Developing, Maintaining, and Teaching Clinical Diagnostic Expertise

Main Article Content

Bruce Fisher MD
Liam Rourke, PhD

clinical diagnostic expertise, teaching and assessing clinical reasoning,

Abstract

Understanding the process of expert clinical reasoning improves our ability to develop, practice, maintain, teach, and assess clinical diagnostic expertise. The dual process model describes a synergistic interplay of associative thinking and analytical reasoning. These complimentary processes facilitate the efficient abstraction of data from clinical presentations, the identification of key features, and the production of useful problem representations. These are compared unconsciously to prototypical cases stored in memory as illness scripts for a best match. A lack of a satisfactory match may stimulate a conscious, analytic analysis of discordance, ideally reducing bias and error and promoting further script development.

An awareness of this process and the use of existing observation and assessment techniques can enable both the teaching and the assessment of clinical reasoning. Learners can also be taught to use these techniques to help develop self-assessment of clinical reasoning performance. Teaching and assessing clinical reasoning in others stimulates clinician teachers to reflect on their own clinical reasoning and practice, serving as an effective form of continuous professional learning.

Abstract 658 | PDF Downloads 363 HTML Downloads 514

References

1. Elstein AS. Thinking about diagnostic thinking: a 30-year perspective. Adv in Health Sci Educ 2009;14:7-18.

2. Epstein RM Mindful practice JAMA 1999;282:833-9.

3. Eva KW. What every teacher needs to know about clinical reasoning. Med Educ 2005;39:98-106.

4. Kulasegaram KM, Grierson LE, Norman GR. The roles of deliberate practice and innate ability in developing expertise: evidence and implications. Med Educ 2013;47(10) 979-989

5. Moulton CE, Regehr G, Mylopoulos M et al. Slowing down when you should: a new model of expert judgement. Acad Med 2007; 82(suppl): 109-17.

6. Norman G, Young M, Brooks L. Non-analytical models of clinical reasoning: the role of experience. Med Educ 2007;41: 1140-1145.Redelmeir DA, Ferris LE, Tu JV, et al. Problems for clinical judgment: introducing cognitive psychology as one more basic science. CMAJ 2001;164: 358-360.

7. Schmidt H Rikers R. How expertise develops in medicine: knowledge encapsulation and illness script formulation. Med Educ 2007;41:1133-9.

8. Charlin B, Boshuizen HPA, Custers EJ, Feltovich PJ. Scripts and clinical reasoning. Med Educ 2007: 41: 1178–1184

9. Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ 2010;44:94-100.

10. Bordage G. Prototypes and semantic qualifiers: from past to present. Med Educ 2007;41: 1117-1121

11. Bordage G. Elaborated knowledge: A key to successful diagnostic thinking. Acad Med 1994;69:883-885.

12. Nendaz MR, Bordage G. Promoting diagnostic problem representation. Med Educ 2002;36:760 –766.

13. Chamberland M, Mamede S, St-Onge C. Self-explanation in learning clinical reasoning: the added value of examples and prompts. Med Educ 2015; 49: 193-202.

14. Cianciolo AT, Williams RG, Klamen DL, et al. Biomedical knowledge, clinical cognition and diagnostic justification: a structural equation model. Med Educ 2013;47:309-316.

15. Boydston A (Ed.). John Dewey: The Later Works, 1925-1953 (Carbondale and Edwardsville: Southern Illinois Press, 1987).

16. Del Fiol G; Workman TE; Gorman PN. Clinical questions raised by clinicians at the point of care: a systematic review. JAMA Internal Medicine. 2014; 174(5):710-18.

17. Wegwarth O, Gaissmaier W, Gigerenzer G. Smart strategies for doctors and doctors-in-training: heuristics in medicine. Med Educ;2009;43: 721-728

18. Ericsson KA. An expert-performance perspective of research on medical expertise: The study of clinical performance. Med Educ 2007; 41:1124-1130.

19. Ericsson KA. Deliberate practice and the acquisition and -maintenance of expert performance in medicine and related domains. Acad Med 2004;79: S70-81.

20. Kassirer J. Teaching clinical reasoning: Case-based and coached. Acad Med 2010;85: 1118-1124.

21. Alguire PC, DeWitt DE, Pinsky LE. Teaching in your office: a guide to instructing medical students and residents. American College of Physicians 2001. Philadelphia, PN

22. Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med 1999;74: 41-5.

23. Wenrich MD, Jackson MB, Ajam KS, et al.Teachers as learners: The effect of bedside teaching on the clinical skills of clinician-teachers. Acad Med 2011; 86(7): 846-852.