In view of advances in artificial intelligence and global connectivity, tomorrow's doctors need to develop skills set that would help them to outperform the AI-gadgets and stay relevant in the 21st Century. Critical thinking, Creative Problem solving, Communication skills and Collaborative team-work are among the top skills needed for healthcare professionals of the future.

1. ‘4-C’ for 21st Century
Dr KR Sethuraman MD PGDHE FICA
Senior Professor of Medicine AIMST University
NB: All the images shown are available through internet; the
respective originators are thankfully acknowledged for permitting
non-commercial use of their creations
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2. Dedication
We need to Innovate for the New
Generation
2

3. Google Home (or Amazon Alexa)
 Control your devices and your smart home
 Access info from your calendars and other personal
information
 Find information online (Healthcare, Restaurant/Movie
bookings, traffic & directions, weather and news)
 Make appointments and send messages
 Reminders
 Read your notifications to you
 Real-time spoken translations
 Play content on your smart TV
 Open apps on your phone
Cost = RM 180
Red Bullets indicate possibilities for Medical Assistance

4. Teaching and Assessing
Critical Reasoning in
Medical & HP Education
Medical Professional

5. Top 10 Skills We need Today

6. 4-Cs 4 21-C

7. C- I – Critical Thinker
for Clinical Reasoning &
Decision making

8. Critical vs Non-critical Thinking
 Good Thinking
– Sensitivity
• Interest in gaining
more information
• Seeking alternatives
– Inclination
• Willing to invest
energy in thinking
the matter through
– Ability
• Possess the
cognitive ability
– Activated Knowledge
 Bad Thinking – “cognitive
misers” (inert knowledge)
– Chose to take mental
shortcuts, engage in
“spinal-level” (heuristic)
thinking,
– without interest in deep
thinking
 Also known as
“Activated Ignorance”
– Eg, “Money month” with
5 Fri/Sat/Sundays occur
once in 823 years.
Krupat 2011

10. Clinical Reasoning
 Higher cognition is an Internal
process
 Trainees and faculty need ways
to externalize and teach this
process
 Programs need assessment
methods that document growth
and competency in this skill

11. A Case to test thinking process
The Patient’s story:
 “My knee hurt me so much last night, I woke
up from sleep. It was fine when I went to bed.
It’s the worst pain I’ve ever had.
 Now it’s swollen.
 I’ve had problems like this before in the same
knee, once 9 months ago and once 2 years
ago.
 It doesn’t bother me at all on other days.”

12. Teacher’s inquiry: “What do you think
is causing this patient’s knee pain?”
Novice
 “It could be an infection.
 It could be a new onset
of rheumatoid arthritis.
 It could be Lyme
disease.
 Since he doesn’t recall
falling, I doubt it’s an
injury.
 I don’t know whether
osteoarthritis can
present like this.
Expert
 The patient has acute gout.
 He has had multiple discrete
episodes with abrupt onset of
extremely severe pain involving
a single joint with evidence of
inflammation on examination.
 Before all his episodes, he is
asymptomatic.
 Gout classically affects the first
metatarso-phalangeal joint, but
it can present in the knee.
 Nothing suggests any ongoing,
chronic problem in the knee.

13. Clinical Reasoning is for Action
Patient/situation
characteristics Prior knowledge
Problem Representation
Information Gathering
Context
Evaluation Action
Gruppen and Frohna, International Handbook on Research, 2002

14. Factors that influence the outcome of
Clinical Reasoning & Decisions
 Knowledge for the task
– subject matter required for successful
completion of the task
 Skill: intuition and a logical approach
– correctly apply knowledge to a problem
• non-analytic approach (intuition) when the
problem is familiar
• Analytic approach for unfamiliar problems
 Self (confidence and emotion)
 Self-regulation of skill and self: “patients first”

15. Intuitive versus Analytical Thinking…
INTUITIVE ANALYTICAL

16. Adverse Events and Clinical Reasoning
 Graber¹ adverse event study:
– Most errors: individual plus systems factors
– Average ~6 system & cognitive error per case
 “Cognitive factors”
– 320 cognitive factors in 74 cases
– 45 due to faulty data gathering (~15%)
– 264 due to faulty synthesis (problem
representation – clinical reasoning) (~80%)
¹ Arch Intern Med. 2005; 165: 1493.

