Clinical Reasoning Teaching Clinical Reasoning: Case-Based and Coached

Optimal medical care is critically dependent on clinicians’ skills to make the right diagnosis and to recommend the most appropriate therapy, and acquiring such reasoning skills is a key requirement at every level of medical education. Teaching clinical reasoning is grounded in several fundamental principles of educational theory. Adult learning theory posits that learning is best accomplished by repeated, deliberate exposure to real cases, that case examples should be selected for their reflection of multiple aspects of clinical reasoning, and that the participation of a coach augments the value of an educational experience. The theory proposes that memory of clinical medicine and clinical reasoning strategies is enhanced when errors in information, judgment, and reasoning are immediately pointed out and discussed. Rather than using cases artificially constructed from memory, real cases are greatly preferred because they often reflect the false leads, the polymorphisms of actual clinical material, and the misleading test results encountered in everyday practice. These concepts foster the teaching and learning of the diagnostic process, the complex trade-offs between the benefits and risks of diagnostic tests and treatments, and cognitive errors in clinical reasoning. The teaching of clinical reasoning need not and should not be delayed until students gain a full understanding of anatomy and pathophysiology. Concepts such as hypothesis generation, pattern recognition, context formulation, diagnostic test interpretation, differential diagnosis, and diagnostic verification provide both the language and the methods of clinical problem solving. Expertise is attainable even though the precise mechanisms of achieving it are not known. Acad Med. 2010; 85:1118–1124. All teaching methods are of necessity pragmatic and context-dependent. Teaching approaches lack a firm scientific underpinning because of the paucity of scientific evidence about optimal learning. Despite substantial advances in our understanding of human cognition during the last few decades, our teaching methods are still based largely on expert opinion. If these assertions are true for elementary teaching, they are even more compelling when applied to a field as complex as clinical reasoning. Given these modest scientific underpinnings, we might just throw up our hands and give up any hope of imparting reasoning skills to students and residents, yet we know there is much to learn, that many do become expert clinical problem solvers, and that the welfare of patients depends as much on reasoning and problemsolving abilities as it does on the use of the latest technology. Clinical cognition encompasses the range of strategies that clinicians use to generate, test, and verify diagnoses, to assess the benefits and risks of tests and treatments, and to judge the prognostic significance of the outcomes of these cognitive achievements. Needless to say, clinical medicine consists of much more than clinical cognition, including meticulous gathering of data, careful examination of patients, empathy with the sick, ability to communicate with patients, and professional demeanor, among many others, but this essay is restricted to clinical cognition. Though we still have much to learn about clinical cognition, several sources can be combined to define a reasonable pragmatic approach that can be subjected to critical evaluation. These sources start with commonsense notions of learning from some of the most venerated and respected educators, from modern theories of adult learning, from research on clinical cognition, and from the experience of educators, such as myself, who have been working at it for decades. Insights From Educational Theory Seventy years ago, John Dewey, the great educator and pragmatist, outlined criteria for teaching that have stood the test of time. One fundamental principle, which seems almost mundane today, is that experiences are critical determinants that influence the quality of learning, and that the teacher has an obligation to provide optimal experiences. Dewey believed that teaching experiences should arouse curiosity, enhance personal initiative, and allow free expression of learners’ ideas. In explaining the importance of individual experiences on the development of expertise, he wrote, “What [the student] has learned in the way of knowledge and skill in one situation becomes an instrument of understanding and dealing effectively with the situations which follow.”1 Modern concepts of “adult learning” supplement these concepts. They hold that the role of the teacher is not to transmit knowledge but to facilitate learning, encourage spontaneity, and engage in mutual inquiry.2 Such a strategy requires that the educator be comfortable when others in a group engage in critical thinking and challenge the educator’s opinions and convictions. As in Dewey’s formulation, adult learning theory holds that people learn new knowledge and skills most effectively when they are presented in the context of Dr. Kassirer is distinguished professor, Tufts University School of Medicine, Boston, Massachusetts, and visiting professor, Stanford University, Palo Alto, California. Correspondence should be addressed to Dr. Kassirer, Tufts University School of Medicine, 136 Harrison Ave., Boston, MA 02111; telephone: (781) 237-1971 or (617) 306-9788 (cell); e-mail: [email protected]. Academic Medicine, Vol. 85, No. 7 / July 201