One of the challenges for many of us involved in student and resident education is helping our trainees to learn from their mistakes to become the best physicians possible. In order to do this, we have to identify and characterize the errors trainees make to then create a plan of improvement. In many cases, it is easy to identify that an error occurred but hard to describe that error in a way our trainees can understand and use it to learn to improve. It is very helpful, then, for educators to have a vocabulary around which to frame discussions. Here are a few important descriptive terms to help frame conversations with your trainees. 

Illness Scripts

This term is very important because it differentiates the way in which experts think from that of novice clinicians. It is simply the common presentation of a particular disease, a picture in our mind of what a diagnosis looks like. Plantarmedial heel pain with poststatic dyskinesia is most commonly plantar fasciitis (or -fasciosis if you prefer). Medial ankle pain in a 40-year old overweight female with progressive unilateral pes planus is commonly adult acquired flatfoot. I learned to use this concept from one of my partners, Rebecca Moellmer, DPM, an excellent attending. This is useful when doing clinically teaching when little time is available to leisurely discuss things. I’ll ask the student to give me the diagnosis first (rather than the classic presentation method starting with the chief complaint). I’ll then ask the student to recite what aspects of the history and physical support that diagnosis. This allows me to test – usually in under a minute – the student’s ability to diagnose, reason, and logically support that diagnosis with an organized physical exam.

Representative Bias

As important as clinical scripts are, it is possible, especially for novice physicians, to fall into the trap of representative bias, wherein a clinician looks for the classic presentation of a disease and misses the variant or atypical pattern of a different disease. To use the heel pain example, over the years I’ve received second opinion consultations for patients who have been diagnosed with plantar fasciitis who actually have lumbosacral radiculopathy at the L5, S1 level. This less common differential of heel pain is missed less often with experienced clinicians who recognize some suspiciously different aspect of the history or physical that points to the less common diagnosis. Representative bias tends to reduce with experience, so clinical teachers should keep in mind that their novice learners are likely to miss these diagnoses and should vigilantly double check trainees’ work at all times.

Premature Closure

This is an error of thinking in which an initial diagnosis is made and the clinician then stops looking for other possible diagnoses. This is one of the most common errors I see when examining students and residents. For example, recently during an academic conference a student was asked to read the radiograph of an ankle fracture which was easy to identify. However, when asked if there were other pathologies present, he was unable to find the second and third metatarsal fractures that were also present. He simply could not peel his eyes away from the obvious fracture to see the other issues. He prematurely closed his mind to other possibilities. I have found two successful ways to combat this. First, be systematic in one’s approach to reading radiographs (proximal to distal method, soft tissue-bone-joint method, etc). Second, once you see the obvious pathology, consciously ignore it for a moment and examine the rest of the image carefully. This method works in most situations.  

Summary Statements

These are assessment statements found near the end of a chart note, most commonly used by our MD and DO colleagues (and some podiatrists). I was originally trained to use a bulleted or listed assessment rather than a sentence, and I still prefer this method for its efficiency. A listed assessment might be:

A summary statement instead uses a format that states the essence of the clinical picture. An example of the bulleted list above might be something like: “A 52-year-old male presents with 6 months of sharp, plantar 2^nd metatarsal head pain. Examination reveals a pes planus foot type, increase medial arch mobility, dorsiflexed 1^st ray, and pain with direct palpation and dorsal drawer of the 2^nd MTP joint right foot.” This statement supports the diagnoses listed above. I recommend using this method not for charting, per se, but rather to help those trainees who have a difficult time putting together the full clinical picture or to test that they know the important factors contributing to a diagnosis. 

Using concepts such as these will help educators diagnose clinical thought process errors and provide a useful vocabulary to explain these errors to our trainees to help them grow and learn.

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