17. How can we set objectives to
teach and assess clinical
reasoning to reduce
diagnostic error?

18. CT at Higher Levels of Bloom’s – 1

19. CT at Higher Levels of Bloom’s – 2

20. Socratic Questions for Case Discussion
Types of
Questions
Sample Questions
1 Clarification What do you mean by ____?
Could you put that another way?
Can you give me an example?
2 Probing Ass
umptions
What are you assuming?
How did you choose those assumptions?
What could we assume instead?
3 Probing
Reasons and
Evidence
How do you know?
Why do you think that is true?
What would change your mind?
http://www.1000advices.com/guru/communication_questions_socratic.html

21. Socratic Questions for Case Discussion
4 Viewpoint and
Perspectives
What are you implying by that?
What effect would that have?
What is an alternative?
5 Probing
Implications
and
Consequences
How can we find out?
Why is this issue important?
What generalizations can you make?
6 Questions
about
Questions
What does that mean?
What was the point of this question?
Why do you think I asked this question?
Types of
Questions
Sample Questions

22. Activity – 1 (10 mins)
 In your own field, write a student-outcome at a
higher level (Application for Problem-solving,
Analysis / Synthesis / Evaluation)
 Plan how to achieve the outcome and assess
the same
 Some examples from your group are to be
presented in the plenary session
Cue: At the end of the class on – (topic) -- , the
learners shall be able to __________________
______________________________________
______________________________________

23. Is PBL the only way of
problem based learning?
– Barrows proposed a
taxonomy
– Spectrum of
methods
Achieving objectives
by degrees
PBL PSE

24. Barrows’ taxonomy of PBL methods
SCC CRP SDL MOT
Lecture-based cases 1 1 0 1
Case-based lectures 2 2 0 2
Case method 3 3 3 4
Modified case-based 4 3 3 5
Problem-based 4 4 4 5
Closed-loop problem-
based
5 5 5 5
Complete case or case vignette
Partial problem simulation
Full problem simulation (free
inquiry)
Teacher-directed learning
Student-directed learning
Partially student & teacher directed
Abbreviations:
CRP - Clinical Reasoning Process
SCC - Student Centered Curriculum
SDL – Self Directed Learning
MOT – Motivation to Learn

25. 21-C-TIMES-Con
Problem Knowledge Coupling

26. 21-C-TIMES-Con 26
T: How will you
treat a pregnant
woman with
anemia for RM.30
per month?

27. Development of Positive Attitude to CT

28. C- II – Effective Communicator
No Exercises!
Only Role-Plays, Stories and
Reflections…

29. Words Of Comfort, Skillfully
Administered, are the Oldest
Therapy Known to Man - Louis Nizer
CURRENT PARADOX !
Global Communication & Internet Based
“Cyber-medicine"
 Breakdown In Doctor - Patient
Communication

30. Communication is Contextual
Novices often have problems
because of this…

31. Lack of Q-skill is a problem
Are you married?
No
How many children?
#*%(angry mutter)
Do you have kids
Yes, I do.
Are you Married?
You libelous fool…
Hey! Don’t worry.
Ask your questions
the other way
around.

32. Routine Communication, sans context,
can land one in big trouble …
Do you have kids
Yes, I do.
Are you Married?
You libelous fool…

33. WHAT is COMMUNICATION?
It is a process of talking with
another person to -
 Transfer & Share Meanings
 Form Impressions About Things, Events
or Persons
 Make Opinions & Judgements
Am I Talking With (or ~To) My Patient?

