Todd Felix, MD, Penn State University, Department of Family Medicine, Hershey Medical Center

Clinical reasoning (CR) is the application of critical thinking to the formulation of a differential diagnosis, diagnostic evaluation, and treatment plan for clinical problems. Information mastery and evidence-based medicine (IM/EBM) are the integration of clinical expertise with the best available external clinical evidence. Obtaining and critically appraising the evidence does not always equate with better decisions in clinical care, though. The evidence should be linked to the clinician’s expertise, clinical context or setting, and the patient’s individual circumstances, values, and preferences.

While CR and IM/EBM are, along with clinical experience and knowledge of the patient, essential for the practice of medicine, few medical schools have CR training or a formal IM/EBM curriculum through all 4 undergraduate years. Recent data have shown that clinical reasoning skills plateau after the second year of medical school, with a lack of accelerated progress during the clinical years of training.¹

Our faculty addressed this plateau in development of CR skills by establishing a 4-hour case-based conference titled “Coffee Talks,” where third-year students bring cases seen during their month-long family medicine clerkship back to a group of 12–14 students and several faculty at the end of their rotation. The typical forum includes three to four experienced faculty with an EBM focus, seasoned clinicians, and an EBM resource librarian. The thinking skills of medical students are enhanced by faculty-led discussions of the cases in formulating a working differential that is assessed and modified after each segment of the student’s systematic case presentation. The discussions are focused around key points of the differential, diagnostic decisions, and treatment regimens based on available data presented by the student. Students identify key clinical questions that arise during the discussion, and small teams of two to three students with an assigned faculty member are then tasked to utilize EBM resources in answering the identified questions. This is followed by a student-led discussion in the larger forum that enables the students to recognize the cognitive skills utilized daily by family physicians in the care of their patients.

Consider this scenario below as an example of how CR and EBM may be incorporated into one of our Coffee Talks.

A toddler at a birthday party becomes short of breath suddenly—already you are developing a differential diagnosis—the challenge becomes how you would proceed with a diagnostic workup and treatment plan quickly and efficiently.

Clinical reasoning has been defined as the ability to ‘‘. . . sort through a cluster of features presented by a patient and accurately assign a diagnostic label, with the development of an appropriate treatment strategy as the end goal.’’² A seasoned clinician would likely use clinical intuition, considering allergy, asthma attack, and foreign body as their top differentials. A medical student, using a more analytical approach, may yield a more expansive differential, perhaps pneumothorax, pneumonia, cardiac shunt, etc.

Regarding our case scenario, what if the child was a known asthmatic?

Most physicians move freely between pattern recognition and analytic reasoning as a given case necessitates, although the majority of our thought process is intuition/pattern recognition. Introducing Bayes theorem (pretest probability and likelihood ratio) to students reinforces the value of determining the probability for a given disease prior to testing and gives grounds to whether physicians will test, treat, or observe. In our scenario above, our pretest probability would likely be equal for the three diagnoses listed. The personal history of asthma would increase the likelihood for allergy and asthma.

Common things being common, you start treatment for an acute asthma exacerbation—but what should be your initial management option (albuterol, levalbuterol, racemic epi, steroids)?

The skill set to interpret medical data, search valid resources, and apply this to clinical scenarios in real time is an invaluable tool for students and residents. Specific training in application of EBM in clinical care is often lacking during the clinical years of medical student education. Role modeling an evidence-based approach is an important part of teaching clinical reasoning. Without data, well-founded diagnoses and management decisions are difficult to make and may become anecdotal exercises, which can leave students puzzled by the decision-making process.

But the patient worsens, so you reexamine the child and consider the birthday party environment, realizing that there was peanut butter cake, and symptoms started soon after ingestion.

Physicians frequently misdiagnose patients, despite significant improvements in diagnostic technology, including advanced imaging techniques. Groopman estimates about 15% of all people are misdiagnosed, possibly as high as 25%.³ Think of the last radiographic diagnosis made that did not seem to fit the diagnosis. Regular discussions are had with students and residents about the “pneumonia” admission without cough, fever, or leukocytosis despite a positive CXR finding. Most doctors, within the first 18 seconds of seeing a patient, will interrupt the patient’s story and generate an idea/diagnosis, which can easily be influenced by the cognitive bias of premature closure once a “diagnosis” is found.³

Our patient is administered an Epi Pen and improves quickly, then discharged with a diagnosis of peanut allergy. Oral desensitization therapy was reviewed with parents, who elected to follow total avoidance based on evidence presented.

Our Coffee Talks attempt to prepare future physicians with the tools necessary to practice in the ever-changing medical landscape. With studies showing physicians have up to two questions for every three patient visits and an average search time of less than 1 minute, developing information mastery skills is vital to student education.⁴ By focusing on the necessary clinical reasoning skills and appropriate use of information in a systematic fashion, students will be better positioned to enter their medical careers with a solid foundation. This unique forum has allowed for clinical experience, student collaboration, critical thinking, information mastery, and professionalism to be highlighted.

References
1. Williams RG, Klamen DL, White CB, et al. Tracking development of clinical reasoning ability across five medical schools using a progress test. Acad Med 2011;86(9):1148-54.

2. Rencic J. Twelve tips for teaching expertise in clinical reasoning. Med Teach 2011;33(11):887-92.

3. Groopman J, ed. How doctors think. Boston: Houghton Mifflin Company, 2007.

4. Ely JW, osheroff JA, Ebell MH, et al. Analysis of questions asked by family doctors regarding patient care. BMJ 1999;319(7206):358-61.

Other resources
Trowbridge R. Twelve tips for teaching avoidance of diagnostic errors. Med Teach 2008;30(5):496-500.

Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med 2011;86(3):307-13.

Croskerry P. The theory and practice of clinical decision making. Can J Anesth 2005;52:R1-R8.

Mamade S, Schmidt HG. The structure of reflective practice in medicine. Med Educ 2004;38(12):1302-8.

Sackett D, ed. Evidenced-based medicine: how to practice and teach EBM. New York: Churchill Livingston, 1997.

Slawson D, Shaughnessy A, Bennett J. Becoming a medical information master: feeling good about not knowing everything. J Fam Pract 1999;48(2):135-9.

Slawson D, Shaughnessy A. Teaching EBM: should we be teaching information mastery instead? Acad Med 2005;80:685-9.