HMI: What led you and your colleagues Robert Trowbridge and Steven Durning to put this book together?
Dr. Rencic: We were all teaching clinical reasoning courses and noticed a lack of a comprehensive resource on the subject. Although no definitive evidence-based approach to teaching clinical reasoning exists, we felt that there were enough valuable theories in the literature to provide some guidance to readers.
HMI: Why is teaching clinical reasoning so challenging in today’s healthcare environment?
Dr. Rencic: Teaching clinical reasoning has always been challenging because it requires teachers to have both a broad and deep knowledge of typical and atypical presentations of disease (known as illness scripts) and the ability to breakdown their usual non-analytic diagnostic problem solving (e.g., pattern recognition) into analytic components. Today’s time constraints on learners (e.g., duty hours, shorter hospital lengths of stay) and attendings (e.g., productivity pressures) make this even more difficult. Furthermore, many patients that learners see in the inpatient setting today already have a known diagnosis, so opportunities for learning how to make diagnoses and to get feedback on the diagnostic process are less common now.
HMI: Can you share some quick tips for teaching clinical reasoning with our busy readers?
Dr. Rencic: I like to break down these tips into teaching strategies to enhance non-analytic or analytic reasoning.
1.The foundation of non-analytic reasoning is the development of a broad and deep repertoire of illness scripts. To help learners develop these scripts, teachers should highlight the defining and discriminating features of diseases. Comparing and contrasting two or three different diseases on the differential diagnosis is a best practice in teaching illness scripts.
2.To apply analytic reasoning, learners should become comfortable using Bayesian reasoning concepts, such as pre- and post-test probability, likelihood ratios, and thresholds to test and treat. Explicit discussion about pre-test probability can help students understand diagnostic and therapeutic decisions. For example, say a student thinks a stress test is indicated but the attending disagrees. The attending can help demystify the decision making process by saying “I used a prediction rule to determine that the pre-test probability of obstructive coronary artery disease is 84%. The probability of the disease is so high that a stress test result either way will not change our management.” Teaching about the positive and negative likelihood ratios of historical, physical examination, laboratory and radiologic tests is also critical. For example, many students (and attendings) still use the Phalen maneuver to diagnose carpal tunnel syndrome when the evidence suggests it is virtually useless (likelihood ratio positive 1.4, likelihood ratio negative 0.7)! Many of these values can be found in the literature, such as Evidence-based Physical Diagnosis by Steven Mcgee and the JAMA Rational Clinical Examination series.
3.Finally, there are strategies that can combat some of the biases that can lead to cognitive error, so called “cognitive forcing strategies” (CFS). For example, even though a medical student is confident in her diagnosis of heartburn-related chest pain, her attending can remind her to always consider life-threatening conditions, like myocardial infarction, aortic dissection, and pulmonary embolism before deciding not to pursue any additional work-up (“worst-case scenario” CFS). The current evidence on CFS is contradictory but most teachers of clinical reasoning believe there is value in teaching students to use CFS and metacognition (“thinking about one’s thinking process”).
HMI: What was the most surprising thing you learned in editing this book?
Dr. Rencic: Assessment of clinical reasoning has been called the “Holy Grail” of assessment and in co-editing this book, I re-learned this fact. No gold standard exists for its assessment. In addition, clinical reasoning knowledge is context-specific. The key take-home point on assessment of clinical reasoning is to obtain multiple samples in multiple contexts using multiple different assessment strategies (e.g., end of rotation global assessement, Objective Structured Clinical Examinations (OSCE), multiple choice question (MCQ) examinations, etc).
HMI: How have your HMI experiences influenced your writing and teaching?
Dr. Rencic: Prior to my HMI experience, I had done no significant writing. My HMI experience gave me the confidence and desire to disseminate my thoughts, which culminated in my co-editing Teaching Clinical Reasoning. From a teaching perspective, Bob Kegan opened my eyes to the dramatic identity transformation that students undergo during medical school and the power of the hidden curriculum. For the first time in my teaching career, I began explicitly discussing these topics with my clerkship students.
HMI: What was the last book you read for fun?
Dr. Rencic: I enjoy books about cognitive psychology and the last one I read was a non-fiction book entitled Drive: The Surprising Truth about What Motivates Us by Daniel Pink. It discusses the power of internal motivation and its basis in having a sense of purpose, autonomy, and mastery. It made me think about my own life and what drives me. In addition, it reminded me that I should try to construct educational experiences that promote these feelings within learners.
Joseph Rencic, MD
Dr Rencic is Associate Professor of Medicine at Tufts University School of Medicine, an Associate Program Director of the Tufts Internal Medicine Residency Program, and a primary care physician. When not teaching and writing about clinical reasoning, you can find him spending time with his wife and 2 daughters or playing ultimate frisbee. You can download his new e-book, Teaching Clinical Reasoning, at the ACP online store.