The NEW ENGLAND JOURNAL of MEDICINE REVIEW ARTICLE MEDICAL EDUCATION Nalealm Cox M.D, and David MI, Ph, Eto Educational Strategies to Promote Clinical Diagnostic Reasoning Judith L. Bowen, M.D. LINICAL TEACHERS DIFFER ROM CLINICIANS IN A FUNDAMENTAL WAY. ‘They must simultaneously foster high-quality patient care and assess the clin- ical skills and reasoning of earners in order to promote their progress toward independence in the clinical setting.* Clinical teachers must diagnose both the pa- tients clinical problem and the learner's ability and skill, To assess a learner’s diagnostic reasoning strategies effectively, the teacher needs to consider how doctors learn to reason in the clinical environment. Medical stu- dents in a classroom generally organize medical knowledge according to the structure of the curriculum, For example, if pathophysiology is taught according to organ sys- tems, then the student's knowledge will be similarly organized, and the recall will be tuiggered by questions related to specific organ systems or other contextual clues. In the clinical setting, the patient's health and care are the focus. Clinical problems may involve many organ systems and may be embedded in the contest of the patient's story and questions. Thus, in the clinical setting, the student's recall of basic science knowledge ftom the classroom is often slow, awkward, or absent. Only after learners ‘make new connections between their knowledge and specific clinical encounters can they also make strong connections between clinical features and the knowledge stored in memory.>* This report focuses on how clinical teachers can facilitate the learning process to help learners make the transition from being diagnostic novices to becoming expert clinicians, jOSTIC REASONING ‘There is a rich ongoing debate about our understanding of the complex process of nical diagnostic reasoning." In this report, some of the basic processes involved in clinical reasoning, as understood according to current knowledge, ate translated into practical and specie ecommendations for promoting the development of strong diagnostic reasoning skills in learners. The recommendations ate illustrated by a clini- cal case presentation, Clinical ceachers observe learners gathering information from patients, medical records, imaging studies, results of laboratory tess, and other health care providers. (On the basis oftheir observations, and through the discussion of clinical cases, teach- cers draw conclusions about the learners’ performance, including their reasoning pro- cesses. A hypothetical case provides an example of a conversation involving a patient, ‘wo learners with different levels of expertise, and the clinical teacher (see Box). In this case,’ a patient with knee pain makes an urgent visit to an ambulatory care practice. A novice resident (with relatively litle experience with this patient's prob- lem, which is gout) and an expert resident (who is familiar with this problem, hav- ing seen other patients with gout) each independently interviews the patient, performs ‘The New England Journal of Medicine From the Deparment of Medicine, Or {gon Heakh and Science Unversity Port land Adres reprint request to Dr Bow tne the Depriment of Medine, 38 SW Sam Jackeon Park Re, LA75, Port und, 08 97238, oF at bowenj@ehsuedu N Engl) Med 2006,355:201725 Downloaded fom neo by José Comprido on May 7, 2024. For personal use only [No ther uses witout permission, Copyright © 2006 Massacisets Medical Society, Al ighs reservedThe NEW ENGLAND JOURN. aan examination, presents the case to the precep- tor, and separately discusses the case with the preceptor. As becomes evident, the expert resident hhas transformed the patients story into a mean ingfal clinical problem. The novice resident has also transformed the patient’ story, but less elabo- rately. What the teacher hears from both resi- dents differs substantially from what the patient told them, ‘The expert resident brought two sets of skills to the encounter with the patient. First, this resi- dent probably formed an early impression — a mental abstraction — of the patient's story. Al- though possibly unaware of this formulation, the resident's mental abstraction influenced his diag- nostic strategy. Guided by his early impression, the resident probably asked a series of questions, and the patient's responses guided both further ques- tioning and the planning of a focused physical examination, The resident's approach involved search for information that could be used to dis- ctiminate among any number of diagnostic expla- nations of the patient's problem. The novice resi- dent might not have formed a mental abstraction of the case and probably was not sure