Busy clinician-educators are often tasked with remediating medical students who have deficits in clinical reasoning. In this essay, we share our early experience with providing less feedback and more practice to these trainees. We suggest that front line teachers can streamline their feedback to struggling reasoners by focusing solely on the problem representation and prioritized differential diagnosis of the main problem in their oral presentations and then engaging in repeated loops of feedback until the student achieves competency in real time. By receiving feedback targeted to the assessment alone and employing deliberate practice, struggling students have the opportunity to make concrete improvement during short-term clinical assignments. This remediation approach is feasible for busy clinician-educators and warrants formal study.
Guiding students who struggle with clinical reasoning is one of the greatest challenges faced by clinician-educators . These students’ difficulties with clinical reasoning typically become apparent when they are unable to tell a cohesive history or articulate and defend a prioritized differential diagnosis in their oral presentations.
A large body of scholarship addresses the acquisition of clinical reasoning skills; this work has led to important insights about the remediation of clinical reasoning [2, 3]. Formal remediation programs are effective , but they are labor intensive, require a longitudinal, institutional response, and are not well suited to the real-time clerkship environment where the unexpected struggling student is one of many learners on the teacher’s team .
When students and faculty work together for a short period of time (e.g. a few clinic sessions or 2 weeks on a ward team), teachers often struggle with the enormity of the problem and find it difficult to focus on a specific, tangible skill that can be refined from one clinical encounter to the next. In this essay we describe an approach that we are developing in our work with struggling reasoners that devotes less time to comprehensive feedback and more time to deliberate practice with the goal of improving the crux of clinical reasoning: the assessment.
Less is more
The student’s oral presentation is the standard vehicle for assessing clinical reasoning in clerkship settings and is a common starting point for formative feedback. In working with students on our internal medicine clerkship and pre-clerkship elective, we previously employed the common approach of providing feedback on all areas of the oral presentation – starting with the chief complaint and ending with the assessment and plan – in one sitting. We came to see that two aspects of our extended conversations hindered the development of presentation skills in the struggling student. First, as cognitive load theory suggests, this volume of feedback can be overwhelming for the learner . Second, by concluding the discussion without having the student act on the feedback (and waiting until the next presentation to see if improvements were made), we forfeited a valuable opportunity to ensure that the student was able to incorporate the feedback.
Audétat outlined a taxonomy of five categories of reasoning difficulties that present in clinical teaching settings . All deficiencies but one (data collection) are manifest in the assessment section of an oral presentation. Accordingly, we began limiting our feedback to the heart of the assessment: the problem representation and the prioritized differential diagnosis of the patient’s main problem.
Practice, practice, practice
On rounds, we listen closely to the student’s presentation but give minimal feedback in the moment. Later that day we deliver feedback limited to the assessment, and the student is asked to immediately present a new version of the problem representation and the prioritized differential diagnosis. We provide corrective feedback on this new version, and the student tries again (see Table 1). These feedback loops are short, with each iteration incrementally moving the student closer to an acceptable product. Real time deliberate practice is continued as many times as needed until the student presents a competent diagnostic argument, which replaces the memory of failure with the memory of success.
|Student||Clinical reasoning coach|
|This is a 55-year-old man with dyspnea.||I agree that this patient’s main problem is dyspnea. In your problem representation (PR) you want add one or two key details of the patient’s past medical history (PMH) which frame how we should think about his dyspnea. Are there any problems that stand out in this patient’s PMH that impact the possible causes of his dyspnea?|
|I guess his HIV and his COPD are important. And he has really severe gout.||I agree HIV and COPD shape how we think about the differential. But do you think his gout changes your approach to his dyspnea? If not, you will want to leave that out. Let’s try your PR again with the relevant information included.|
|This is a 55-year-old man with HIV and COPD presenting with dyspnea.||That’s better. Now, are there any key features of his presentation that further define his dyspnea? For example, what was the time course? Was dyspnea associated with any other major symptoms?|
|It started a couple of hours before he came to the emergency department. And he also had some chest pain.||Great. When you start adding those types of details, the listener can now start triggering diseases that might explain shortness of breath – like acute coronary syndrome or pneumonia. Let’s try the PR again incorporating this new information.|
|This is a 55-year-old man with HIV and COPD presenting with acute onset of dyspnea and chest pain.||Just to push you one step further, was there anything particularly notable about the kind of chest pain he had? For example, what was the quality of the pain?|
|It was worse when he took a deep breath. I think we call that pleuritic chest pain.||Exactly. Let’s add that detail to your PR.|
|This is a 55-year-old man with HIV and COPD presenting with acute onset of dyspnea and pleuritic chest pain.||Now as I am listening to your PR, I am able to consider several conditions right away because you have expanded upon the problem with some key differentiating features. With your next patient, I want you to include this type of expanded PR. Just so I am sure we are on the same page, what will be important to include?|
|I will think about what PMH might be directly related to the presenting problem, and I will try to mention details of the presentation that will help frame and describe the chief complaint.||Sounds good. Now let’s go over your prioritized differential diagnosis for your patient’s main problem, dyspnea.|
This approach embodies the core principle of deliberate practice: isolating a single high-yield skill (in this case, making a persuasive assessment) and using iterative feedback from a coach until the gap between current and desired performance closes . In many ways, this exercise is similar to a sports drill or music rehearsal, where the teacher observes performance, provides corrections, and then says “let’s take it from the top.” Critically, in both instances, the instructor does not wait for another day to see if improvement materializes.
