Clinical Problem Solving/Diagnostic Reasoning Sessions

Background: Clinical reasoning remains a central skill of the successful clinician. To improve or master these skills, it is essential to outline the cognitive steps that lead to success in eliciting, framing and then solving medical problems. In this era of increasingly hectic time schedules and duty hour restrictions, it is less common for the learner to hear a master clinician’s distinct steps used when solving problems. Moreover, since reasoning transpires largely at the subconscious level, it can be difficult for busy clinicians to articulate the steps in their thought process. Thus, more inexperienced learners are left to pick up reasoning in bits and pieces and to figure out their own way to “connect the dots” when faced with a patient problem. The clinical problem solving/diagnostic reasoning session is designed to provide a window into the master clinician’s thought process and reasoning strategies. The session serves as a valuable tool to learn and teach the process of hypothesis generation (eliciting the right question), problem representation (problem list), prioritized differential diagnosis and finally problem-solving strategies (pattern recognition and analytical reasoning).

Clinical Problem Solving Session Goal: to provide a mechanism for residents to learn the skills and to become more adept at clinical reasoning by listening to expert clinicians talk through process of making decisions and actively participating in discussion around a clinical problem.

Objectives: By making the thought process of a master clinician more transparent, the clinical reasoning session will:

highlight the intricacies of the diagnostic process.
help learners better understand how an experienced clinical formulates complex clinical decisions by combining prior experiences with evidence-based knowledge.
demonstrate history-taking, examination and diagnostic skills as a foundation for clinical reasoning.
teach the process of progressive problem solving.
outline the cognitive steps that lead to success in eliciting, framing and then solving medical problems.
engage learners in the diagnostic process.
allow master clinicians to serve as role models for less experienced learners.
help develop a collective espirit de corps while developing skills and confidence with the diagnostic reasoning process.

Clinical Problem Solving Session Format:

The 55- minute session uses the “Stump the Professor” format.
Those chosen to serve as master clinician will not have heard the case.

Tips for Facilitating Diagnostic Reasoning Sessions

Picking the Case: Pick well-suited cases that force clinicians to revise and explain their working hypotheses, including evolving stories that draw on broad differential diagnoses.
Use Artistic License: A balance needs to be achieved between information that makes the case realistic and challenging and excluding details of day-to-day care that can be distracting and potentially unfair, having nothing to do with the final diagnosis
Time Management: Cases should be 25-30 minutes, providing time for discussion, questions, and concluding remarks.
Avoid Premature Closure: Do not include clinical information on the initial slide. All that is necessary is the title "clinical problem solving or diagnostic reasoning" and the identifying information of the discussant.
Start Simple: The first case slide should be a succinct statement about the patient with the chief complaint and demographic or clinical information.
Present Data as an "Infusion," not a "Bolus:" A discussion break should follow every two to four slides of clinical data.
Mind the Gap: A blank slide can serve as a buffer to prevent inadvertent divulgence of subsequent information compromising the analysis of the previous slide's data.
Keep the Didactics Short: While a brief didactic session at the end of the presentation can promote additional understanding of the case or diagnosis, audiences learn more if two or three slides at the conclusion include three key points.
Find a Peer Reviewer: It is easy for a presenter to understand the difficulty of a case. Having an experienced clinician review the presentation before it is presented can avert errors in content and organization.
Keep it Real: Just give the facts without any interpretation. Do not fabricate a response based on what the presenter expects it to have been.
The Postscript: The audience should comment on the diagnosis and its thought process after the diagnosis is revealed. The value of the exercise lies in the process that took place before the diagnosis was revealed rather than on the diagnosis itself.
Increase Interactivity: An audience response system where questions are posed to the attendees at multiple junctures during the case is effective and enjoyable to increase interactivity

Dhaliwal G, Sharpe BA. Twelve tips for presenting a clinical problem solving exercise. Medical Teacher. 31:1056-1059,2009.

Activities:

Introduction to session by the facilitator (5 minutes)

articulate goals and objectives of the session
remind all participants that:< >diagnostic reasoning is not “magic” but rather a skill that is developed over timean individual does not need to know everything to participatethe session in about the process; getting the diagnosis right is relatively unimportantoutline session format

Presentation of case by the facilitator with responses/discussion by master clinicians (30 minutes)

The clinical case will be presented in short segments rather than all at once. This allows for an infusion of information which allows for discussion breaks and gives the master clinician an opportunity to verbalize his/her thought process as well as to teach the process of progressive problem solving to the learners throughout the session.
The clinician is expected to “think out loud” allowing the learners insight into the thought process of a master clinician.
The master clinician is also expected to keep the audience engaged in solving the case throughout the presentation.
Session participants are expected to be actively engaged in asking questions and sharing their reasoning.

Discussion led by facilitator (15 minutes)

comments on the process after the diagnosis is revealed.
comments on the diagnosis from the audience.
brief presentation of any new relevant knowledge on specific topics raised by the case.

Teaching points and wrap-up led by facilitator as well as completion of survey (5 minutes)

teaching points will focus on physical diagnosis and diagnostic reasoning
short survey to participants