CAEP GeMES | Clinical Reasoning Problems Among EM Residents

Jack is a first year Emergency Medicine resident. He pours over the content of each cardinal presentation (chest pain, shortness of breath, abdominal pain) after every shift and tries his best to remember all the various questions to ask patients. Being detail oriented, he spends at least one hour with each patient to make sure he has gathered as much data as possible. Jack is good at coming up with the right differential and the right plan, and usually gets positive feedback. On the other hand, Jack sees his staff physicians interact with patients and sees how they are able to arrive at the right diagnosis within only a few minutes and asking only a few seemingly random questions. Jack wonders how his clinical reasoning might become more efficient.

Clinical reasoning is rarely taught explicitly in medical curricula, but differentiates the learner from the expert. This “Great Evidence in Medical education Summary” (GEMeS – pronounced “gems”), titled “Can we identify and characterize clinical reasoning problems amongst residents?” was originally posted by the CAEP EWG GEMeS Team on March 11, 2016. A PDF version of the GEMeS summary is available here.

Education Question or Problem

Can we identify and characterize clinical reasoning problems amongst residents?

Bottom Line

The six main categories of clinical reasoning difficulties are:

1) difficulties in generating hypotheses,

2) identifying cues and directing data gathering,

3) premature closure,

4) difficulties in prioritizing,

5) difficulties in painting an overall picture of the clinical situation,

6) difficulties in elaborating a management plan.

DETAILS
Reference	DOI: 10.3109/0142159X.2012.733041
Link to Journal	http://www.ncbi.nlm.nih.gov/pubmed/23228082
Study Design	Participatory Action Research Method
Funding Sources	N/A
Setting	Professors of the Département de médecine familiale et de médecine d’urgence of the Université de Montréal
Level of Learning	Undergrad and Postgrad

Synopsis of Study

Clinical reasoning difficulties: A taxonomy for clinical teachers

Clinical reasoning difficulties affect 5-15% of medical students. Although essential, teaching in the emergency department (ED) can prove to be a daunting task. The ED’s hectic setting can limit opportunities to perform high-yield teaching methods such as direct observation of entire cases, meaning the recognition of clinical reasoning problems is a challenge.

This study identifies the most common clinical reasoning difficulties as they occur in residents’ patient encounters, case summaries, and notes. Overall, through eight iterative engagement cycles, the authors aimed to alleviate the uneasiness often conveyed by clinicians when facing a pedagogical diagnosis. They provide a step-by-step approach, highlighting the similarities of the educational reasoning process with the clinical reasoning process most clinicians are familiar with (Figure 1). Although some of the steps outlined in Figure 1 are covered in the ensuing articles of the series, this article focuses on the crucial first step of the process: the recognition and pinpointing of a clinical reasoning difficulty, for which they provide a conceptual framework to help isolate specifically troublesome areas.

Clinical reasoning is separated into three main steps: 1) data collection and hypothesis generation, 2) hypothesis sequencing/refining and, ultimately, 3) establishing final diagnosis and treatment plan.

These steps are then subdivided into five potentially problematic areas. In data collection and hypothesis generation, students may display difficulties in anamnesis organization and in the identification of the key elements of the patient’s history, which can limit the comprehensiveness of the generated hypothesis. Difficulties in hypothesis treatment and refinement can stem from premature closure (a.k.a., ‘’Spot Diagnosis’’) or from struggling to appropriately prioritize possible diagnoses. Finally, difficulties in approaching the clinical situation as a whole and in the development of a relevant treatment plan complete the list of potentially problematic areas that should be considered when evaluating clinical reasoning.

THE CLINICAL REASONING PROCESS		THE EDUCATIONAL REASONING PROCESS
From the patient’s story…		Sensing/spotting difficulties…
1. Data collection	a) Generating hypotheses	1. Data collection	a) Generating hypotheses
1. Data collection	b) Verifying hypotheses	1. Data collection	b) Verifying hypotheses
2. Diagnostic impression		2. Diagnostic impression
3. Investigation		3. Investigating/looking for explanations
4. Final diagnosis/comprehensive representation of the situation		4. Final diagnosis/comprehensive representation of the situation
5. Treatment		5. Treatment: educational intervention plan

Figure 1. Clinical reasoning process compared to the educational reasoning process

In summary, the article presents a solid, easy to apply framework to help clinical teachers in the identification and characterization of a clinical reasoning problems in order to pose a solid pedagogical diagnosis for our learners. It represents the first step towards turning what was once viewed as a seemingly insurmountable task into one that is not only accessible, but also highly beneficial for medical students and residents.

Why is it relevant to Emergency Medicine Education?

This guide could aid clinical teachers identify and characterize clinical reasoning problems in medical trainees to ensure that appropriate remediation strategies be developed and applied in a timely manner.

What are common clinical reasoning errors you encounter among your learners? How can we teach better clinical reasoning?

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More About the CAEP GEMeS

This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Great Evidence in Medical Education Summaries (GEMeS) project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive GEMeS each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.

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Alexis Cournoyer

Alexis Cournoyer is Emergency Medicine resident and clinician-investigator at the Université de Montréal.

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CAEP GeMES | Clinical Reasoning Problems Among EM Residents - March 31, 2017

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Daniel Ting

Daniel Ting is an Emergency Physician and Clinical Assistant Professor at the University of British Columbia, based in Vancouver. He is the Editor-in-Chief of CanadiEM and a Decision Editor at the Canadian Journal of Emergency Medicine. He completed the CanadiEM Digital Scholarship Fellowship in 2017-18. No conflicts of interest (COI).