We were initially reluctant to ignore errors made in data collection, presentation structure, or management plans. However, we have found that once students attain a clear understanding of the components of a cogent diagnostic argument, they more naturally understand the key pieces of data needed to develop this argument. In our experience, data gathering (knowing what to ask) and data presentation (knowing what to highlight in the history, examination, or studies) will improve even before specific attention is paid to these domains.
There is no expectation that the student will have radically transformed their medical knowledge in the short time frame that students and attending physicians typically work together. Instead, the goal is for the student to develop a basic understanding of the essential components of a persuasive diagnostic argument. Success is marked by their ability to give a well-defended prioritized differential diagnosis for a single problem.
In order to model, analyze, and teach clinical reasoning, clinician-educators must become facile with its basic lexicon: problem representation, illness scripts, and the prioritized differential diagnosis [9, 10] (Table 2). Using this framework, attendings can share their expectation that the major problem be clearly defined and analyzed with a differential diagnosis where competing diagnoses are compared, contrasted, and prioritized. With these well-defined expectations in place and a brief orientation to closely spaced iterative feedback loops, students can embrace the process that will bring them closer to the articulated standard.
|Problem representation||A one-sentence summary defining the patient’s condition in abstract terms, typically including patient demographics, relevant medical history, syndrome description, and time course.|
|Illness script||A representation in long-term memory of the typical historical, examination, laboratory, and imaging findings of a disease or syndrome.|
|Prioritized differential diagnosis||A listing of candidate diagnoses which match the problem representation nearly perfectly (Tier I), somewhat (Tier II), and remotely (Tier III), or are sufficiently emergent that they require consideration, independent of the degree of match (Tier Ie).|
While the initial conversation setting up the coaching plan does not entail substantial faculty time, the repeated one-on-one feedback cycles surrounding each presentation require dedicated blocks of time for deliberate practice. We have found that effective practice sessions require approximately 20–30 min each. We employ this remediation approach for a few students each academic year.
To complement in-person coaching sessions, attendings may consider electronic communications. One professor of English described how he helps his students develop writing skills by using email to solicit multiple early drafts and engage in repeated feedback cycles on key aspects of the paper before its formal submission for a final grade . Clinician-educators can adapt this idea, with students securely emailing just the problem representation and prioritized differential diagnosis. Faculty can then reply using track changes and comment boxes and request re-writes until the student reaches competency. In our experience, students welcome this electronic feedback.
Clinical reasoning is challenging to remediate in real time in busy clinical settings. When a teacher’s time and a struggling student’s cognitive bandwidth are constrained, both parties should focus their efforts on an objective that is specific, relevant to the workplace, and achievable in one feedback session (Table 3). Our approach turns the teacher into a reasoning coach and gives the learner the opportunity to mark clear progress in a foundational skill.
|Comprehensive feedback||Focused feedback|
|Feedback given on entire presentation||Feedback limited to the assessment (summary statement and prioritized differential diagnosis of problem #1)|
|Wait until next presentation to assess understanding and improvement||Feedback loops with deliberate practice: student repeatedly revises argument in real time until competency is demonstrated|
|Goal: a better presentation||Targeted goal: articulating a persuasive diagnostic argument for a major problem|
While it may be difficult for the teacher to limit feedback to the assessment and let errors in the remainder of the presentation go uncorrected, we have seen clarity develop organically in other areas of the presentation once students fully grasp the diagnostic assessment. Conversely, when a sea of feedback is provided, struggling students can often drown.
We have not yet collected data or utilized formal assessment tools to evaluate our approach. Rather, we have drawn on observations of our own students, which are subject to confirmation bias. Formal study with a validated oral presentation scoring system is needed to confirm our early experiences. Also, we have focused on what one clinical teacher can do with one struggling student during the short time they have together. However, deliberate practice is most effective when it is sustained; we expect that improvements in clinical reasoning would be maximized when a series of clinician-educators use this approach longitudinally with a student.
We suspect that this singular focus on the assessment may refine the early organization of students’ illness scripts, which underpin all clinical reasoning skills. When students have a better understanding of what data are needed to make a coherent clinical argument, they are better equipped to select the right kinds of information to encode in their growing library of illness scripts. Instead of memorizing every aspect of a disease, students come to prioritize and encode features that they now realize are needed to make a convincing diagnostic case. Sparking this insight, more than anything else, may ultimately catalyze these students’ journey toward competence.
The authors thank Calvin L. Chou MD, PhD for his helpful review of an earlier version of this manuscript.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: Gurpreet Dhaliwal, MD is on the editorial board of Diagnosis.
Honorarium: None declared.
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©2015, Denise M. Connor et al., published by De Gruyter
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