Factors associated with clinical reasoning ability

pgbentonmd pgbentonmd at AOL.COM
Sun Sep 11 02:09:03 UTC 2016

Stephanie,Patients appreciate the physician who displays that most important  quality in any physician - HONESTY. Saying "I don't know, but I will get you to a colleague who does" earns their respect more than ever.Phil Benton, MD, JD Atlanta, GA

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-------- Original message --------
From: Stefanie Lee <stefanieylee at GMAIL.COM> 
Date: 9/9/16  23:50  (GMT-05:00) 
Subject: Re: [IMPROVEDX] Factors associated with clinical reasoning ability 

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,
On 31 August 2016 at 11:30, Grubenhoff, Joe <Joe.Grubenhoff at childrenscolorado.org> wrote:
It would be great to hear from others on the listserv about this.  What observable behaviors characterize clinicians who excel at diagnosis?

In the academic setting, providers who tend to use a Socratic approach to draw out their learners’ reasoning are often very adept at diagnosis.

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.

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?”

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)

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.   

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

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