Ágoston Kecskés

992868991

January 20, 2012

Blog Entry #14: Tips on clinical reasoning

A new ‘Twelve tips’ article appeared in a recent issue of Medical Teacher on clinical reasoning.[1] Unfortunately, I was not terribly inspired by what I read. The tips were very broad and were applicable mainly in retrospect. That is, I did not feel that had I an opportunity to redo my core rotations I would have acted much differently.

My performance in the clinic is far from perfect – that’s part and parcel of being a learner. I could think of many ways that I could have improved my core rotations. However, there is a difference between advice that works in the present and advice that’s works in retrospect.

The first tip is to maximize learning from each patient encounter. Residents and attending physicians often tell their clerks to read around their cases. Throughout my core rotations I heeded this advice. I carried around a small pad to jot down concepts I wanted to follow up on in my studying. But I never had trouble thinking of how to connect my learning to the cases I had seen in the course of the day. The problem was always that I had TOO many cases to read up on. Furthermore, I inevitably had to choose between reading up on something esoteric and weird and wonderful, and something relatively common but relatively mundane. And then I also had to keep up with the required studying and readings for the final examinations.

The second tip is to capitalize on pathophysiologic knowledge to make diagnoses. The trouble with this approach is that bread and butter presentations often have a tried and true list of possible diagnoses. One often cannot derive these diagnoses from pathophysiologic first principles – or at least no easily. In addition, often the pathophysiology is only understood piece-meal and connecting the dots is either unintuitive or simple incorrect. A lot of the pathophysiology taught in medical school are “just so” stories. More to the point, one’s time with each patient is limited. There often simply isn’t enough time to think through the pathophysiology of the diagnosis for each patient. Moreover, the diagnosis is often unclear so one would have to think through the pathophysiology of several diagnoses and compare each.

The other tips suffer similar limitations. Most motivated medical students already either know these tips or can quickly derive them. More often than not, the problem is motivation and time.

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[1] R. A. Kusurkar, G. Croiset, and Olle Th. J. Ten Cate, “Twelve tips to stimulate intrinsic motivation in students through autonomy-supportive classroom teaching derived from Self-Determination Theory,” Medical Teacher, http://informahealthcare.com/doi/pdf/10.3109/0142159X.2011.599896; accessed 19 January 2012.