Clinical Reasoning Terms Included in Clinical Problem Solving Exercises?

Abstract

Background Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown. Objective We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators. Methods A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013. Results The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators. Conclusions Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms.

Off Trail, On Track: an Exercise in Clinical Reasoning

“…BSlowing down when you should^refers to the critical juncture when clinicians recognize that initial diagnostic considerations do not adequately explain a patient's presentation, prompting additional investigation. 4,5 This juncture marks a transition from automated and intuitive thinking (system I), to analytical and cognitively laborious thinking (system II). Through deliberate practice, clinicians develop situational awareness and background knowledge to carefully monitor for clues that warrant re-framing patients and systematically re-considering their differential.…”

“…Through deliberate practice, clinicians develop situational awareness and background knowledge to carefully monitor for clues that warrant re-framing patients and systematically re-considering their differential. 4,5 In this case, the discussant's initial thinking was automatic: she used pattern recognition to note Bstocking-glove^distribution of symptoms, activating her illness scripts for lengthdependent peripheral polyneuropathies. However, by noting mismatches between the patient's symptoms (involvement of hands prior to feet; ulnar pattern of involvement, rapid progression; bowel and bladder dysfunction) and her illness scripts for length-dependent peripheral polyneuropathy, she Bslowed down,^and was ultimately able to localize the lesion to the cervical spinal cord.…”

Clinical Reasoning: Talk the Talk or Just Walk the Walk?

“…The article by Musgrove et al 4 reminds us that this can happen in the context of a real world case or a published case, and that the latter can be a powerful learning tool for individuals or teams. The best clinical problem solving exercises begin with a challenging problem, stimulate trainees to practice their decision-making skills, and selectively introduce the nomenclature of clinical reasoning.…”

“…3 Given this evolutionary process, it is helpful to periodically examine the state of terminology and its utility to the members of a community. In this issue of the Journal of Graduate Medical Education, Musgrove et al 4 compared the frequency of clinical reasoning terms in 79 published clinical problem solving exercises to a ranking of clinical reasoning concepts by a group of educators at a single academic center. They found that educators prioritized some of the same concepts that were featured prominently in published exercises (eg, problem representation, illness script, and dual process thinking), but that published exercises placed greater emphasis on such concepts as bias and context specificity.…”

Using an informatics education strategy to resolve the dilemma of teaching transplantation in medical institutions

“…The Script theory could help one understand their own actions and could be used to achieve satisfactory results for staff training. [ 29 – 32 ] The establishment of a script could provide a theoretical framework to explain how organ donation/transplantation and expertise can be created and could help identify key issues and priorities in problem-solving. A script should be created by experienced and well-trained experts and scholars that have knowledge of clinical practice, time, and patient/family structure.…”