Teaching for

Clinical Reasoning
Hirotaka Onishi MD, MHPE
International Research Center for Medical Education
University of Tokyo
Do You Think If Teaching
Clinical Reasoning is Difficult?
Yes
No
Why?

Example Clinical Reasoning

Process (1)
Mr. P, a med student, saw a 22 yo
female patient with abdominal pain.
He remembered irritable bowel
syndrome is one of the major causes
of this chief complaint but other
differential diagnoses were ischemic
colitis, colon cancer, etc.
Example Clinical Reasoning
Process (2)
Dr. Q, a resident in internal medicine, saw a
22 yo female patient with abdominal pain.
Dr. Q listed categories of causes as: GI,
urinary tract, and OB/GYN. She had a
change in bowel movement but nothing
happens for urine and menstruation which
has just finished. She also noticed mild
symptoms of having cold. Mr. P diagnosed
her as viral enterocolitis.
Direction of Information
Chief
Complaint
Signs &
Symptoms
Differential
Diagnoses
Diagnosis
Chief
Complaint
Signs &
Symptoms
Textbook
Clinical Practice
Direction of Reasoning
Colon cancer constipation (lecture, textbook)
Constipation colon cancer (Dx from interview)
Cognitive process from symptom/sign disease is
rather inductive and formal teaching of medicine
does not often mention such direction.
Symptom/sign differential diagnoses further
information gathering to compare and confirm the
diagnosis (hypotheticodeductive approach).
Clinical reasoning training should include
recalling differential diagnoses relevant to
a chief complaint and signs/symptoms.
Hypotheticodeductive
Approach
In 1978, Elstein et al. published that both
medical students and physicians gather
information of signs and symptoms
determined by diagnostic hypotheses.
Numbers of dx hypotheses: 4 / 1 for
both med students and physicians.
Most basic theory of clinical reasoning.
Elstein A et al. Medical problem solving: an
analysis of clinical reasoning. Cambridge, Harvard
University Press, 1978.
Case Specificity
Elstein found that accurate Dx rates for case
1 and 2 did not correlate with each other.
Dr. A is good at cardiology cases but Dr. B is
good at neurology cases.
Diagnosing a case is not so supported by
any generic skill of clinical problem solving,
but specific knowledge around the case.
The purpose of PBL was reconsidered.
Drs. A & B have different amount of
knowledge around different area of cases?
A Model of the Clinical
Reasoning Process
Patient/situation
characteristics
Problem
representation
Evaluation
Context
Information
gathering
Action
(treatment/
management)
Gruppen & Frohna. Clinical reasoning. In: International
handbook of research in medical education. 2002
Prior
knowledge
Outcome vs Process
Which is More Important?
If the final diagnosis was
correct
Outcome
If the differential
diagnoses were thorough
If the information
gathering was OK
Process
Does EBM Help Dx?
In the company prevalence of colon cancer
is 0.1%. A senior member received a
positive result of stool occult blood, with 90%
of sensitivity and 70% of specificity. When
you heard about the result, how much do
you think the probability of colon cancer for
this senior member is?
(1) 0-0.5% (2) 0.5-1% (3) 1-5% (4) 5%<
Bayesian Model of Dx
Solution by
2x2 table
Colon ca

Occ
blood

6993 1 6994
2997 9 3006
9990 10 10000
Probability of the disease upon positive result is:
9 / 3006 = 0.003 more or less than you thought?
Does Bayesian Theorem
Help Diagnosis?
Used in EBM for diagnosis.
Calculation is complicated and its result often
seems different from gut feeling.
Bias from human cognitive limitation is hard
to be corrected.
One of the hardest issue is how to overcome
the condition when someones pre-test
probability of a diagnosis is zero.
Please Diagnose Drs
A & B by Presentations
Case presentation after seeing a patient
in outpatient department
Two interns from different training sites
of similar rotation program
They have experiences of OPD
consultation once a week for 1 year.
Short presentation (1-2 minutes)
Intern A
Patient is 41yo male, whose chief complaint was
chest pain. He is working for a company of textile.
His father was suffering from cardiac infarction
and died at the age of 45. The patient is thinking
that he will die by the same disease of his father.