which ques- tions to pose to the patient. Second, the expert resident's clinical case pre- sentation was a succinct summary of the findings, providing the teacher wich a clinical picture of the patient as seen through the resident's eyes. On the basis ofthe ease presentations by both the expert and the novice residents, the teacher may or may not have had a firm idea of what was wrong with the patient. Rather than offer n opinion, however, the teacher asked the expert resident to reason aloud about the case, thereby providing the teach- ex with additional clinical information about the patient as well as considerable insight into the resident's clinical reasoning skills. The teacher used the same strategy withthe novice resident, and although the result added little information bout the patient, the teacher learned something about the novice residents limited clinical rea- soning. Key clements of clinical diagnostic reasoning are shown in Figure 1. The first step in diagnostic reasoning, which is based on knowledge, experi- ence, and other important contextual factors, is always data acquisition. Data acquisition, depend- ing on the setting, may include elements of the history, the findings on physical examination, and the results of laboratory testing and imaging stud- jes, Another caly step isthe creation of the men- tal abstraction or “problem representation,"=*3 usually as a one-sentence summary defining the specific case in abstract terms. Clinicians may hhave no conscious awareness ofthis cognitive step. The problem representation, unless elicited in the “The Case as Sean by a Novice Resident and an Expert Resident. Patient’ story: My kres hurt me so much lastnight, woke up fram sleep. twas ine when | went to bed, Now its ‘allen =the wort pain ve ever had I've had problems like this Before inthe same knee, once 8 ma tnd once 2years ag. Ir doesn bother me between times Novice residents presentation: My next patent Expert resident's prsenttion: My nest palentis 254 ld white isa Styearald white man with Kres pai Ie started lst ight He does not port ny ttauma. On examination his val sign are normal His kre is swolen, ed, and tender {etouth thurs him» htwhen Ist his range of motion. He's had ths problem twee before, “Teaches inquiry What do youthinkis causing this patients knee pain? Novice residents respons: It cou be ani fection lrcould bea nen onset of seus tod ati. Itcould be Lyme disease Since he doesn’ real falling, doubts anny. don't know whether ostearin Ais evr presents ke this, bute dees havea history afanee pain Exper resident's response: The patent has acute gout. Hehas hag man with sudden anset of pin inhis right knee tha ake {hed him from sleep He doesnot reper sry tara and was eeertll asymptomatic when he went te bed. His histori tmartable fortwo eplodes of silt, severe pan 9 months nd 2 years ago. Hes painffer betwcen episodes He sae bre today Hieknee ie swollen, tender so touch, and enthem multiple discrete epizodes with abrupt onset of exterel se ‘ere pain involving a ingle joint with evdence of inflamma tion an examination Before al his eprodes, nes seymptor ati. Twould have expected gout 0 aft the fst metatarso phalanges joint, butt can present inthe knee. Nothing sug {Eeits any ongoing, chranic problem inthe knee, | dort see Sry portal oferty to suggest acute infectious rhs ang he Teoks gute wel for that Mis eter joints are normal on exam: nation doubt that he hata flsteup of estecarthie wi paeudogout or a systemic inflammatory arts such a8 Freumatoid athe ‘The Now England Joural of Medicine Downloaded fom nejm.org by José Comprido on May 7, 2024, For personal use only Nother uses without permission, Copyright © 2006 Mastachsets Medical Society, Al ighs reservedteaching setting, is rarely articulated. Rather, the teacher infers the learner's problem representa- tion from the leamer's presentation of the ease. For the case used as the example, the expert resident's problem representation, had it been el ited, might have been the following: “The acute onset of a recurrent, painful, monoarticular pro- cess in an otherwise healthy middle-aged man.” ‘The problem representation illustrates the trans- formation of patient-specific details into abstract ast night” became “acute onset,” “I've had problems like this before” became “recur- rent,” “same knee” became “monoarticulay,” and the patient's age, sex, and medical history are summarized as “otherwise healthy, middle-aged ‘man.” In this transformation, the characterization of the problem facilitates the retrieval of pertinent information from memory? The novice resident ‘may be less able than the expert resident to devel- ‘op an accurate problem representation. When prompted by the teacher