Blog | 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.