His symptom, chest pain in the deep area of
sternum, was the same as his fathers symptom.
He likes driving a car. He does not have pain
during driving but has pain when walking
especially in the morning.
I think his problem is psychological one because
he does not have any pain when he is driving and
has pain when commuting. I asked him about the
psychological stress in the company.
Intern B
Patient is 41yo male, whose chief complaint
was chest pain. Location of the pain is
behind sternum. Pain is oppressive and very
severe. Pain is often felt in the morning and
during some exercise such as walking to the
station. When he climbs up a staircase, the
pain occurs more easily. When he has chest
pain, he also feels pain on left shoulder and
left teeth. He does not have hypertension or
diabetes but has hyperlipidemia. His father
died of cardiac infarction when he was 45
years old. He smokes 1 pack a day. ECG did
not show any problem. I thought this patient
has psychosocial problem.
Intern C
Patient is 41yo male, whose chief
complaint was chest pain. The sternum
pain gets worse on exercise in the morning
but not related with the meal. He does not
have heart burn. The severe pain on the
chest always stops him walking. I think he
has heart problem because the
characteristics of the pain are similar to
angina pectoris. Angina should not be
misdiagnosed because it is quite a fatal
disease.
Characteristics of
Each Case Presentation
Intern A
Scattered order of information
Intern B
LQQSTFA Location, Quality, Quantity,
Setting, Timing, Factors, Associations
Intern C
Categorized differential diagnoses
Diagnostic Hypotheses
We sometimes use category of
diagnoses:
Abd pain: GI, urinary, OB/GYN, psycho
Chest pain: Heart, artery, esophagus,
lung/pleura, thoracic wall
Headache: Acute, chronic
Importance of Basic
Science
Basic science knowledge is used only
when routine reasoning process does
not diagnose a case.
Lack of basic science knowledge makes
clinical reasoning processes too
straightforward and sometimes illogical
(immature pattern recognition).
Amount of Knowledge
Amount does not guarantee how much
network is established.
MCQ and SAQ do not assess the
quality of networked knowledge but the
amount of knowledge
How Should Knowledge
Be learned?
1. Is basic science important for
diagnosing patients?
2. Does amount of knowledge mean
higher ability to diagnose patients?
3. Does PBL help students acquire
higher ability to diagnose patients?
Meaning of PBL
PBL itself does not guarantee the
quality of stored knowledge.
Quality and quantity of self-directed
learning facilitated in PBL may relate to
quality of stored knowledge.
Best Structure of Clinical
Knowledge
Reorganise knowledge along the
direction from sign/symptom to Dx.
Possible differential Dx should be
categorised into clinically relevant
forms (anatomical, pathological, etc).
Experience actual clinical reasoning
process for a patient without Dx or
training using mock cases.
How to Teach
Clinical Reasoning
Each physician has a different
process to diagnose patients
Unable to teach the best method
Modify each clinicians reasoning
process into better way.
It is important to disclose how the
clinician think about the case without
hiding some information. No blame
culture is a key.
Representation as
Abstractions
83 yo man complained lt knee joint
pain from yesterday. He had similar
pain 1 mo ago too.
Heres an older man with an acute,
recurrent attack of severe pain in
a single, large joint, a mono-
arthritis. This could be gout or
septic arthritis.
Reflective Practice for
Clinical Reasoning
Students/residents notice real setting key
point by reflection in action, and they
realize unwritten rule by reflection on
action independently or in the group.
They have to share what they did not
know while they listen to or examine the
patient to improve their clinical reasoning.
Reflection-in-Action
While medical interview
Differential diagnosis of LLQ pain?
How should I ask this to the patient?
This notification of weakness will help
them diagnose the next patient
Reflection-on-Action
While preparation for the presentation
I should have asked this info
Why didnt I notice the differential
diagnosis at that time
If they know how to overcome the
weakness, they can improve clinical
reasoning for the future
Experiential Learning Cycle
Theory
Reflection
Students will see an abd pain outpatient
P : Ask category of differential Dx for abdominal pain.
E : A student interviewed the patient.
R : Case presentation. Ask tentative Dx and its reason.