to reason about the case, the expert resident used abstract seman- tic qualifiers to describe the case findings. Seman- tic qualifiers ae paired, opposing desctiptors that can be used to compare and contrast diagnostic considerations. The resident used several implied pairs when considering hypotheses for a diagno- sis of gout: multiple (not single) and discrete (not continuous) episodes, abrupt (not gradual) onset, severe (not mild) pain, and 2 single joint (not mul- tiple joints). The use of such semantic qualifiers is associated with strong clinical reasoning. ‘To exeate a concise, appropriate problem rep- resentation and to reason succinctly, the resident ‘aust have clinical experience with similar patients and must be able o recognize the information that establishes gout as the diagnosis while ruling out ‘other possibilities. The way the clinical experience is stored in memory either facilitates or hinders the ability to formulate the problem representa- tion, Expert clinicians store and recall knowledge as diseases, conditions, or syndromes — “illness scripts” — that are connected to problem repre- sentations.?4 These representations trigger clinical memory, permitting the related knovl- edge to become accessible for reasoning. Knowl- ledge recalled as illness scripts has a predictable structure; the predisposing conditions, the patho- physiological insult, and the clinical consequenc- es (ig. 2) Constructed on the basis of exposure to pa tients, illness scripts are rich with clinically rele- ould Paven’s stony | | cere problem representation’ cont —| | | Search oad section fines st | perce Figure 1. Key Elements ofthe Clnial Diagnostic Reasoning Process. vant information, Their content varies for each physician and among physicians. Some illness scripts are conceptual models, such as groups of diseases, whereas others are representational ‘memories of specific syndromes. With expetience, clinicians also store memories of individual pa- tients, and the recollection of a particular patient often triggers the recall of relevant knowledge.** ‘The defining and discriminating clinical features Gig. 3) of a disease, condition, or syndrome be- come “anchor points” in memory. In the future, recollection of such stored experiences expands the clinician’s ability to recognize subtle but im- portant variations in similar cases.** ‘When prompted to reason aloud, the novice resident listed possible causes of knee pain. The expert resident, however, compared and contrasted several relevant hypotheses — acute gout, infec- tious arthritis, osteoarthritis with pseudogout, and theumtatoid arthritis — and included the diserimi- nating features of each possibility. Such reasoning -may represent the mental processes of searching for and verifying an illness scrip, with the elimi- nation of hypotheses for which the defining fea- tures of a speeific illness script are absent 2-2 Such comparisons often take place in the expert clinician’s mind during the data-acquisition phase and form the basis of a focused strategy for ques- ‘The Now England Journal of Medicine Downloaded fom nemo by José Compido oa May 7, 2024, For personal use ony. othe uses without permision, Copyright © 2006 Massachsets Medical Society, All igs reservedThe NEW ENGLAND JOURNAL of MEDICINE Mise Nesbaluse Use of dures Patnophyalege cle ‘Arnal afc aa metabain Preaptsion serps njore Fehaormaton of been Cea epee Sine, eva the fat Treisaophilrgsl ine Figure 2. Example ofan ye Script for Gout. tioning the patient and for the physical examina- tion, Additional data gathering is purposeful: itis a search for the defining and discriminating fea- tures of each illness script under consideration Clinicians familiar with the clinical present3- tion of gout will recognize the pattern of symp- toms and signs of gout in the expert resident's case presentation. Such rapid, nonanalytc clinical reasoning is associated with experience with the type of problem, in this case gout. The defining feacures for a diagnosis of gout are associated in ‘memory as an illness script and, for some clini- cians, are also associated with memories of indi- vidual patients. Access to these memories is easily triggered when the clinical findings of gout are present. The expert resident recognized the pat- {ern of symptoms and signs of gout and selec- tively accessed the illness script constructed on the basis of experience, ‘The novice residents clinical experience with gout was limited; perhaps knowledge gained from prior eases of gout failed to be transferred to memory, The novice resident used a slower, more deliberate method of testing a hypothesis for this clinical problem, generating multiple plausible hypotheses for acute