Instructions: Spend 10 minutes reviewing the case below and considering the questions that follow. Case Study 1: Teaching Clinical Reasoning
The main goals of clinical teaching include assessing students’ clinical reasoning skills, facilitating and strengthening their development, and providing them with opportunities for practice and feedback. These goals have important implications for learning because the quality of the clinical reasoning strategies that medical students use influences diagnostic success. In 2004 clinicians at Case Western Reserve University School of Medicine decided to test the effectiveness of a technique that promised time- efficient teaching methods in the clinical setting that provide insights into the students’ clinical reasoning strategies and uncertainties while also allowing the preceptor to remain fully engaged in the priorities of patient care. 15 The SNAPPS technique is a learner-centered case presentation technique that depends mostly on the student for its successful implementation. The six-step mnemonic outlines a collaborative case presentation that the student leads and the preceptor facilitates. A concise summary of the facts is followed by five steps that facilitate the expression of diagnostic reasoning and case-related uncertainties. SNAPPS is intended to redirect, but not lengthen, the learning encounter by condensing the reporting of facts and encouraging the expression of reasoning and uncertainties. Brief faculty development coupled with more extensive learner development serve as companion pieces in the successful implementation of this learner-driven technique: Summarize briefly the history and findings. Narrow the differential to two or three relevant possibilities. Analyze the differential by comparing and contrasting the possibilities. Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches. Plan management for the patient’s medical issues. Select a case-related issue for self-study. Sixty-four third-year medical students were randomly assigned to three groups: SNAPPS, feedback training, and usual-and-customary instruction. Although the authors did not assess whether the differential diagnoses were accurate, they found that students using the SNAPPS technique performed better on all outcomes, including analyzing possibilities of the differential diagnosis, expressing uncertainties, and obtaining clarification. “SNAPPS greatly facilitates and enhances expression of diagnostic reasoning and uncertainties during case presentations to ambulatory care preceptors,” the authors reported. “Students can conduct case presentations using a technique that makes each step explicit and gives learners, rather than preceptors, the responsibility for expressing their clinical reasoning and uncertainties.”
1. Thinking about your own institution or your own training, how effective do you think teaching about clinical reasoning skills is (or was)? In what ways could that teaching be improved?
2. Do you think the steps in the SNAPPS approach are realistic in modern teaching hospitals? Why or why not?
3. What do you think is the single most important skill medical students and practicing clinicians need to develop to improve decision-making abilities and reduce diagnostic errors?
A study by Smith and Slack (2015) of family medicine residents who participated in a debiasing workshop found that the residents’ ability to formulate an acceptable plan to mitigate the effect of cognitive biases significantly improved after the training (p=0.02), although the residents were not able to translate the plan into practice, as evidenced by no change in the outcomes of preceptor concurrence with the residents’ diagnoses, residents’ ability to recognize their risk of bias, and the preceptors’ perception of an unrecognized bias in the residents’ presentations. 16 Novice diagnosticians, such as medical students, may lack sufficient experience to employ nonanalytic reasoning, rendering these methods increasingly more useful as experience increases.
Training on the use of heuristics Heuristics are decision strategies, or mental shortcuts, that allow fast processing of information to arrive at a decision or judgment. One type of heuristic is representativeness; the use of the degree to which an event is representative of other, similar events to assess the probability of an event occurring. Although the literature around the use of heuristics in medicine tends to focus on the biases they introduce, there is a recognized potential for training with heuristics to achieve better diagnostic accuracy. Mohan et al. (2018) conducted a randomized controlled trial comparing two training interventions designed to improve the use of the representativeness heuristic to improve trauma triage by emergency physicians. 17 The authors developed two serious video games to
train in the use of the heuristic. The first was an adventure game, based on the theory of narrative engagement, and the second was a puzzle- based game, based on the theory of analogical reasoning, using comparisons to help train the learners on applying decision principles. Both games incorporated feedback on diagnostic errors and how they could be corrected. Results showed that both games had positive effects on trauma triage, whereas traditional medical education had none. Training to improve visual perception skills In radiology, diagnostic errors fall into two broad categories: perceptual errors, in which an abnormality on an image is not seen or identified, and interpretive errors, in which an abnormality is seen but the meaning or the importance of the finding is not correctly understood.
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