From the August 12, 2022 issue of the Transformational Times newsletter
Diagnostic Reasoning – A Call for Faculty Engagement
By Jayshil J. Patel, MD - Director of MCW's curriculum "Critical Thinking in Medicine" thread
Dr. Patel shares, in earnest, this call to interested clinical faculty to engage in the diagnostic reasoning curriculum. In many ways, our patients and posterity depend on it ...
As many of you know, threads will be woven into the new medical school curriculum. The Critical Thinking in Medicine thread will be a synergistic marriage between diagnostic reasoning and evidence-based medicine which, I think, are the key constituents for deliberately practicing medicine in today’s clinical environments and setting learners on paths towards diagnostic expertise. Over the past few years, components of the curriculum have been tried and tested in various venues throughout undergraduate and graduate medical education and many learners have embraced and incorporated the language of the diagnostic process into their medical lexicon. Some have left training equipped with skills to metacognate.
I am thrilled the curriculum will become a staple of undergraduate medical education at the Medical College of Wisconsin, but the initial implementation and sustainability of any curriculum, let alone ours, relies on an acceptance and participation from learners and faculty. Thus, faculty development will be crucial.
If, at this point, you’re asking, “Well, how are you going to do that?” Don’t fret. I share your line of questioning. My honest answer is that I don’t know. Or rather, I haven’t figured it out yet.
But before embarking on a journey to capacitate and train the trainers, I would like to share why I think clinical faculty members would benefit from engagement, including becoming fluent in the semantics, scientific underpinnings, and metacognitive strategies related to the diagnostic process. Here, I outline the impact (and really benefit) for three key stakeholders.
For the sake of patients: Reducing medical errors by teaching how to arrive at a correct diagnosis
Clearly, the goal for many front-line specialties is to get an accurate and timely diagnosis. Without it, management is ineffective, wasteful, and potentially harmful. With an accurate diagnosis, management and prognosis are guided.
A diagnostic error is defined as a “failure to develop an accurate explanation for a patient’s health problem and/or failure to communicate that explanation,” and studies of autopsies, secondary reviews, and voluntary reports suggest diagnostic errors occur in up to 15% of cases, culminating in adverse events in up to 90% of cases. It turns out cognitive errors are by far the most common cause of diagnostic error. An analysis of 583 physician-reported diagnostic errors suggested a failure/delay in considering diagnosis, suboptimal weighing of information, or too much emphasis placed on competing diagnoses were the most common reasons for “what went wrong.”
As a result, patients may be subject to unnecessary testing and incorrect therapies, which may subsequently lead to psychologic/physical harm, toxicity, prolonged hospitalization, financial distress, and even death. Therefore, if the primary goal during an initial undifferentiated patient encounter is to arrive at a diagnosis, shouldn’t medical education, for the sake of patient care, strive to teach learners how to arrive at a diagnosis by explicating the diagnostic process into discrete teachable components to be deliberately practiced? And in doing so, is it possible to reduce diagnostic errors?
While I can’t cite literature, and even if the answer is “no,” I opine, from a philosophical standpoint, that there’s intrinsic value, for doctoring and the doctor-patient relationship, in better understanding the diagnostic process.
For the sake of learners: Giving them tools to build their diagnostic expertise
It is not uncommon for novice learners to be “full of facts.” However, they may have a difficult time “putting it all together.” In fact, the diagnostic process is often considered a “black box” where learners can see what goes in (the data) and what comes out (the eventual diagnosis) but may not be able to articulate (in written or verbal communication) the intermediate steps. And in some cases, the diagnoses are often drawn from a grab bag of differential diagnoses, which are verbalized using reflexive and biologically unlinked thinking.
Instead of just creating competent graduates, what if we aim to set learners on a path towards diagnostic expertise? After all, and as stated earlier, nothing good happens without an accurate diagnosis. And so, what if the learner could:
(a) Recognize how to appropriately utilize and toggle between different systems of thinking
(b) Recognize when their cognitive load is high
(c) Utilize different approaches to problems (e.g., hypothetical-deductive versus inductive approach)
(d) Acquire a template for knowledge storage, expansion, and retrieval
(e) Learn to conduct a cognitive autopsy and scan their environment for cognitive pitfalls
(f) Learn to calibrate their thinking for future similar but not identical cases
It is not a stretch of the imagination, and in fact, when we launched this curriculum in the internal medicine residency program, these components were exactly what learners desired out of their training. For learners to grasp and deliberately practice these components, they’ll need their faculty counterparts to share their understanding of the diagnostic process (or at minimum, speak the same language).
For the sake of faculty: Creating a culture where they can share their skills
A few years ago, before delineating the components of a diagnostic reasoning curriculum, I began with the end in mind. Assuming resources abound, I envisioned a Center for Diagnostic Reasoning (and Evidence-Based Medicine). It would be a place where educators would encourage learners to think aloud, deliberately dissect clinical cases into aliquots, and expound systematic approaches. They would approach problems embedded in a patient context and within a consciousness of the scientific underpinnings of decision-making and evidence-based medicine, all the while reflecting and calibrating their thinking. The Center would be magnetic, attracting educators into the logos of diagnostic reasoning, creating sustainability.
To me, that is aspirational and exciting. Here’s why. Sure, for young learners, the acquired skillsets are meant to promote lifelong learning and equip them to stay on the path towards diagnostic expertise. But for clinical faculty, the acquired skillsets provide an opportunity to illuminate their thinking and provide a window (for learners) into their mind, within a culture of democratized rounds where both learners and faculty are encouraged to say, “I don’t know,” without the worry of perceived failure.
Faculty might be overwhelmed and say, “I just don’t have time to do this.” I will submit to you that you (faculty) are already, some in an extemporaneous manner, reasoning; however, the addition of semantic and scientific structure may provide greater clarity for learners (and yourself).
Importantly, such a culture would enable the expression of virtues such as courage, prudence, empathy, grace, and humility. For example, it takes courage and humility to say, “I don’t know.” The manifestation of these virtues is central for the success of the hidden curriculum, which has far-reaching implications, perhaps more than the exposed curriculum. And an explicated awareness of an individual’s thinking may be the key in accruing tacit knowledge.
After all, it was Aristotle who said, Knowing yourself is the beginning of all wisdom.
Jayshil J. Patel, MD, is an Associate Professor of Medicine in the Department of Medicine at MCW. He is on the Learning Environment Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and the Critical Thinking in Medicine Thread Director at MCW.