The Doctor by Sir Luke Fildes © Tate (2015) Available under a CC-BY-NC-ND 3.0 (Unported) license http://www.tate.org.uk/art/artworks/fildes-the-doctor-n01522
The Exercises in Clinical Reasoning (ECR) section of JGIM Web will provide tools for faculty and trainees interested in both learning and explicitly teaching core concepts in clinical reasoning. Ultimately, we aim to have a positive impact on students and trainees as they develop expertise in the diagnostic process, with the core aim of improving patient care.
In 1994 I had the good fortune to be a Chief Resident at the University of California, San Francisco based at the San Francisco Veterans Affairs Medical Center. As a generalist, I wanted to learn how to solve cases from UCSF’s world-renowned diagnostician Dr. Larry Tierney, or LT. Every residency program has that senior clinician who all of the residents want to emulate—Drs. Faith Fitzgerald or Mark Henderson at University of California, Davis, Dr. Judy Bowen at Oregon Health Sciences University, Drs. Steve McGee or John Sheffield at University of Washington, Drs. Bob Centor, Carlos Estrada or Lisa Willett at University of Alabama Birmingham, just to name a few—and I wanted to become a master clinician in their image. I thought that after one year of leading daily report sessions in LT’s presence, I could learn to solve cases the way he did. Two months into my Chief year I realized that I would never be like Dr. Tierney. LT had a way of remembering every interesting case he ever saw as it related to the patient’s story and their diagnosis. His knowledge was encyclopedic and completely unobtainable for me. The reality is that few of us can become master clinicians in the same image as our hometown heroes. Nevertheless, each of us can become the thoughtful diagnosticians we strive to be through learning more about clinical reasoning.
My approach to thinking about patients changed completely 10 years ago when Dr. Gurpreet Dhaliwal started discussing “transparency” in the clinical reasoning process at UCSF. He taught the concepts of problem representation, illness scripts and dual process theory in an accessible way. Suddenly a lightbulb went off—physicians did not need to be the hospital hero to think deeply about the process of clinical decision-making. In fact, all of us can and should engage in metacognition as a way to improve the care for our patients and to provide better role modeling to our trainees.
In 2010 the editors of the Journal of General Internal Medicine, Drs. Richard Kravitz and Mitchell Feldman, were willing to innovate and take a chance on our new series called Exercises in Clinical Reasoning (ECR). This series presents interesting cases to outstanding clinicians and captures the essence of clinical problem solving. The ECR series then takes the novel step of including a meta-cognitive commentary to decipher the clinical reasoning process used by expert diagnosticians. This parallel process allows the reader to understand the framework by which the clinician solves (or doesn’t solve) the case.
Because there are a limited number of experts in clinical reasoning, we decided to use the ECR series as a springboard to create a downloadable curriculum to help clinician educators learn and teach these critical concepts. Each case on the website will include an introduction to the clinical reasoning technique or concepts highlighted in the case. There will also be downloadable teaching slides with an embedded study guide and links to other clinical reasoning resources. We are hoping that this website will inspire others to become facile with clinical reasoning and use these concepts to enhance their teaching, and potentially, to even contribute to the JGIM ECR series.
I am lucky to be working with two of the next generation of outstanding young physicians who are taking this work to the next level—Drs. Denise Connor and Reza Sedighi Manesh. We hope you will find these resources useful in teaching your students and residents how to engage in meta-cognition when caring for patients, and as a tool to help your trainees become the best physicians they can be.
Jeff Kohlwes MD, MPH
Professor of Clinical Medicine
Denise M. Connor, MD Assistant Professor of Clinical Medicine University of California, San Francisco School of Medicine San Francisco Veterans Affairs Medical Center
Carlos A. Estrada, MD, MS Professor of Clinical Medicine University of Alabama School of Medicine Birmingham Veterans Affairs Medical Center
Mark C. Henderson, MD Professor of Clinical Medicine University of California, Davis School of Medicine University of California, Davis Health System
Jeff Kohlwes, MD, MPH Professor of Clinical Medicine University of California, San Francisco School of Medicine San Francisco Veterans Affairs Medical Center
Neil Mehta, MBBS, MS Assistant Dean for Education Informatics and Technology and Associate Professor of Medicine Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic
Reza Sedighi Manesh, MD Assistant Professor of Medicine Johns Hopkins University School of Medicine Johns Hopkins Hospital
Contact the ECR Team
Learn How to Submit Here
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