Clinical Reasoning Toolkit

Clinical Reasoning Toolkit

Diagnostic Reasoning is fundamental for any clinician.

 

Overview


About this Toolkit

This Toolkit shares resources collected to serve as an introduction to clinical reasoning for:


  • Clinicians who want to pursue diagnostic excellence
  • Educators who are engaged in training about the diagnostic process


Basics of Clinical Reasoning

Research in clinical reasoning: past history and current trendsby Geoff Norman 
Opinion piece providing insights into the clinical reasoning process through three broad research traditions: 1) the reasoning process, 2) knowledge and memory, and 3) mental representations. 

"Clinical Reasoning," by Geoff Norman 
A good starter video to learn about clinical reasoning from a physician who researches expert diagnostic reasoning

The New Diagnostic Team, by Mark Graber, DIAGNOSIS, 2017
A founder of the field of diagnostic error prevention proposes that diagnosis is a team effort, and discusses how effective teamwork aids the diagnostic process. 

"Clinical Problem Solving" (Coursera)
by Catherine Lucy
A comprehensive video set on clinical thinking, drawing on many concrete examples, as taught by UCSF's vice dean for education who is renowned for her grounding in the learning sciences.

A Universal Model of Dx Reasoning, by Pat Croskerry
An engaging description of Croskerry's rationality-based approach to decision-making, including System 1 and System 2 decision-making, and the interactions between the systems.

Educational Strategies to Promote Clinical Dx Reasoning, by Judith Bowen
Trying to help a struggling learner? This article assists in diagnosing problems involved in clinical reasoning and provides helpful coaching strategies that can be implemented immediately.

The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking, by Geoffrey Norman, et al.
A counterpoint to dual process theory, this article reviews literature which suggests that both Type 1 and Type 2 processes contribute to errors, and that strategies directed at the recognition of bias are less effective than the reorganization of knowledge.

Cognitive interventions to reduce diagnostic error: a narrative review, by Mark Graber et al.
How can medical novices transition to diagnostic expertise? This classic article helps educators support the development of reasoning and provides useful diagram examples of illness scripts.

Educational strategies to reduce diagnostic error: can you teach this stuff?, by Mark Graber
How can medical novices transition to diagnostic expertise? This classic article helps educators support the development of reasoning and provides useful diagram examples of illness scripts.


Great Books to Learn More

Medical Decision Making by Harold Sox et al.
This “go-to” textbook presents a step-by-step guide to understanding how, through the processes of decision analysis, a physician can reach valid, reasoned conclusions about medical treatment despite imperfect information about the patient.

The Science of the Art of Medicine by John Brush (iBook available on iTunes)
Providing simple examples, visual explanations, and historical context, this book teaches how to think clearly about the logic, probability, and cognitive psychology of medical reasoning to help make better probability estimates in clinicians' daily work.

Thinking, Fast and Slow
by Daniel Kahneman
How do cognitive biases affect us as humans? This book lays the groundwork broadly across life.

Learning Clinical Reasoning
by Jerome Kassirer, John Wong, Richard Kopelman
This seminal book explains the chief components of the clinical reasoning process and discusses cognitive error in medicine. The second section contains 69 cases in which clinicians "think out loud" about diagnostic and therapeutic dilemmas, and the authors critique these clinicians' reasoning.


How We Make Decisions

 

From Mindless to Mindful Practice – Cognitive Bias and Medical Decision Making by Pat Croskerry

Addressing error is fraught territory; this article discusses why, and further encapsulates the taxonomy of Type 1 and Type 2 reasoning, as well as some examples of biases.

 

Achieving quality in clinical decision making: cognitive strategies and detection of bias. By Pat Croskerry

This primer provides a description of 30 heuristics and biases in the context of Emergency Medicine. The reader learns biases ranging from the Gambler's Fallacy to Sutton's Slip in the service of improved patient care. Throughout the article, it is emphasized in a nonjudgmental manner that these are human flaws in cognition and require effective debiasing strategies.

CAEP Card with Biases

Two-page PDF document with a concise summary of 21 heuristics/biases.

 

Diagnostic Failure: A Cognitive and Affective Approach. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors, By Pat Croskerry
Two major phenomena that may undermine rational thinking are cognitive dispositions to respond (CDRs) and affective dispositions to respond (ADRs) toward the patient. This report reviews key determinants and characteristics of the major CDRs and ADRs, and further describes a "cognitive and affective autopsy."

A universal model of diagnostic reasoning, by Pat Croskerry

An enaging description of Croskerry's rationality-based approach to decision-making, including System 1 and System 2 decision-making, and the interactions between the systems.

 

The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking, by Geoffrey Norman, et al.

A counterpoint to dual process theory, this article reviews literature which suggests that both Type 1 and Type 2 processes contribute to errors, and that strategies directed at the recognition of bias are less effective than the reorganization of knowledge.