arthritis. Additional data gathering would be useful either to confirm or to rule out these diagnostic considerations in conscious, analytic fashion, Both nonanalytic and analytic reasoning strat- egies are effective and are used simultaneously, in aan interactive fashion.» Nonanalytic reasoning, as exemplified by “pattern recognition,” is essential to diagnostic expertise 24°24 and this skill is developed through clinical experience, Delibera- tive analytic reasoning is the primary strategy when a case is complex or ill defined, the clinical findings are unusual, or the physician has had litle clinical experience with the particular disease entity, Clinicians often unconsciously use multiple, combined strategies to solve clinical problems, suggesting a high degree of mental flexibility and adaptability in clinical reasoning,** By prompting the learner to reason aloud or eliciting the learner’s uncertainties, the clinical teacher can uncover the reasoning process used by the learner, In responses to the teacher's questions “What do you think” or “What puzzled you ‘weak and strong diagnostic reasoning can be read- ily distinguished*> As was true of the novice resi- dent in the case example, learners whose discus- sion is poorly organized, characterized by long, ‘memorized lists of causes of isolated symptoms, or only weakly connected to information from the cease ate reasoning poorly They do not connect stored knowledge with the current clinical case because they lack either experience with such cases or basic knowledge. Learners with strong diagnostic reasoning skills often use multiple abstract qualifiers to dis- cuss the discriminating features of a clinical case, comparing and contrasting appropriate diagnos- tic hypotheses and linking each hypothesis to the findings in the case, The discussion between such a learner and the clinical teacher is often quite concise and may be so abbreviated that its result, the diagnosis, appears to be a lucky guess. In such situations, the teacher may need to ask additional questions that probe the learner's rea- soning or uncertainties to be sure that reasoning, rather than luck, brought the diagnosis to light. Strong diagnosticians can readily expand on theit thinking.9*° RECOMMENDATIONS FOR CLINICAL TEACHERS Clinical teachers ean use several strategies to pro- mote the development of strong diagnostic rea- ‘The Now England Journal of Medicine Downloaded fom nejm.og hy José Comprido on May 7, 2024, For personal ss only. ‘Nother uses without permision, Copyright © 2006 Massachosets Medical Society, Al igs reservedsoning skills. The recommendations that follow are drawn from research on how doctors rea- son.*48920353788 Although experienced clinical teachers will recognize the validity of some of these recommendations, many of the ideas still need empirical testing in the clinical teaching en- vironment. Experience with patients is essential for es- tablishing new connections in memory between learned material and clinical presentations, for developing illness scripts, and for developing the ability to reason flexibly with the use of analytic reasoning and pattern recognition.» As learners listen to patients’ stories, learn to transform these stories into case presentations, develop their own illness scripts, and learn to reason about clinica! information, teachers can use case-specific i structional strategies to help learners strengthen their skills (Table 1). Failure to generate an appropriate problem xepre- sentation can result in the random generation of hypotheses that are based on isolated findings in the case, When the case presentation or discussion is disorganized, the clinical teacher can prompt the learner to create 2 one-sentence summary of the case with the use of abstract terms.” However, teaching learers to articulate problem represen- tations as an isolated teaching strategy is insuffi- cient Rather, problem representation must be connected to the type of clinical problem —a con- nection that facilitates the learners tetzieval of per- tinent information from memory. In the teaching environment, several learners with different levels of expertise may be involved in the same case, and eliciting the learners’ vari- ‘ous problem representations will help the clini- cal teacher to understand their different perspec- tives and learning needs. In complex, ill-defined clinical cases, more than one problem represen tation may need to be considered. The discussion of the different problem representations will help novice learners to appreciate the complenity of the case as well as their own early, limited under- standing. ‘Teachers should articulate theit own problem representations to demonstrate the type of abstract