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Teaching Medical Students Clinical Reasoning Skills

Windish, Donna M. MD

Educating Physicians: Essays

To be an effective clinician, a physician must excel at clinical problem solving. Nevertheless, few physicians have been specifically taught clinical reasoning skills during their medical training. This paper describes the format used to teach clinical problem solving to second-year medical students at the University of Connecticut School of Medicine.

Dr. Windish is a recent graduate of the University of Connecticut School of Medicine (class of 1999) and is currently doing her residency training in internal medicine at the University of Rochester/Strong Memorial Hospital in Rochester, New York. Dr. Windish worked on developing the Clinical Reasoning curriculum during her fourth year of medical school as her senior selective project.

Address correspondence to Dr. Windish, 1209 East Avenue #9, Rochester, NY 14607.

The author thanks Dan Henry, MD, Lynn Kosowicz, MD, Judy Lewis, MPhil, Eugene Orientale, MD, Eileen Storey, MD, MPH, and Sara Thal, MA, at the University of Connecticut School of Medicine, for their thoughtful contributions.

Recognizing the importance of giving its students the reasoning skills they need to “think on their feet” during a clinical encounter, in 1998-99 the University of Connecticut School of Medicine implemented a new clinical reasoning curriculum for second-year students. The curriculum is made up of four sessions offered throughout the second-year Principles of Clinical Medicine course; in each session, students are encouraged to expand their knowledge and skills while learning how to generate an effective problem list, assessment, and plan for a patient. Clinical scenarios were developed to encompass common medical problems and to complement the pathophysiology being taught in the Mechanisms of Disease course. Students work together in pairs during each case in a role-play format, with one student acting as the patient and the other as the clinician.

Prior to each role-playing session, faculty who teach the Principles of Clinical Medicine (PCM) course gather the student-patients in small groups to discuss the patient presentations. At this time, students can clarify any uncertainties they have about the cases, but they are not told the diagnosis. Any visual findings (e.g., cutaneous manifestations of disease) can be accessed during the role play on the PCM web page.

In the role play, the student-clinician begins the doctor-patient encounter by obtaining a complete medical history. When the history taking is completed, the clinician-patient pair work together to answer questions about the case. At this point, the pair creates a problem list, develops differential diagnoses, and writes down the appropriate elements of the subsequent physical exam. Because second-year students often do not know specific names of disease processes, they are given a mnemonic to help them focus on different etiologies of disease.

In the next part of the role play, the student-clinician performs a focused physical examination. Since vital signs and certain physical manifestations are not reproducible, the patient describes the findings as the exam is performed. The clinician then accesses the PCM web page to view any visual manifestations of disease.

After the physical exam, the student pair works together again in clinical problem solving. Here, they refine their original problem list, reassess their differential diagnoses, and decide which laboratory and/or diagnostic studies to order. Radiographs are available on the PCM Web page and laboratory results can be obtained from the PCM preceptors. The clinician-patient pair then develops a final problem list, assessment, and plan, including pertinent information to support their approach.

At the end of the session, the entire PCM group reassembles, and one student from the group presents the case. The PCM faculty facilitate the final discussion, encouraging students to reflect upon the decision-making process.

Although the true value of these sessions cannot be determined until the students progress to their third-year clerkships and beyond, clear benefits have already been seen in the initial implementation of the course. In the sessions, students were able to correlate their knowledge of a disease process with a relevant medical history, physical examination, and diagnostic workup. By answering carefully structured questions at various steps in the clinical encounter, students were able to develop, modify, and challenge initial hypotheses for each case. This allowed students to reflect on their basic science knowledge, an important task as they begin to restructure that information to make it useful in patient care.1 This also helped them to focus on the process of clinical reasoning. Finally, having students work together in pairs gave individual thinking a top priority, while the sharing of thoughts and ideas promoted meaningful collegial relationships.

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1. Irby DM. Clinical teaching and the clinical teacher. J Med Educ. 1986;61 suppl:35–45.
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