How did you LEARN the skill of clinical reasoning in medicine? What strategies do you use to generate a differential diagnosis, come up with a leading diagnosis, interpret tests, and assess the pros and cons of treatment plans?
Even more complex, how would you TEACH the skill of clinical reasoning?
Adult learning theories state that clinical reasoning (or clinical cognition) comes from both book-knowledge and real experiences. Teaching complex reasoning skills requires a multimodal approach, which may include:
- Large group and small group lectures
- Hands-on workshops
- Computer-based instruction
- Simulation training
- Self-directed reading
This well-written article suggests that an integral part of this approach should involve case-based teaching using actual patient examples. Think about when you were a medical student. I personally learned tons just by listening to my attending verbalize his/her thought-process in managing actual patients. Patients almost never fit the classic pattern outlined in textbooks. This teaching approach attempts to transplant and expand this high-yield experience into the classroom setting.
The driving principle supporting this approach is that gaining expertise requires the learner to be active in learning. This contrasts the passive learning experienced in a traditional lecture setting. Thus, the faculty member should not transmit knowledge to the passive learner but rather serve as a facilitator of learner-driven discussions.The keys to success in case-based teaching include:
- Selecting and setting up a case appropriate for the learner audience. A case presentation for 2nd year medical students will not be the same as that for 2nd year residents.
- Selecting a case which clearly illustrates some of the concrete concepts in clinical reasoning (see figure below from the article)
- Training the faculty member to facilitate analytical thinking
- Incorporating a "debriefing" session after the case to discuss potential cognitive errors or near-misses. This teaches "metacognition", or the method of looking introspectively at one's own thinking. What clues led to the right or wrong diagnosis? What would or could have been done differently in reaching the conclusions?
An interesting concept that the author proposed was to have the faculty member also "be in the dark" about the case. S/he would be a "coach" and manage the "patient" alongside the learners. A different person (not the faculty member) would disclose aliquots of information about the case upon request. Although this may make some faculty members uncomfortable for fear of being wrong or not knowing the answer to students' questions, facilitation is a critical skill for academic faculty to learn. It is an integral part of adult learning theories.Reference
Kassirer, J. (2010). Teaching Clinical Reasoning: Case-Based and Coached Academic Medicine DOI: 10.1097/ACM.0b013e3181d5dd0d