Conditions for Intuitive Expertise, by Daniel Kahneman, et al.

Two renowned psychologists compare Naturalistic Decision Making (NDM) with Heuristics and Biases (HB) in a spirited discussion, sharing the pearls and pitfalls of each approach as they are applied to Dual Process Theory.

 

NSTEMI or Not? By J William Schleifer, et al.

An expert diagnostician reasons through a high-stakes scenario while the cognitive strategies involved are unveiled and explained.  This is a useful demonstration of illness scripts, System 1 vs. System 2 thinking, and the utility of a mental “pre-mortem” examination. 

 

 




 




 

 



 

Improving Decision Making


Cognitive Strategies

Cognitive interventions to reduce diagnostic error: a narrative review by Mark Graber, et al.

This review identifies interventions that might reduce the likelihood of errors.

 

Cognitive forcing strategies in clinical decision making, by Pat Croskerry

A broad discussion of cognitive forcing strategies including rationale for use, types of strategies (universal, generic, and specific), and suggestions for implementation in clinical decision-making.

 

The effectiveness of cognitive forcing strategies to decrease diagnostic error: an exploratory study, by Johnathan Sherbino, et al.

 

A study of teaching intervention for medical students on avoidance on two common biases via low-fidelity simulation. Results suggest limited utility.


Diagnostic Checklists

Checklists to reduce diagnostic errors, by John Ely, et al.

A review of the potential role of diagnostic checklists in preventing diagnostic error, including the rationale for use, types of checklists (general, differential diagnosis and specific to common errors), and considerations for use.

 

Checklist slides, by Mark Graber

A comprehensive review of the potential role of checklists in diagnostic medicine including the rationale for use, the role checklists play in similar situations, and several checklists clinicians may find useful.

 

General Checklist for Diagnosis (AHRQ), by Mark Graber, et al.

A suggested general diagnostic checklist for use in identifying clinical situations that pose a high risk for diagnostic error.

 

Demonstrating checklist with a patient, by John Ely, et al.

A brief video demonstration of how a differential diagnosis checklist can be used collaboratively with a patient.

 

Thinking about Thinking: Coaching Strategies, by Elizabeth Stuart, et al.

This resource provides a map of the diagnostic process with guidelines for "fine scalpel" ways to address specific pitfalls in student reasoning. This guide harvests the fundamentals of the process from research, and offers specific coaching strategies and activities that educators can use to identify and remediate pitfalls in thinking quickly and effectively.

 

Clinical Reasoning Difficulties, by Marie-Claude Audétat, et al.

Written for supervisors, this piece assists in recognizing the specifics of learners’ difficulties in clinical reasoning and in crafting appropriate remediation plans. This practical guide makes visible the errors in clinical thinking (root causes and cues to help recognize them), as well as provides examples and scripts for coaching/feedback.


 

For Educators

 

Diagnostic Error and Improvement Curricula

"Clinical Problem Solving" (Coursera) by Catherine Lucy
A comprehensive video set on clinical thinking, drawing on many concrete examples, as taught by UCSF's vice dean for education who is renowned for her grounding in the learning sciences.

"Clinical Reasoning" by Geoff Norman
A good starter video to learn about clinical reasoning from a researcher who studies expert diagnostic reasoning.


Cognitive Bias and Diagnostic Error for Medical Residents (University of Pennsylvania Curriculum)

A great resource for educators jumping into teaching clinical reasoning and mitigation of common biases that impact reasoning, this folder contains "off-the-shelf" materials such as lecture slides, instructors guides, activities, and handouts. Be sure to compare it with the other curricula provided.

 

Cognitive Debiasing Workshop for Medical Residents, by Brent Smith

Sometimes we don't see what's right in front of us--the kind of errors that are most devastating to physicians. This teaching resource addresses the mental traps that can cloud physician judgement and shares strategies for reducing risk of diagnostic error. Generously shared by Brent Smith, this folder contains all materials to operationalize teaching and assessment of two-lecture workshop for residents.

 

Dalhousie University Critical Thinking Curriculum, by Pat Croskerry

This curriculum on critical thinking as a core competency of diagnostic excellence shares a program overview as well as materials for curricular integration and assessment.

 

Education for the Next Frontier in Patient Safety: A Longitudinal Resident Curriculum on Diagnostic Error, Emily Ruedginer et al

This highly-rated curriculum includes strategies to understand the medical decision-making process, build skills in critical thinking, and provide strategies for diagnostic error mitigation.

 

Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. by James Reilly, et al.
A longitudinal curriculum in cognitive bias and diagnostic error for residents designed to teach residents about recognition of cognitive biases. Includes a novel assessment tool.

 

Seen through their eyes: residents' reflections on the cognitive and contextual components of diagnostic errors in medicine by Alexis Ogdie, et al.
Sharing residents' reflections on the cognitive and contextual components of diagnostic errors in medicine, this article suggests how the process of reflective writing can help residents richly describe what and how they are learning about cognitive errors.

