#90: Clinical Reasoning: Become an expert diagnostician

April 9, 2018 | By Matthew Watto, MD

Become an expert diagnostician like Dr Gurpreet Dhaliwal, Professor of Medicine at UCSF. Join us for this deep dive into clinical reasoning and how doctors think! Topics include: how to improve your own clinical reasoning and diagnostic skills, how to teach these skills, and the initial steps to building your own expertise/mastery in clinical medicine! Dr. Osler once admonished his students to build experiential wisdom and follow-up with their clinical cases (clear cases, doubtful cases, and mistakes), but to do so, one must “…learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch.”

Test yo’ self: Take our quiz here

Written and produced by:  Stuart Brigham, MD; Images by Hannah Abrams; Edited by:  Matthew Watto, MD

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Clinical Pearls (highlighted by quotations from the show with a time-stamp):

1. Clinical Reasoning requires deliberate practice to reach maximum potential
2. Teaching clinical reasoning can be difficult, but is ultimately taught by example and should focus on the why, not the what.
3. Clinical reasoning requires, first and foremost, a foundation of knowledge.  However, knowledge without deliberate experiential practice will not help the clinician attain expertise.
4. Learning the nomenclature of clinical reasoning helps frame “how to think” and not just “what to think,” improving diagnostic accuracy.
5. In order to learn from experience, the clinician should keep a patient log (clear cases, doubtful cases, and mistakes) and follow-up on their ultimate conclusion.  Also, Dr. Osler’s quote is just awesome.
6. Heuristics (cognitive shortcuts [positive outcome] or biases [negative outcomes]) are, in general, beneficial.
7. “Going slow just makes you slow.”  Using “System 2” (Slow, deliberate thought process) does not necessarily improve diagnostic accuracy.
8. Ultimately, knowledge is still king and diagnostic accuracy requires the clinician to improve their fund of knowledge. To that end…
9. …exams and tests helps with retrieval practice.

In-Depth Show Notes – highlighted by “Quotations” (with a time stamp) to help you follow along!  You’re welcome!

