Factors associated with clinical reasoning ability

Stefanie Lee stefanieylee at GMAIL.COM
Sat Sep 10 03:50:48 UTC 2016


Thank you all for the thought-provoking insights! To add an observation
from the settings where I've worked: a common characteristic of clinicians
who rarely get into serious trouble with diagnostic error seems to be their
ability to "know what they don't know."

In practice, this means they are skilled at discriminating when they can
confidently make a diagnosis, versus when a case may be out of their depth.

In the latter instance, they acknowledge and take steps to manage that
uncertainty: doing more research on the topic, consulting colleagues, or
recommending a course of action that ensures the patient is reevaluated in
a timely manner.

If someone does not recognize a case as needing extra attention/assistance,
they may offer a diagnosis with more confidence than is warranted, not seek
input from others, or fail to convey the need for close followup and/or
further workup, increasing the risk of diagnostic error.

-- Questions: How successfully can the ability to "know what you don't
know" be fostered in trainees or practicing clinicians? (attached an
article on teaching metacognitive skills)

Does work on this essentially overlap, or does it differ in any way from
efforts to teach cognitive debiasing or improve situational awareness?

With appreciation for everyone's input,
Stefanie

On 31 August 2016 at 11:30, Grubenhoff, Joe <Joe.Grubenhoff at childrenscolor
ado.org> wrote:
>
>
>
> It would be great to hear from others on the listserv about this.  *What
> observable behaviors characterize clinicians who excel at diagnosis?*
>
> *1)      **In the academic setting, providers who tend to use a Socratic
> approach to draw out their learners’ reasoning are often very adept at
> diagnosis.*
>
> *2)      **Providers who tend to share their personal stories of
> erroneous diagnosis AND impart their deconstruction of what led to the
> error demonstrate an introspection and willingness to serve the success of
> all by admitting their own “faults”: this underlies a general commitment to
> improve one’s own dx acumen.*
>
> *3)      **The generalist who, when getting advice from a consultant, is
> willing to say: “I did not know X,Y,Z. Can you explain this to me so I can
> catch in the future?”*
>
> *4)      **Along the lines of #3, being willing to tell a patient, I’m
> not sure what this is and I’m going to look something up. (humility and
> quest for new knowledge)*
>
> a.       As a med student I was seeing a gentleman with AIDS in a VA gen
> surg clinic with deep purple skin lesions. The surgeon told me to go read
> up on skin manifestations of AIDS since I admitted I knew nothing. The man
> had Kaposi sarcomas. I’m now a peds ER doc so never see these but the
> lesson stayed with me*.   *
>
>
>
>
>
> *[image: Sig1]*
>
>
> *Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics  *Section of
> Emergency Medicine | University of Colorado
>
> Children's Hospital Colorado
>
> 13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO
> 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
>
> joe.grubenhoff at childrenscolorado.org
>
>
> *Connect with **Children's Hospital Colorado*
> <http://www.childrenscolorado.org/>* on **Facebook*
> <http://www.facebook.com/childrenshospitalcolorado> *and **Twitter*
> <http://twitter.com/childrenscolo>
>
>
> [image: CHC_Logo_E-Mail_Color.jpg]
>
> *For a child’s sake…*
>
> *                We are a caring community called to honor the sacred
> trust of our patients, families and each other through *
>
> *                humble expertise, generous service and boundless
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>
> *…This is the moment.*
>
>
>
> *From:* Mark Graber [mailto:mark.graber at IMPROVEDIAGNOSIS.ORG]
> *Sent:* Wednesday, August 31, 2016 7:38 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Factors associated with clinical reasoning
> ability
>
>
>
> Thanks for sharing Dr Manesh’ survey, Shantanu.
>
>
>
> If the goal is to assess their clinical reasoning, I’d like to see other
> questions, like these:
>
>             When confronted with a new diagnostic challenge, I regularly
> construct (and document) a differential diagnosis
>
>             When I’m not sure of a diagnosis or ’the next step', I get a
> second opinion from a peer
>
>             When I’ve reached a tentative diagnosis, I consider whether
> my conclusion might have been influenced by a cognitive bias
>
>
>
> If the goal is broader, looking at success in the diagnostic process,
> there are other key behaviors that are relevant:
>
>             Have I succeeded in making the patient a partner in the
> diagnostic process?
>
>             Does my patient know when, why, and how to get back to me if
> the symptoms persist, change or don’t respond to treatment?
>
>             How often do I personally interact with the radiologists or
> pathologists interpreting diagnostic tests on my patients?
>
>             According to independent surveys, how effectively am I
> communicating with my patients?
>
>             Do I keep a record of tests and consults ordered and make
> sure I close the loop on all of these?
>
>             Do I designate a surrogate to review returning test results
> if I’m going on vacation?
>
>
>
> It would be great to hear from others on the listserv about this.  *What
> observable behaviors characterize clinicians who excel at diagnosis?*
>
>
>
> Mark
>
>
>
>
>
> Mark L Graber MD FACP
>
> Senior Fellow, RTI International
>
> Professor Emeritus, SUNY Stony Brook
>
> President, Society to Improve Diagnosis in Medicine
>
>
>
>
>






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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