Name that lesion… This simple phrase brings me back to preclerkship Neurology learning that had me scrambling to figure out what part of the brainstem was impacted to result in the patient’s symptoms. I am guessing that this may ring true for many healthcare providers. Some of us have fonder memories and some of us may break out into cold sweats. However, the concept has followed us through our training and careers. There is a process that has a variety of steps and ways that completion of the process can go awry. Whether it is the act of transmitting a signal to pick up a cup or it is a process of making sufficient levels of thyroid hormone, we have been trained to consider the process and try to deduce why things are not going as planned. On the more macro scale, this is true for learner development too. Trainees have a variety of processes they are developing - study processes that result in desired testing outcomes, self care processes that result in desired wellness, and clinical reasoning processes that result in desired patient care outcomes, amongst others. Thus, as supervisors, coaches, and teachers we should be working to name that lesion when it comes out of learners to help tailor more precise feedback and actionable ways to improve.
“Read more” is an all too common area for improvement mentioned in evaluations I sift through for students. Who would not benefit from reading more? This type of generic feedback ignores the process the learners are working through everyday in an attempt to improve their clinical reasoning. As the progression of medical trainees embraces competency based medical education (CBME) it is imperative to give directed feedback that is actionable and helps ensure we are graduating competent physicians. As supervisors we need to be able to diagnose each learner to assist in their individual growth. There are many facets of being a competent clinician and the rest of this post will focus on clinical reasoning.
At our institution we are fairly explicit about the process of clinical reasoning we would like for students to follow:
- Use pre-encounter information to form a differential diagnosis prior to collecting data
- Collect data through history, physical exam, and sometimes other testing in a hypothesis driven manner
- Synthesize this information into a more concise problem representation (summary statement)
- Compare the key features of the patient’s presentation to illness scripts (previously learned or potentially researched in the moment) to help narrow the diagnostic possibilities and help move forward with one or a a few working diagnoses
- Use a working diagnosis/diagnoses to build a diagnostic and management plan
- Review ongoing information and cycle back through the above steps as needed
Each of these steps are potential areas for strength and areas for development. In an ideal world, a well formed case discussion can and should pave a path through them to help with step by step analysis and diagnosing the learner. These cases can be formed from our own practice or AI generated. For example, in our remediation efforts, we ask the struggling learners to lead us through a case that we curate. However, there are many factors that can contribute to success or confound struggle with completing these steps. My colleagues and I have worked with numerous learners and tend to discuss factors contributing to struggle in the follow buckets:
- Lack of structure - This can be related to many things as well, including:
- never learning or forgetting a previously taught structured approach
- challenges with particular steps of a structured approach - which lead to developed shortcuts and workarounds
- time pressures (perceived or real)
- anxiety (performance or otherwise) and other mental health concerns - structure can break down when anxiety is high
- Lack of knowledge - Learners that do not possess the key knowledge of possible diseases and their illness scripts will struggle for differentials, ask appropriate questions, and narrow the differential based on available information.
*At this point, I should acknowledge the elephant in the room. I am not a mental health provider and do not attempt to diagnose mental health conditions in my learners. The learner and I will discuss in general how these concerns can contribute to struggling with clinical reasoning and demonstration of these skills to supervisors. It is up to the learner and our student affairs deans to help address these confounders. That being said, in my own struggles with performance anxiety and public speaking (as rounds can sometimes feel like) I have found that adherence to a structured approach can overcome some of my nerves. I try to share that with learners and hope that they will see the benefit in structure too.
Discussing a case in the (hopefully) safe space of a 1:1 meeting with a learner removes the time pressure component and perhaps alleviates some of the anxiety after rapport is established. It is also our practice to ask the learner ahead of time to provide some chief concerns (aka chief complaints, CC) that they feel most comfortable assessing. This is in hopes of reducing the impact of medical knowledge deficits derailing the assessment of their overall process.
I realize that not everyone supervising learners functions in the idealized remediation space or may not even have the time to spend an extra hour with a learner. However, I will operate under the assumption that those who dedicate themselves to academic medicine would like to encourage individualized growth of those that they supervise (stop reading now if this does not apply to you and reconsider whether you should have read this at all). Thus, this assessment can occur in the flow of regular patient care. Being intentional with how we approach a clinical encounter and breaking the clinical reasoning process into component parts can allow for more targeted learner development. Asking your learner to “think aloud” about their pre-encounter differential diagnosis, observing their hypothesis driven data gathering, having them “think aloud” again as they are synthesizing the information and forming a plan for the patient will be informative. Consider each step and whether the learner is developing in the expected way. Give feedback to encourage maintenance of strengths and areas for development anchored in observed processes and behaviors.
We could all “read more” but diagnosing your learners gives them clear areas for improvement and a way forward to competency.
