Blog | Friday, September 14, 2018

On teaching clinical reasoning, all about case conferences

When we studied ward attending rounds, the thought process represented the top attribute that learners valued. Learners can learn facts from textbooks, but using those facts requires experience and role modeling.

I have given many lectures on clinical reasoning and I have attended many lectures on clinical reasoning. These lectures can entertain, but one lecture does little to help our colleagues and our learners.

We must structure case conferences as a primary way to teach and learn. Lectures may help occasionally, but often the information in a lecture leaves our memory quite rapidly. But a case discussion gives the story bones on which to attach the meat!

Many years ago I had GI distress and hives after a seafood lunch. For years I thought I had developed a scallop allergy. Then I heard a similar case presented with a diagnosis of scombroid. That one case made my diagnosis, and has helped me make several more diagnoses.

At our institution we address case conferences in several ways. The majority of our morning reports use case presentations with a clinician discussing the case as it unfolds. Residents often rate these conferences as the number two learning opportunity in residency (after daily rounds). At our Grand Rounds, while we often have pure lectures, we do have occasional CPCs that remain quite popular. Our GIM noon conference has both CPCs and CPS (clinical problem solving). We do CPS every month with 1 attending physician presenting patients to another attending physician. The discussion focuses on the thought process. Residents and students love this conference.

But for me the best conference is Tinsley conference (named after our hero, Tinsley Harrison, our Osler-like influence). At Tinsley, the chief residents choose the most interesting patients from our teaching service (also name after Dr. Harrison) and present it to a room full of students, residents and attending physicians. In this conference, faculty do most of the talking. We have many subspecialists who attend regularly. Thus, we have general internists and a variety of subspecialists helping to dissect the details of the presentation. I always learn a great deal.

We must model clinical reasoning. Patient stories provide the bones, and the discussion provides the meat. The meat sticks because it attaches to the bones. When done properly these conferences help us all improve as clinicians.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.