Blog | Friday, May 22, 2015

Teaching diagnostic reasoning


Amidoc wrote this comment:

Thank you for sharing this with us.

How about focus on teaching how to avoid clinical errors during medical school and residency? I am sure someone smart can come up with a curriculum and the apply it in real life.

Yesterday I gave Grand Rounds at my alma mater, the Medical College of Virginia in Richmond (sometimes called VCU but I reject the relabeling). The title, “Learning to Think like a Clinician,” is pithy, but may not convey the essence of the talk. In this talk I present patients whose diagnostic process helps us understand the source of diagnostic errors as well as the path to diagnostic excellence. The talk borrows heavily from cognitive psychology and particularly 2 books, “Thinking Fast and Slow,” by Daniel Kahneman and “Sources of Power,” by Gary Klein.

This talk and those books outline a curriculum for understanding the basis of diagnostic reasoning. As noted a physician as Jerome Kassirer, MD, former editor of the New England Journal of Medicine, has called for diagnostic reasoning to be included as a basic science throughout medical school. He and Rich Kopelman started the NEJM Clinical Problem Solving exercises (another great way to learn medicine and the diagnostic process).

But I would argue that writing a curriculum is not the answer. The answer must come from improved clinician educators. We assume that anyone who finishes a residency and/or fellowship can teach medical students and residents. But skilled medical education requires specific skills. One skill that some cannot master is the skill of making explicit ones thought processes. Our research on ward attending rounds, and my anecdotal experience in talking with many students and residents, teaches us that learners want to understand how the process works. So we need to trainer the educators on how to teach medicine. We should develop more rigorous training for medical educators so that they can help their learners grow into great diagnosticians.

Unfortunately, we who value the art of diagnosis are handicapped because diagnostic excellence is difficult to document with measures. We cannot measure diagnostic error rates, because diagnoses are often difficult and gold standards are difficult to determine.

But we do have a responsibility to try. We should value diagnostic reasoning more as our learners know that they need to learn these skills.

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 Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.