34. Dichotomy in Information Needs
 Doctors’ Needs -
i. To Establish Diagnosis
ii. To Plan Management
 Patients’ Needs -
i. To Understand the Symptoms
ii. To Feel Known as a ‘Person’
iii. To Feel Understood by the Doctor

36. Top Attributes of Effective
Communication…
 Accuracy
 Balance
 Availability & Timeliness
 Consistency
 Understandability
 Socio-Cultural Competence (astro-beliefs)
 Reliability & a Strong Evidence Base
 Repetition
Let us Try and identify the attribute
highlighted in each of the Role Plays

37. Repetition...
This is to ensure understanding. But do not repeat
the same words (like a parrot) .
Statement – Repetition – Explanation is effective
Example:
“It is important to act now before it is too late.”
Statement: “We think it’s important to act now”
-- pause --
Repetition: “It’s important to act now, -”
Explanation:“ because tomorrow may be too late.”
Making the patient repeat it is even more
effective
15-10-2019 3721-C-TIMES-Con

38. Communication Skills:
Assessment for Learning
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941375/
15-10-2019 3821-C-TIMES-Con

39. C- III – Collaborator
(for team-work towards common goal)
No Exercises to Do!
– Let us Just Play a Game and then Reflect…
OVER to Dr Mariette D’Souza

40. For Introspection…
 Who was willing to give away pieces of the puzzle?
 •Did anyone finish his/her puzzle then somewhat divorce
himself/herself from the struggles of the rest of the group?
 Was there anyone who continually struggled with his or her
pieces, but yet was unwilling to give any or all of them away?
 How many people were actively engaged in mentally putting
the pieces together?
 Did anyone seem especially frustrated?
 Was there any critical turning point at which time the group
began to cooperate?
 Did anyone try to violate the rules by talking or pointing as a
means of helping fellow members solve their puzzle?

41. 15-10-2019 4
1
Win – Win
Collaboration

42. https://miro.medium.com/max/704/1*2IlQQxRw_Om47fIeK71WHQ.png

43. The Five Principles of Collaboration
 Applying Trust,
 Respect,
 Willingness,
 Empowerment, and
 Effective Communication

44. C- IV – Creative Problem Solving

45.  A Russian businessman walks into a Swiss bank in
Geneva and asks for a $100 loan. He offers his luxury
Mercedes car as collateral.
 The collateral is too good, and the bank manager
approves the loan.
 A year later, the Russian comes back. He repays the
loan and the 10% interest and is ready to collect his car.
A Great Collateral !
The puzzled bank manager asked him:
“... did you really need the meagre
sum so badly? For $100, you left
your luxury car with us for a whole
year!”

46. The Russian laughed and said,
"That's simple – I just thought:
‘where else in Geneva can I find
such a great parking place for just
$10 a year?’”

47. Developing Creativity - i
 Brainstorming
– it encourages “uncritical generation” of possible
solutions to a well defined problem
• E.g., What are the various ways to coax a
smoker to quit?
 Lateral Thinking
– reject standard methods for solutions
– take a fresh perspective, involving spatial or
visual support for ideas
21-C-TIMES-Con 4
7

48. Developing Creativity - ii
 Problem Solving
– Break down the problem into smaller solvable
components
– Generate possible solutions, consider pros and
cons of each and choose the most appropriate
 Synectics
– to explore relationships between apparently
unconnected elements of a problem using
analogy and metaphors
• E.g., When is the liver/kidney large and shrunken
at the same time?
21-C-TIMES-Con 4
8

49. Buzz Session – Brain-storming
 Think of one example of an open-ended
problem in your own field (subject/discipline),
which could be given to students to think of
creative solutions to the problem
An example of an open-ended problem:
How could you treat a pregnant woman with anemia for RM
30 per month? She lives only 5 kms away but is unable to
visit the hospital to collect the medicines.

50. We must make our Graduates
 Think critically and be able to solve complex,
real-world problems
 Use creative problem solving to offer patient
centered ethical care
 Be able to Communicate effectively and with a
holistic appraisal of the Context
 Be able to Work as a productive Team-member
and when needed, Lead the team effectively
Can We Do it ?

51. We can !
If we have the self belief
and motivation like this
modeler, who shapes
“mere Clay” in to
“Desirable objects”

52. 15-10-2019 5221-C-TIMES-Con