Practice Perfect 652
Clinical Teaching Vocabulary for Teachers
Clinical Teaching Vocabulary for Teachers
If you are an educator of any level of trainee, from student to resident to fellow, a common activity is to identify an error by the trainee during the clinical encounter and do something to correct that error. A relatively common mistake that I see by early clinical podiatric students while reviewing radiographs is to identify one pathologic entity and then fail to see other important findings. This error is often due to the trainee focusing excessively on the first aspect while failing to recognize other important findings. This error is called premature closure (as in prematurely not look further once a diagnosis is found).
Is it necessary for the clinical teacher to know the name of this error? One may argue that knowing the jargon related to understanding clinical reasoning (that oh-so-important skill we are always trying to teach our trainees) is not necessary. “I can teach my student to systematically review a radiograph to avoid missing other findings without resorting to labels,” you may claim.
I contend that, although it is not absolutely necessary to know terms, there are important benefits to having a vocabulary that describes clinical reasoning. Let’s use an analogy: anatomy. Must I know the name of “That bone just beyond that long bone that comes after the joint in the middle of the leg”? This is an awfully cumbersome way to describe the talus. Would it not be better to use anatomical terminology and state, “The talus is immediately distal to the tibia”?
When your trainee makes an error, identify it by name and then discuss it using the correct terminology. You’ll find that this discussion yields the fruit of much faster understanding and improved performance by your trainees.
Terminology provides an efficient and descriptive common language. Dhaliwal and Ilgen describe this as the “scaffolding on which clinical teachers develop their teaching practices,” while learners use terminology to reflect on their performance.1 To practice something, you need to know what it is you’re practicing. This common language allows teachers to speak with students to dissect their reasoning errors to better understand the physiology of those errors. This also provides teachers with a system to assess trainees. Having something to identify, an entity with a name, creates a conceptual skeleton on which a teacher can evaluate the specific actions of a trainee before providing that essential feedback. Successful learning is the result.
What does the anatomy of clinical reasoning look like? Let’s take a look at a list of commonly used clinical reasoning terms that may be unfamiliar to some.2 This list is not all-inclusive, and I urge the interested reader to explore the growing body of published literature on the subject of metacognition (thinking about thinking).
- Dual-Process Thinking – This refers to the Nobel prizing-winning work by Dr Daniel Kahneman in his work Thinking Fast and Slow describing system 1 (fast thoughtless) and system 2 (slow, deliberate) thinking.
- Problem Representation – A one sentence summary describing the key features of a clinical case stating who the patient is, the temporal pattern of illness, and the key signs and symptoms.
- Illness Scripts – These are snapshots of a disease that allow us to quickly diagnose a problem based on common characteristics. For example, plantar fasciitis is quickly diagnosed based on a history of plantarmedial heel pain and poststatic dyskinesia.
- Hypothesis Generation – In a sense, this is the opposite of an illness script. When a diagnosis is less obvious, we use abductive reasoning to use information generated during the history and physical to build a case for a particular diagnosis.
- Slowing Down – This concept builds off of dual-process thinking in which a student is using system 1, erroneously coming to a conclusion too quickly. The educator may suggest the student slow down and think through the problem in a more systematic fashion.
- Framing – Coming up with a diagnosis based on how the information is presented rather than the reality of that diagnosis. For example, a patient who frames her symptoms as plantar forefoot pain that “feels like a stone in my shoe” may cause the student to incorrectly diagnose the problem as a neuroma. If the patient had framed the problem as achy pain in a joint, the student may have come to a different diagnosis.
- Premature Closure – Failing to consider or look for additional information once a diagnosis is made.
- Anchoring – Relying too heavily on a specific piece of information. Failure to consider another diagnosis when a patient fails therapy may be due to a clinician’s being anchored to that first diagnosis.
- Availability – Referring to what comes most easily to mind. Making an incorrect diagnosis based on a recent prior patient interaction may occur if one relies on the most recent information available rather than the baseline prevalence of a problem.
- Confirmation – The most common cognitive error in which one assigns preference to information that confirms one’s prior beliefs.
As an exercise, look for some of these during your next educational interaction with a learner. When you see the error, identify it by name and then discuss it using the correct terminology. You’ll find that this discussion yields the fruit of much faster understanding and improved performance by your trainees.
-
Dhaliwal G and Ilgen J. Clinical Reasoning: Talk the Talk or Just Walk the Walk? J Grad Med Educ. 2016 May;8(2):274-276.
Follow this link -
Musgrove JL, Morris J, Estrada CA, Kraemer RR. Clinical Reasoning Terms Included in Clinical Problem Solving Exercises? J Grad Med Educ. 2016 May;8(2):180-184.
Follow this link
Comments
There are 0 comments for this article