summary they seek from learners. Teachers can then reason aloud, linking the summary statement to their own illness scripts and highlighting the discriminating features clinicians seek in the his- Newel) mu syi2t www nEMane Neveu 3, 2006 Infection Single epsote Pate re ted Detning ‘esr coor Discrminning ape its vod a Longse gece mn fnctonng Figure 3. Defining and Discriminating Features ofa Set of Diagnostic Hypotheses for Acute Arthritis “The problem representation is “acute onset of recurrent, painful, mo rteular process in an otherwise healthy middle-aged man.” Defining es tures are descriptors that are characteristic ofthe diagnoses (eg, gout, septic arthritis, osteosrhets). Diseriminating features ae descriptors that, sre useful fr distinguishing the diagnoses from one anather. tory and physical examination for the consider- ation of appropriate diagnostic possibilities.»” Novice learners often generate numerous possible diagnoses for any given case. To prioritize such a lengthy list, they should be encouraged to com- pare and contrast possible diagnoses on the basis of the relationship among the actual clinical data ‘on the case, typical presentations for each diagnos- te possibility, and the relative probabilities of dif ferent diagnoses.” Forcing learners to prioritize the lst of diagnostic possibilities and explain their justifications helps them to create linkages between the clinical findings in the ease and relevant di- agnoses, bolstering their ability to develop perti- nent illness scripts ‘The development of elaborate illness scripts and pattern recognition involves knowledge of the typical presentation of a problem as well as the many atypical presentations or variations on the typical one. It is important for novice learners ‘The New England Journal of Medicine Downloaded ftom nejm.og hy José Compido on May 7, 2024, For persona se only. No othe uses without permission, Copyright © 2006 Massacussts Medical Society. 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No ther uses without permission, Copyright © 2006 Massachuseits Medial Society, Al righs reservedspt nok pip ou 08 pur ss0u3e)9 sap fue sepsuos not pq sBurpuy papain 4a pouodéns 5111 moy pu ss0uteIp hud ‘ek sma, u3psa1 4435 ayy 42509 ge aay nok op fusion tut, peasy ,quoneivasea, Wo|G0/d ‘uaiayipeaney aueKueSoeg, -dneid 94.954 (voarusssidos sy 2304) fou stop ‘whup suit pur seouderp sniewan age tuoseas= 350049 s2upuy frutp 434g p> odds 51 sisouFep hiewiud snot ey 9, se pautra aney no reys ou Jay euewe) Sss0uFep yo aj Bueatauosip pu fay usps “or moray voeiara paid a a ieduse> pu snd jo uosewuas914 Forel sutsnoge peas eh not ven | essuaned 9s0u) nage soqussuss nok op yey cave se ‘im suaged ipo a3 uayes nok one sy nage mouy 0 pa2u a8 9p 25 Binwores js epi a> uyuosens up pur vonrstdas waygord uno ‘rote oaue prefs uose3s 0 51> saieajouds siouryse'3ss9de3J0 sols ous yore see on Suen ‘ee qunead sutra 0 90 cont uy Suoseiuaseie, wage Buuoseas eon pur suoevassidss wagord uno nok sprue asta 0 ssn) ugeulutosip pur hoy Bsn sas0u Seip hrpuoses pur esis punjap pur Guapo eo] 94958 'Su0 uneaiga aod 9g 908 393 sue Buyunses se pasos poy saaut9| ip 9m sunning ‘pausa| sem ey ufo soeaptsuo> 1940940153] Ssoudep ewido see 9 0} 583 a oge2ulpeas vay ‘auina aq nau euariuasaie reoidQoieid pur susgerd uowsuse> Srey oy subi’ ues] uzisse uj a a5 9 4 Yih 348 x9 942 I aROGE 199] 3 95 sys0uSep 242 ‘prom ea ep jasotoid a tosap sue 24h) {9509 rage uese>s 6 4 syauies] op paid fyensea ous Button jo aBey 29) 9509 de 9509 J0 sui prog e3 Slyder 94) uaa, “nog 4 (¢8908 bya uy 99 fel ‘muse sins almaeurid jo dure stung yqssod st uonty dosed ub]geve ue Ue 3.0 ‘i090 ‘adune esau ina 0: waygoed yp 244 sgh yim sousuade 20} $04 ‘ours ut sdjonod jopue, ue pasD 104 Sty sue] ro0ie anes josune « apr] fo aee a0 ‘upuersapun lood ey oule3) Supuesiapun json Susen jo 93099:83 caaigd Hp p99 put r2jduiosej6 ogeubsoid ponueziesig oo od vousod ©3029) peas 28 Moog uuoseas ze uoneussaig stsoudepp pawieysey os enaue sans rasuidopng peg poy sno ‘The Now England Joural of Medicine Downloade fom nj. og by José Comprido on May 7, 2024, For personal ss only. othe see without permision, Copyright © 2006 Massachosets Medical Society, Al igs reservedThy NEW ENGLAND JOURN, to begin by creating in memory an anchor proto- type of the typical presentation, rather than giving equal consideration to a number of undifferenti- ated possibilities 72 Early im their training, medi- cal students should be assigned to evaluate pa- tients with common problems — ideally, problems for which there are prototypical presentations After the features of the prototype have been so- lidified in memory, additional clinical exposure to similar problems can offer a basis for