T : Some deeper discussion
Experience
Planning
Role of Case Presentation
for the Preceptors
To confirm if the diagnosis and
management is OK
To diagnose clinical reasoning ability
of the students/residents
Quality of case presentation depends on
the quality of the information gathered
Quality of information depends on the
quality of differential diagnoses and
problem representation
1-minute Preceptor
Determine the level of the learner
Listen
Get a commitment
Probe for supporting evidence
Teach general rules
Tell them what they did right
Correct mistakes
Learner-initiated objectives
One-minute preceptor
Simplest model for teaching
1. What do you think?
2. Why do you think that?
3. What Im thinking
4. Where do we go from here?
Example Skit
Dr: You saw the patient, right?
St: Yes, Ms Eri Yamamoto, 56 yo female with dull
lumbago and low grade fever for 2 days. She has
been healthy but for a week she has had discomfort
on urination. She does not have significant past
history.
Dr: What do you think?
St: Urinary tract infection first.
Dr: Why do you think that?
St: She has been busy because her daughter
came to her house to deliver baby for 1 month.
I think she was tired from such a life event.
Dr: All right. Connecting the condition and change
of life is very good way of thinking. I agree
with your diagnosis so far.
St: Can I order urinalysis?
Dr: Yes. Lets confirm the diagnosis is correct.
Clinical Teaching
Asking Relevant Questions
Asking relevant questions to each
condition is the most important skill for
clinical teachers.
If a student does not understand
important issues, do not blame on it
otherwise students will hide their ideas
to teachers.
Clinical Teaching
In clinical settings
Case-based
In small group
Ask questions
Avoid medical accident
Responsibility brings
motivation
Why Is Clinical Teaching
Difficult?
Teachers are too busy
Students/residents are difficult to use
knowledge in real setting
Teachers cannot explain how they
obtained the skills to solve problems
Some teachers are used to lectures
Ward round and conferences also work
as administrative activities
How Are Cases Used for
Teaching?
To let the audience think about clinical
reasoning and context
To share reasoning processes with
colleagues
To model reasoning processes of a
trainer
How to Select Cases for
Better Teaching
Ex) The objective of a conference for Internal
Medicine ward for interns was to be able to
list differential diagnoses commonly seen in
the ward. However, most cases selected
for the conference already had their
diagnoses. Interns do not have any other
opportunities to see first-contact patients.
Inconsistency between objectives and
learning contents
Conference: Group Size and
Its Members
Ex) 5 senior doctors, 10 residents, 20 medical
students are involved in the same conference.
3 senior doctors are seriously discussing how
the diagnosis should be determined but
residents and medical students seem bored.
The number of members is too large for all
residents and medical students participate in
the discussion.
Discussion by 3 senior Drs is too specialized
to involve residents and medical students in
the discussion.
Conference: Group Size and
Its Members (2)
The size should be 5-10 for discussion
The facilitator should motivate every member
to participate in the discussion
More than one facilitator might argue with
each other in case conference
Monitoring each small group is important to
maintain the quality of teaching
Asking Questions
Ex) The objective of a conference in internal medicine
ward was to be able to decrease misdiagnosis in
acute care in emergency department. One chest
pain case was presented.
The teacher should ask differential
diagnoses of chest pain which should not be
missed.
Skit 1
St: 70 yo woman has got high fever of 39.0
degree. She has also productive cough since
last night.
Dr: Does she have pneumonia? Did you order
any blood test?
St: WBC 12000 with 15% of stab. CRP is 12.8.
Dr: OK. Definitely pneumonia. Please give her
Unasyn (ABPC + SBT).
St: How much?
Dr: 1.5g, two times a day.
St: OK, sir.
Skit 2
St: 70 yo woman has got high fever of 39.0
degree. She has also productive cough since
last night.
Dr: What do you think?
St: I think pneumonia is most probable.
Dr: Why do you think that?
St: I heard coarse crackle on her right lower area.
Gram stein of sputum showed diplococcus.
WBC 12000 with 15% of stab. CRP is 12.8.
Dr: OK. I agree with your diagnosis. What do you think
the next step is?
St: Id like to give her Unasyn (ABPC + SBT).
