Problems with clinical reasoning (wrong, delayed, or missed diagnosis and/or treatment) make up a sizable portion of preventable adverse outcomes.1,2 In 1 review of diagnostic errors, 75% were at least in part due to cognitive errors.3 Of 320 cognitive factors identified in 74 cases, 45 were due to faulty data gathering and 264 resulted from errors in problem representation and clinical reasoning.1 Teaching good clinical reasoning is an important component of resident education.
What Is Known
One framework for defining “Good Clinical Thinking” is presented in 3a1box 1. A good clinical thinker routinely approaches a clinical presentation by using an analytic approach, a nonanalytic approach, or a combination.4 The nonanalytic approach is more common, accounting for 80% of clinical reasoning and is based on pattern (or illness script) recognition, and the use of heuristics.5 This allows for the rapid diagnosis of clinical presentations that match preformed illness scripts. When such matches are not apparent, clinicians must transition to a more deliberate hypothesis-driven model for diagnosis. Clinicians often toggle back and forth between the 2 methods. The ability to evaluate for potential errors in the diagnostic process differentiates the seasoned clinician from the novice.
Interest in gaining more information
Willing to invest energy in thinking the matter through
Possess the cognitive ability
Teaching and Assessing Residents' Clinical Reasoning Skills
Residents must learn the importance of thinking critically to minimize error; faculty needs explicit ways of teaching these skills.
A set of 12 tips to avoiding error in clinical reasoning (4a1box 2)6 offers a concise, easy-to-use set of concepts for discussion with residents, and allows them to gain a better understanding of principles relevant to making accurate diagnostic decisions. In addition, programs need a way to assess and document growth in residents' clinical reasoning skills. This assessment is relevant to “a trainee's readiness to bear professional responsibility.” It calls for validated tools that assess clinical reasoning in learners, especially tools for the bedside and clinic.7
Use “diagnostic timeouts”
Think “worst-case scenario medicine”
Systematic approach to common problems
Teach/emphasize physical examination
Teach Bayesian theory
Acknowledge your emotions
Identify what does not fit
Some initial tools to assess resident clinical reasoning are shown in 4b1box 3. They can be customized through the use of the “critical thinking” milestones (4b1box 3) to inform the assessment process.
Portfolio—with required defense by learner
Focused narrative writing
Chart stimulated recall
Structured questioning regarding the 12 tips milestones to assess clinical thought, using the medical record (history and physical or discharge summary)
The 1-Minute Preceptor
The SNAPPS precepting technique8
Standardized direct observation (mini-CEX)
Abbreviation: CEX, clinical evaluation exercise.
How You Can Start TODAY
Calibrate faculty to the assessment process and use of these tools to evaluate trainee critical thinking skills.
Prepare trainees for the assessment process by explaining the importance of critical thinking skills and the goals of the assessment process.
Use the 1-Minute Preceptor (5a1box 4).
Increase the focus on clinical reasoning in conferences (morning report, morbidity and mortality).
What You Can Do LONG TERM
Build and provide faculty development programs in teaching and assessing clinical reasoning skills for clinical faculty.
Promote a teaching culture centered on clinical reasoning.
William F. Iobst, MD, is Vice President of Academic Affairs, American Board of Internal Medicine; Robert Trowbridge, MD, is Director of Undergraduate Medical Education, Maine Medical Center; and Ingrid Philibert, PhD, MBA, is Senior Vice President, Field Activities, Accreditation Council for Graduate Medical Education.