Teaching Clinical Reasoning
“On the Fly” Part 1
Donald R. Bordley, M.D.
Residency Program Director
University of Rochester
(585) 275-2874
[email protected]
Key Points to Remember
• Teach while you work
– Clinical reasoning is most effectively taught as
you care for patients together, not in a lecture
hall or conference room
• Live what you teach
– If you don’t “role model” sound clinical
reasoning as you discuss all your patients, the
students won’t think it’s really important
Clinical Reasoning:
Steps to Success
• GATHER DATA CAREFULLY
• Define the patient’s central problem
• Generate and prioritize the differential
diagnosis
• Plan your work-up based on the
differential diagnosis
Step 1
• GATHER DATA CAREFULLY
All subsequent steps in the clinical
reasoning process depend on:
– Accurate history
– Accurate physical exam
– Accurate lab data (if relevant)
• Involve the student
– Students have the luxury of time to do this
well and this step can be partially delegated to
them.
Step 2
• Define the patient’s central problem
– List problems
– Define central problem(s)
• What’s in the foreground?
• What’s in the background?
– State the central problem clearly and
concisely
• (Foreground) in a (patient) with (background)
• For example: Hemoptysis in a 62 y.o. woman
with an 80 pack-year smoking history
Step 3
• Generate and prioritize the differential diagnosis
– Start with a complete list: common things are
common, but don’t miss high stakes diagnoses
– For each possible diagnosis decide, is it:
• Likely?
• Possible and high stakes (potentially lethal or requires
prompt specific therapy)?
• Possible and low stakes?
• Unlikely?
Step 4
• Plan work-up based on differential
diagnosis
– Aggressively work-up all “likely” diagnoses
– Aggressively work-up all “possible high
stakes” diagnoses
– Defer work-up of possible low stakes and
unlikely diagnoses
Practice Case Step 1:
Data Collection
• Mr. Jones is a 55 y.o. man who presented to the ED this
afternoon after developing the sudden onset of chest pain
after he had a coughing fit while mowing his lawn. The pain
is constant and sharp, made worse with inspiration and
associated with moderate dyspnea. Past history is positive
for hypertension, type 2 diabetes, high cholesterol and
seasonal allergies.
Abnormal findings on physical exam: HR 120, BP 150/90, R
28, O2 sat 92% on room air. Absent breath sounds over the
right chest. There is no JVD and the trachea is midline.
Practice Case Step 2:
Define the Patient’s Central Problem
• Problem list
– Foreground:
• chest pain, dyspnea, absent right breath sounds
– Background:
• HTN, Type 2 DM, high cholesterol
• Central problem statement
– Chest pain, dyspnea and absent right breath
sounds in a 52 y.o. man with HTN, Type 2
DM, and high cholesterol
Practice Case Step 3:
Prioritize the Differential Diagnosis
• Likely
– pneumothorax
• Possible, high stakes
– acute coronary syndrome
• Possible, low stakes
– muscle tear, rib fracture
• Unlikely
– aortic dissection, pericarditis, pneumonia
Practice Case Step 4:
Plan Work-up Based on Differential
• Work up the likely diagnosis
– CXR
• Work-up the possible, high stakes
diagnoses
– acute coronary syndrome - EKG
• Defer work-up of other possibilities
CXR
Bottom Line
• Teach as you work and live what you
teach!
• Be systematic and think out loud
– What are the problems? Foreground and
background.
– What’s the differential? Focus on likelies and
high stakes possibles.
– Let your differential drive work-up and
management