comparison ‘with the prototypical case, providing learners with an appreciation of atypical or subtle findings. ‘The teacher's expectation of evidence of strong rea- soning should vary according to the stage of train- ing of the learner, but the learner's developmental level is often related more to the extent of clinical ‘experience with the case at hand than to the year of training, First-year residents, for example, may hhave clinical reasoning skills that are as advanced as those of senior residents when it comes to com- ‘mon clinical problems that they saw frequently as medical students.» Thus, although the stage of ‘waining is somewhat helpful to the teacher in de- termining expectations of and roles for learners, specific questioning strategies are necessary to probe the understanding and elicit the uncertain- ties of learners at any level® Several different steat- egies can be used, but open-ended questions are especially useful for assessing the learner's clini- cal reasoning abilty*2? Using this or other simi- lar frameworks, clinical teachers can evaluate a learner's performance on the basis ofthe expected performance at different developmental levels. ‘The clinical teacher should provide the learner with specific cognitive feedback. The teacher should point out diagnostically meaningful information in the data on the case, identify redundant or ir- relevant findings, and highlight the discriminat- ing features, including their relative weight or im- portance for drawing conclusions as to the eorzect diagnosis” When a learner suggests a possible but not plausible diagnostic consideration, the teacher can ask the learner to describe the key features of a prototypical case and then to compare the pro- totype with the findings in the ease at hand. Leamers should be encouraged to read about their patients’ problems in away that promotes diagnos- tie reasoning, rather than to read about topics in 4 rote memorization fashion, without context, The organization of knowledge stored in memory fa- cilitates the recall of key concepts for application to the next relevant clinical case.? To enhance theiz organization of knowledge and their understand- ing, novice learners should read about at least two diagnostic hypotheses atthe same time (g., gout and infectious arthritis), comparing and contrast- ing the similarities and discriminating features. Clinical teachers should encourage reading that promotes conceptualization rather than memori- zation and provides learners with an opportunity to share what they have learned, testing what has been understood well enough to be explained” and reinforcing the importance of self-directed learning. ‘Some medical textbooks are better organized than others to encourage learning by comparing and contrasting diagnostic considerations.” The judicious use of the original literature, even by novices, can be an effective clinical learning tool, especially when it provides important new orga- nizing principles or pathophysiological insights that have yet to permeate textbooks. Learners should be encouraged to identify progressively broader and more complex issues, explore them ‘more deeply, and apply the principles of evidence- based medicine in arriving at answers. In summary, clinical teachers can promote the development of diagnostic reasoning while simul- taneously diagnosing both the patient’s disorder and che learner's abilities. To do so, however, they must have an appreciation of clinical learning theory and practice and an accurate understand- ing of the clinical problem in question. Such an undertaking requites that the teacher accompa- ny the learner to the bedside or examination room and perform an independent assessment of the patient and, at the same time, assess the develop- ‘mental stage and clinical reasoning ability of the learner. Ensuring the quality of patient care and ‘modeling professionalism while promoting diag- nostic reasoning skills constitute the true art of clinical teaching. ‘No potential cout intrest elevate this ale was pone ‘The Now England Joural of Medicine Downloaded fom eja.org by José Comprido on May 7, 2024. 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Emphasaag seme te sretares, esd Med 19903599 sate ng 2 266 Mat Me Se {ONAL ARIES THE JOURVAL ONLAE Indvdvl ebrenibers ean tar areles and rarhes ting fete ‘on the Jura Web ie or. nejm.ong called “Personal Archive.” Bach ace and satel eu link oth featue. Ure acres al fds nd roe als nto thes for eoureiea tea lat. every mee ss) ‘The Now England Journal of Medicine Downloaded from nemo by José Compido oa May 7, 2024, For personal use only. Nother uses without permission, Copyright © 2006 Massachsets Medical Society, Al igs reserved