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 to 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 every day 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.
What does a structured clinical reasoning process look like?
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 to help narrow the diagnostic possibilities and move forward with one or a few working diagnoses
- Use a working diagnosis 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.
What causes clinical reasoning to break down in trainees?
My colleagues and I have worked with numerous learners and tend to discuss factors contributing to struggle in the following buckets:
- Lack of structure — This can be related to many things, 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); and anxiety 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 with differentials, asking appropriate questions, and narrowing 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, 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.
How do you give feedback that actually improves clinical reasoning?
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 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 have the time to spend an extra hour with a learner. 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, and having them “think aloud” again as they synthesize information and form a plan 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.
Frequently asked questions
What is competency-based medical education (CBME) and why does it change how we give feedback?
CBME is an approach to medical training in which progression is determined by demonstrated competency rather than time spent in training. It shifts the goal of feedback from summarizing performance to diagnosing the specific process breakdown that is preventing advancement.
Why is “read more” such an ineffective form of clinical feedback?
“Read more” treats clinical reasoning failure as a knowledge deficit, when the actual cause is often structural — lack of a consistent reasoning framework, anxiety under pressure, time constraints, or shortcuts that bypass critical steps. Without diagnosing which component of the reasoning process is breaking down, the feedback gives the learner no specific behavior to change and no way to assess whether they’ve improved.
What is the difference between a knowledge gap and a reasoning structure gap in medical trainees?
A knowledge gap means the learner lacks familiarity with a disease, illness script, or clinical presentation — they cannot generate a differential because they don’t know what conditions to consider. A reasoning structure gap means the learner has relevant knowledge but cannot apply it consistently because they lack a reliable framework for moving through the reasoning steps. Both require different interventions: knowledge gaps need content exposure, while structure gaps need deliberate practice with a consistent process.
