases

Very common, long list

Associated with:

Incomplete information

First impressions or emotional responses

Context and expectations

Assign an incorrect probability to a diagnosis

Premature diagnosis

Kassirer J. Acad Med 2010; 1118

Heuristics (mental shortcuts)

Utilized to solve common problems, without cognitive effort

Present in our daily life

Many sources, previous experiences, friends, colleagues

Not necessarily good or bad, helpful but may fail

Examples

Leg edema after prolonged trip = DVT

Thrush = HIV

Sometimes can lead to errors

Case

54 yo homeless man, admitted with hemoptysis

CXR reveals cavitary lesions

AFB in sputum negative times 3

Diagnosed with TB, starts treatment

Case

Two months later cultures are still negative, treatment is continued

Patient requires second opinion, MD says not needed

One month later develops sinusitis

ID doctor sees patient, continue TB treatment

Patient looks for a third opinion, dx with granulomatosis with polyangiitis

Common cognitive biases

Heuristics

Hemoptysis and lung cavity in a homeless = TB

Not always right

Availability bias

If one sees a lot of X, or has read about X, then we are

more likely to think of X as a likely diagnosis

Common cognitive biases

Premature closure

Tendency to stop the diagnostic process too soon and

not consider other alternative diagnoses

“Classic case of TB”

Anchoring

We hold on to a diagnosis even if there is information that suggests otherwise

Negative sputum, cultures, the MD insists this is TB

Diagnosis momentum

Previous diagnosis of X, then we assume X is the correct diagnosis

Common cognitive biases

Overconfidence

We overestimate our diagnostic abilities

Very frequent and part of human nature

94% of physicians in academic practice think they are in the top 50% of their profession

“Because I am a doctor I know what is going on and I don’t need to refer her to another doctor”

Berner ES. Am J Med 2008; 121:S2

Diagnostic errors

Biases are inevitable, learn to recognize them

Heuristics and other cognitive biases

Consider routine use of 3 questions:

What else could this be?

Is there something that does not fit?

Is there more than one diagnosis?

Thank you

Homework

Watch clinical reasoning video: Amanda Vick, MD (15 min)- link http://tinyurl.com/ml3sb43

Read article: Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006;355:2217-25. PMID:17124019.

Read Groopman, Jerome. What’s the trouble? The New Yorker. January 29, 2007; 34-39. http://tinyurl.com/le8pt36

References Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006;355:2217-25. PMID:17124019.

Croskerry P. A universal model for diagnostic reasoning. Acad Med. 2009; 84:1022-28. PMID:19638766.

Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med.

2007;82(10 Suppl):S109-16. PMID:17895673.

Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85(7):1118-24. PMID:20603909.

Norman G. Diagnostic errors and dual processing. Adv Health Sci Educ Theory Pract. 2009. Suppl 1:37-49. PMID:20078760.

Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ, US: Prentice-Hall, Inc; 1986.

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Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493-9. PMID:16009864

Groopman J, Hartzband P.Thinking about our thinking as physicians. 2011. http://www.acpinternist.org/archives/2011/10/mindful.htm.

Graber ML. Educational strategies to reduce diagnostic error: can you teach this stuff? Adv Health Sci Educ Theory Pract 2009;14(suppl

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Marie-Claude Audetat, et al, What is so difficult about managing clinicial reasoning difficulties? Med Education 2012;46:216-227. PMID:

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