 

From Problem Lists to Illness Scripts, by Catherine Lucey

This presentation provides a clear approach for teachers to assess learners' thinking and effective ways of responding using several examples.

 


General Clinical Reasoning Teaching Strategies

Becoming a Teacher of Clinical Reasoning, by Robert Trowbridge and Andrew Olsen
Speaking directly to faculty engaged in guiding learners towards mastery in clinical reasoning, this piece shares wisdom and strategies applicable across sites. Authored by two physician-educators leading two different touchstone programs in clinical reasoning at different medical schools, this piece honors teaching that is closely in contact with research from the learning sciences.

You too can teach clinical reasoning! By Amy Fleming, et al.

This article outlines the pedagogical structure for one method of teaching reasoning in pediatrics.

 

Supervision of clinical reasoning: methods and a tool to support and promote clinical reasoning, by Marie-Claude Audetat, et al.

This article shares methods and a tool that supervisors can use in cases when they did not directly observe the clinical interaction.

 

What every teacher needs to know about clinical reasoning, by Kevin Eva.

Advocating for the importance of flexibility when solving clinical problems, this article includes a brief review of research on teaching clinical reasoning then provides general recommendations for clinical teachers, with particular insight into the arts of balancing analytic and non-analytic reasoning, and of accounting for context.

 

Improving Diagnostic Reasoning, by Gurpreet Dhaliwal

After reviewing the cognitive psychology of diagnostic reasoning, the authors propose steps that clinicians and healthcare systems can take to improve diagnostic accuracy.

 

 

Diagnostic Error Teaching Strategies

Educational strategies to reduce diagnostic error: can you teach this stuff, by Mark Graber.

How can medical novices transition to diagnostic expertise? This classic article helps educators support the development of reasoning and provides useful diagram examples of illness scripts.

 

Twelve tips for teaching avoidance of diagnostic errors, by Robert Trowbridge

How can educators familiarize learners with the cognitive underpinnings of diagnostic error? This article describes how to teach several approaches to the diagnostic process that may lessen likelihood of error, emphasizing techniques for metacognition, the clinical examination, and simple strategies such as 'diagnostic time-outs,' and the practice of 'worst-case scenario' medicine.

 

Diagnostic error in medical education: where wrongs can make rights, by Kevin Eva

Great resource in the service of destigmatizing error in order to promote learning.

 

Teaching clinical reasoning: case-based and coached, by Jerome Kassirer

Drawing on a depth of literature from adult learning theory, this seminal article demystifies concepts such as hypothesis generation, pattern recognition, context formulation, diagnostic test interpretation, differential diagnosis, and diagnostic verification. 

 

 

Learning From Feedback

Minimizing diagnostic error: the importance of follow-up and feedback, by Gordon Schiff

This commentary discusses the lack of systematic feedback loops in health care and implications for physician’s ability to continually fine-tune diagnoses. Dr. Schiff proposes a new paradigm for reducing diagnostic error, shifting the focus from the cognitive process (physician overconfidence, cognitive biases, and heuristics) to the work environment (barriers to feedback and follow-up), and patient and family engagement (co-production of diagnoses and the treatment response).

 

The feedback sanction, by Pat Croskerry

This review article offers pointers on strong feed back loops and avoiding barriers in the ED.

 

Feedback in clinical medical education, by Jack Ende

This article presents guidelines for feedback drawing from the literature of business administration, psychology, and education, and is adapted for clinical teachers.

 

 

Important Medical Education Research Articles

Clinical Reasoning Education at US Med Schools, by Joseph Rencic, et al.
A survey of clerkship directors with a high response rate found that less than half of schools have a formal curriculum on clinical reasoning, and that 80% were dissatisfied with student reasoning competency at the end of the clerkship. 


How can students' diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases, by Mamede, et al.
A prospective educational study investigated the effects of reflection on cases compared with generating a single or differential diagnosis suggesting that reflection enriched mental representations of diseases, and also influenced the representations of adjacent, but different, diseases.

How to Improve the Teaching of Clinical Reasoning: a Narrative Review and a Proposal, by H. Schmidt and S. Mamede
An important review performed by two thought leaders in diagnostic education concerned with real-world strategies educators can use to improve diagnostic education.

 

The effectiveness of cognitive forcing strategies to decrease diagnostic error: an exploratory studyby Jonathan Sherbingo
This study explores the impact of cognitive forcing strategy training on diagnostic error on 56 students. Preliminary findings suggest that application and retention is poor.

 

Drawing Boundaries: The Difficulty in Defining Clinical Reasoningby Meredith Young, et al.
In this research-based article, the authors acknowledge the challenges of defining concepts of clinical reasoning; much variability exists.

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