1. “Everyone here is smart; you distinguish yourself by being kind.” (11:34) Everyone in medicine is ostensibly smart, but what truly distinguishes separates clinicians is not necessarily your fund of knowledge, but the kindness you show for your fellow man.
2. “The goal isn’t to be brilliant… it’s to strive for expertise.” (13:38)  Experience does not equate to expertise.  In order to strive for expertise, one must consciously put forward “…some special effort.”
3. Clinical Reasoning is when you take “…all of the data… and go through a series of mental steps.” (16:15)  Although seen everyday in clinical practice, defining clinical reasoning is difficult.  At its core, it’s just problem solving and improves through deliberate practice.
4. “Train the brain.” (18:38)  In order to improve clinical reasoning, you have to perform deliberate practice and “train the brain.”  Reaching your maximum potential requires one to put forward extra effort.
5. It’s a problem to be “…book-smart, but not street-smart.” (20:40)  A clinician that has an expansive fund of knowledge may do well on tests, but might be horrendous at clinical reasoning; this is why deliberate practice is so incredibly important.  When a learner lacks synthesis, one must first define the underlying issue. Is this a specific issue (i.e. not good reasoning around one issue) or is it a more generalized issue underlying clinical reasoning.  Fear not, synthesis improves with deliberate practice and educators can aide learners with constructive feedback.
6. “Can we do it again right now?” (25:10)  Feedback, when specific and timely in execution, can be helpful to redirect learners.  However, once a learner has internalized this feedback, asking them to “…take it from the top…” can be an incredibly powerful tool (as seen in professional sports, theater, music, etc.) to solidify one’s understanding of the concepts presented and rewire the brain.
7. “Practice the skill instead of telling about the skill.” (26:22)  Along with specific and timely feedback, learners may only need one model to show them how to do the skill (reasoning).
8. Defining Terms used in Clinical Reasoning:
   1. Problem Representation:  A concise, possibly subconscious statement, that represents the patient in front of you.  Typically includes acute/chronic, recurrent/relapsing, etc. Should be able to type this into Google!
   2. Illness Script:  An organized mental file that summarizes the a provider’s knowledge of a certain disease.  This illness script should grow in specificity as one grows in expertise, but will ultimately include the wide variations that disease may present.  For example, as a provider grows in clinical expertise, the unusual presentations will ultimately be included with the typical presentations.
9. “You can’t reason without a foundation of knowledge.” (29:30)  While you do need to have some knowledge to start reasoning, you don’t need a lot of knowledge to start reasoning.  If a learner has no knowledge of a certain disease process, no amount of clinical reasoning will help them get to the correct diagnosis.
10. “Decision making [deals] with the why, rather than the what.” (31:23)  Educators should voice not just the “what” of the diagnosis and plan, but voice the reasons “why” they proceeded down a certain diagnostic or therapeutic plan.
11. “There is value in teaching the nomenclature [of Clinical Reasoning]” (32:30)  Teaching the specific verbiage of clinical reasoning helps teach the science behind clinical reasoning.  Furthemore, the nomenclature helps convey the fundamentals in clinical reasoning to learners and how to recognize their cognitive pitfalls.  For instance, maybe their illness script for toxic epidermal necrolysis is “underdeveloped.” Teaching the importance on “how to think” is indescribably more important than “what to think.”
12. “You can’t get the right answer if the brain is solving the wrong problem.” (36:07)  Teaching the nomenclature (#11 above) helps to frame the problem appropriately and, over time, improve specificity and diagnostic accuracy.
13. Keep a Patient Log:  “Mercy for the other man, but none for yourself!” (37:17)  In order to grow from experience, the clinician must keep track of his/her patients and their outcomes.  If you never know what happens, you won’t learn from your mistakes. Even astute clinicians get many cases either completely or partially wrong.
14. “Being wrong feels exactly the same as being right.” (40:47)  Whether you’ve made the right or wrong clinical decision, ultimately it feels the same at the point of care.  This is why it’s so important to review your own cases over time.
15. “We get the diagnosis right about 85% of the time.” (46:12)  In order to improve diagnostic accuracy, feedback is the cornerstone.  This underscores why it’s so important to keep a patient log and follow-up on diagnostic errors.  How could you improve the problem representation? Is your illness script for that diagnosis underdeveloped?
16. “[Heuristics] are net beneficial.” (47:17)  Heuristics (cognitive shortcuts) are more helpful than harmful.  However, we only tend to discuss these heuristics in the context of a negative outcome and not necessarily the myriad of times they helped come to the accurate diagnosis.
17. “Can you debias the mind?” (49:12)  Teaching heuristics or purposefully going slower hasn’t shown any promising results to debias the mind and “undue the wiring” thus far.
18. “Going slow just makes you slow.” (50:00)  While there’s a lot of discussion about System 1 (intuitive, gut reaction) and System 2 (slow, deliberate), if you lack the fundamental knowledge (i.e. a poor understanding of myasthenia gravis), going slower won’t somehow provide you the answer (…how to diagnose and treat myasthenia gravis) and will only needlessly slow you down.
19. “Knowledge is king.” (52:52)  Diagnostic accuracy is ultimately grounded in your core knowledge base keenly honed by deliberate practice.  Only by building upon your core knowledge and, after sufficient deliberate practice, does diagnostic accuracy improve and knowledge become intuitive (System 1).
20. “Practice teaches us restraint not to worry about [zebras].” (54:34)  In medicine, common problems present in multiple different variations and the experienced clinician should be able to accurately recognize when a presentation is “…too far afield…” from these variations encountered during practice.  However, the full breadth of clinical experience will only be garnered if the practitioner has been honest in keeping up the incessant watch.
21. “The joy in medicine is knowing the common diseases and all their variations.” (54:41)  You can’t get daily joy from medicine if you just focus on the rare diseases.
22. Multi-Disciplinary Teams might help improve diagnostic accuracy. “Other professionals on the team… pick up stuff we don’t.” (55:40)  Physicians must be cognizant that they do not have all the answers and we must be open to accepting feedback from team members.
23. “[Exams] are just chances to access knowledge.”  Sorry students, Dr. Dhaliwal feels as though exams are here to stay.  You could always try the Human Diagnosis website!
24. “Master your craft.” (1:01:10)  Autonomy, mastery, and purpose are all strong drivers and help prevent burnout.  Unfortunately, physician burnout is a real problem and, while autonomy is little-by-little being whittled away, mastery can help prevent burnout.

