1. Teaching Clinical Reasoning
“On the Fly” Part 1
Donald R. Bordley, M.D.
Residency Program Director
University of Rochester
(585) 275-2874
donald_bordley@urmc.rochester.edu
2. Key Points to Remember
• Teach while you work
– Clinical reasoning is most effectively taught as
you care for patients together, not in a lecture
hall or conference room
• Live what you teach
– If you don’t “role model” sound clinical
reasoning as you discuss all your patients, the
students won’t think it’s really important
3. Clinical Reasoning:
Steps to Success
• GATHER DATA CAREFULLY
• Define the patient’s central problem
• Generate and prioritize the differential
diagnosis
• Plan your work-up based on the
differential diagnosis
4. Step 1
• GATHER DATA CAREFULLY
All subsequent steps in the clinical
reasoning process depend on:
– Accurate history
– Accurate physical exam
– Accurate lab data (if relevant)
• Involve the student
– Students have the luxury of time to do this
well and this step can be partially delegated to
them.
5. Step 2
• Define the patient’s central problem
– List problems
– Define central problem(s)
• What’s in the foreground?
• What’s in the background?
– State the central problem clearly and
concisely
• (Foreground) in a (patient) with (background)
• For example: Hemoptysis in a 62 y.o. woman
with an 80 pack-year smoking history
6. Step 3
• Generate and prioritize the differential diagnosis
– Start with a complete list: common things are
common, but don’t miss high stakes diagnoses
– For each possible diagnosis decide, is it:
• Likely?
• Possible and high stakes (potentially lethal or requires
prompt specific therapy)?
• Possible and low stakes?
• Unlikely?
7. Step 4
• Plan work-up based on differential
diagnosis
– Aggressively work-up all “likely” diagnoses
– Aggressively work-up all “possible high
stakes” diagnoses
– Defer work-up of possible low stakes and
unlikely diagnoses
8. Practice Case Step 1:
Data Collection
• Mr. Jones is a 55 y.o. man who presented to the ED this
afternoon after developing the sudden onset of chest pain
after he had a coughing fit while mowing his lawn. The pain
is constant and sharp, made worse with inspiration and
associated with moderate dyspnea. Past history is positive
for hypertension, type 2 diabetes, high cholesterol and
seasonal allergies.
Abnormal findings on physical exam: HR 120, BP 150/90, R
28, O2 sat 92% on room air. Absent breath sounds over the
right chest. There is no JVD and the trachea is midline.
9. Practice Case Step 2:
Define the Patient’s Central Problem
• Problem list
– Foreground:
• chest pain, dyspnea, absent right breath sounds
– Background:
• HTN, Type 2 DM, high cholesterol
• Central problem statement
– Chest pain, dyspnea and absent right breath
sounds in a 52 y.o. man with HTN, Type 2
DM, and high cholesterol
10. Practice Case Step 3:
Prioritize the Differential Diagnosis
• Likely
– pneumothorax
• Possible, high stakes
– acute coronary syndrome
• Possible, low stakes
– muscle tear, rib fracture
• Unlikely
– aortic dissection, pericarditis, pneumonia
11. Practice Case Step 4:
Plan Work-up Based on Differential
• Work up the likely diagnosis
– CXR
• Work-up the possible, high stakes
diagnoses
– acute coronary syndrome - EKG
• Defer work-up of other possibilities
13. Bottom Line
• Teach as you work and live what you
teach!
• Be systematic and think out loud
– What are the problems? Foreground and
background.
– What’s the differential? Focus on likelies and
high stakes possibles.
– Let your differential drive work-up and
management
Notes de l'éditeur
April 2005
This is the major point– one of the most efficient ways for a busy house officer to teach and model clinical reasoning is to simply think out loud in the presence of the student and solicit questions.
Students are usually good data gatherers and the house officer could allow the student to present the data on a shared patient to keep the learner involved.
This is a challenging step for students so house officers can use the formulaic approach above to have the student try to define the problem first and then the house officer can share his/her approach and compare/contrast the two versions.
In certain situations there may be time to allow the student to generate the differential and then the house officer and student can prioritize it together using the guiding questions above.
This is a good case to have the group go through together to make sure everyone is on the same page about the process.
Dr. David Gary Smith developed a complementary presentation to be used after this one and it is in the next slide set. Dr. Smith’s case is written with a PGY 1 as the learner but it would apply to a medical student learner as well.