Thursday, September 19, 2013
Teaching medicine requires teaching thinking
Many readers know that I am a founding member of the Society to Improve Diagnosis in Medicine. This society has staked out the position that we no longer focus enough on the diagnostic process in medicine. Thus, we have too many diagnostic errors.
Some want to blame diagnostic errors on “systems problems.” Certainly, poor systems can make diagnosis more challenging and more difficult, but we physicians have the ultimate responsibility to overcome obstacles and find the correct diagnosis.
Some quality gurus are paying attention. For example, Robert Wachter, MD, FACP, will be speaking again at the Diagnostic Errors meeting and last year, Peter Pronovost, MD, PhD, spoke. One cannot reliably judge a clinician’s quality without an assessment of diagnosis accuracy.
But diagnostic accuracy evades measurement. How can we assess accuracy without knowing the diagnosis? Many researchers are looking for proxies, or studying specific situations.
Diagnostic excellence requires careful thought, and persistence. Not all diagnoses present in obvious ways.
Kopelman and Kassirer first introduced clinical problem solving exercises to print in the New England Journal of Medicine. Several other journals now feature these exercises. I would submit that reading these publications helps one understand the thought process involved in getting to the correct diagnosis. As one who has participated in publishing several of these articles, I would argue that all students of clinical medicine should focus on studying these articles and having an experienced clinician lead a discussion of the processes.
During clinical rotations, our teachers must focus on teaching the thought process. For example, you have a patient with a potassium of 2.5. The intern writes for potassium replacement with 20 mEq in each liter of normal saline. Too many attending physicians will tell the intern to change the IV fluids to a different concentration. They are the micromanagers. The best attending physicians use this as an opportunity to make certain that the intern, resident and medical students understand the degree of potassium deficit, the limits of IV replacement, and ask the question “Why is the potassium so low?” That teaching physician gets the same result as the micro-manager, but everyone is happy because they now understand how to approach this problem. They understand the correct treatment depends on understanding how why the potassium is low, as well as understand the physiologic details of replacement.
We must teach thinking. Great medicine does not come from following scripts. Great medicine occurs when the clinician knows enough to either proceed or know that they need another physician to help. Algorithms are not the answer. Excellent thought processes are the answer.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
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Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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