Dr: Why do you like to use Unasyn?
St: WellI dont know why many doctors use Unasyn
for this condition.
Dr: Because pneumococcus has high probability of
resistance to ABPC nowadays.
St: All right. I will administer it.
Other Issues: Physical
Exam in Ward Round
Ex) Medical students were told to perform head-to-
toe physical exam but no one checked their
skills.
Ward round is a valuable opportunity to check
how medical students and resident perform
physical examination.
In Japan many residents complain that their
physical exam results have never been checked.
Presentation Style
Chief complaint Present Illness
Other History Physical exam
Assessment & Plan
More appropriate for medical students
Hx and Physical Ass. & Plan
More appropriate for residents (senior)
Time Length
Ward or Outpatient
Student, Resident or Senior
Simple or Complicated case
Main presenter young or experienced
Work Round vs
Attending Round/Conference
Attending Round/Conference Work Round
No. of
participants
5-10 members with a teacher.
Round: Not threatening for patients.
Conference: Easy to discuss.
All department members
including a number of
supervisors attend
Selection of
cases
Select a few cases to focus on
some specific learning issues.
All the cases of the
department.
Physical
examination
(only for round) Learners perform it.
The supervisor gives a feedback.
The supervisor does/
shows it.
Presentation
style
History only should be discussed
before other information is added.
Time efficiency matters.
Time length Sufficient time for learners to
understand is important.
Time efficiency matters.
No Blame Culture
If a preceptor blames a trainee, he/she
and other trainees will be intimidated.
Some like to hide insufficient part of case
presentation not to be blamed.
This may lead to insufficient sharing of
info with a preceptor.
No blame culture is a key to avoid hiding
diagnostic errors and to diagnose trainees
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How To Assess Clinical
Reasoning Ability
For medical students
Solving case-based problem for a
diagnosis?
For residents
Listening to several case presentations?
Assess Clinical Reasoning
Ability by Case Presentation
Selection of terms and reliability of
clinical examination
Acquisition of presentation format
Comprehension of the case and its
differential diagnoses
List necessary pertinent negative and
positive signs/symptoms
Relevant feedback for each level will
be determined
Improvement of case presentation along with clinical reasoning level
Condition of presentation Levels of the
presenter
Feedback from the trainer to the
presenter
1
st
S
T
E
P
Lack of essential information
of the case or inappropriate
definition or reliability of
information about S/S
Lack of basic clinical
skills for H&P or
required information
for case presentation
Ask the presenter about
inappropriate terms or essential
information of case presentation.
Offer 1-to-1 practice to the presenter
2
nd
S
T
E
P
Insufficient or unordered
information
Inability to capture
each information or
organize information
for the case
Point out what is missing in case
presentation. Ask the presenter to
practice case presentation
3
rd
S
T
E
P
Essential information is well
covered but DD are not well
listed
Able to report the
case but unable to
interpret the patient
problems
Give positive feedback for complete
information. Ask the presenter to
summarize the presentation and DD
4
th
S
T
E
P
DD are covered but pertinent
positive and negative S/S are
insufficient
During H&P no
relevant S/S to DD
obtained
Give positive feedback for DD and
specific feedback for pertinent
positive and negative S/S
5
th
S
T
E
P
Pertinent positive and
negative S/S relevant to DD
are covered
Through H&P whole
picture of the case
and its DD are clearly
described
Give positive feedback for a good
presentation. Ask the presenter to
specify the lesson learned from the
case
H&P: History & Physical, S/S: Signs and Symptoms, DD: Differential Diagnosis
Condition of presentation
2. Insufficient or unordered information
3. Essential information is well covered
but DDx are not well listed
4. DDx are covered but pertinent positive
and negative S/S are insufficient
5. Pertinent positive and negative S/S
relevant to DDx are covered
Feedback from the trainer to
the presenter
2. Point out what is missing in case presentation.
Ask the presenter to practice case presentation
3. Give positive feedback for complete information.
Ask the presenter to summarize the
presentation and DDx
4. Give positive feedback for DDx and specific
feedback for pertinent positive and negative S/S
5. Give positive feedback for a good presentation.
Ask the presenter to specify the lesson learned
from the case