Goal: Listeners will gain an appreciation for the Clinical Reasoning process and the difficulties that underpin building expertise in medicine.

Take Home Points

1. There is a difference between experience and expertise; becoming an expert requires deliberate practice.
2. Track your patients’ outcomes to help improve your diagnostic accuracy on the path towards clinical expertise.
3. While computers are improving in complexity, information processing, and machine learning, clinicians must instead think of ourselves as “learning machines” and continue the process well after training into their careers.  Defense against burnout

Learning objectives:
After listening to this episode listeners will…

1. Develop an appreciation for clinical reasoning.
2. Recall the importance that the educator plays in role modeling.
3. Learn how to improve diagnostic accuracy by keeping a patient log.
4. Identify the common nomenclature used in clinical reasoning and how teaching this common verbiage could serve to improve diagnostic accuracy
5. Recognize that misdiagnosis is common in clinical practice and every clinician could benefit from deliberate practice.
6. Explain the difference between experience and expertise.

Disclosures: None

Time Stamps

• 00:00 Disclaimer, Intro
• 02:30 Guest Bio
• 04:50 Dr. Dhaliwal
• 06:45 Book recommendation
• 09:14 App recommendation
• 11:34 Advice for learners and teachers (Pearl #1)
• 12:40 Can a computer out-think a human?
• 15:49 Defining Clinical Reasoning
• 18:38 “Train the Brain” introduced
• 20:30 Knowledge is a precondition
• 21:46 A learner who lacks synthesis
• 24:23 How to provide learner feedback
• 27:04 Defining problem representation, illness scripts, etc.
• 29:20 How to start teaching clinical reasoning
• 31:00 Focus on the “why” and not the “what”
• 32:11 Teaching the nomenclature of clinical reasoning
• 36:07 “You can’t get the right answer if the brain is solving the wrong problem”
• 36:34 Osler and his “Incessant Watch”
• 40:40 Being wrong feels exactly the same as being right
• 42:00 Patient tracking (Dr. Dhaliwal’s recommendation)
• 45:30 Why keeping a patient log is so important
• 47:00 Are heuristics beneficial?
• 48:55 Can you debias yourself?
• 50:00 “Going slow just makes you slow.”
• 52:00 All evidence has flaws, but knowledge is still king.
• 55:13 Clinical reasoning on multi-disciplinary teams
• 59:27 Take-home points

Links from the show:

1. How to Win Friends & Influence People by Dale Carnegie
2. The Millionaire Next Door by Thomas Stanley
3. Figure 1 (Quiz application)
4. Human Diagnosis (Daily cases to review)
5. Doximity
6. Dhaliwal G. Premature Closure?  Not so fast. BMJ Qual Saf. 2017 Feb;26(2):87-89. doi: 10.1136/bmjqs-2016-005267. Epub 2016 Mar 15. https://www.ncbi.nlm.nih.gov/pubmed/26980778
7. Dhaliwal G. Inpatient Notes: Diagnostic Excellence Starts with an Incessant Watch. Annals of Internal Medicine. 2017 Oct;167(8):HO2-HO3. http://annals.org/aim/article-abstract/2657737/annals-hospitalists-inpatient-notes-diagnostic-excellence-starts-incessant-watch
8. Dhaliwal G. Going with your Gut. J Gen Intern Med. 2011 Feb;26(2):107-9. doi: 10.1007/s11606-010-1578-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3019336/
9. Dhaliwal G. Clinical Excellence: Make it a Habit. Acad Med. 2012 Nov;87(11):1473. doi: 10.1097/ACM.0b013e31826d68d9. https://www.ncbi.nlm.nih.gov/pubmed/23111262
10. Dhaliwal G. The Greatest Generation. JAMA. 2015 Dec 8;314(22):2353-4. doi: 10.1001/jama.2015.10622. https://jamanetwork.com/journals/jama/article-abstract/2474428?redirect=true