Background: Teaching trainees clinical reasoning is a critical skill for clinical teachers. Advances in the fields of cognitive science and educational theory have provided a conceptual framework of core concepts in clinical reasoning: problem representation, illness scripts, treatment thresholds, and test-treatment thresholds.
Purpose: We designed a one-hour workshop to teach interns core concepts in clinical reasoning using visual aids.
Description: The workshop begins with a case, briefly summarized here as a 58-year-old-man from India presenting with three weeks of fatigue, night sweats, weight loss, and dyspnea who is found to have hilar adenopathy and miliary nodules on chest x-ray and non-caseating granulomas on lung biopsy.The group first discusses their hypotheses and ultimately formulate a problem representation (10 minutes), a succinct summary in abstract terms of patient demographics and risk factors, the temporal onset of illness, and key signs and symptoms. The facilitator writes this on a whiteboard as shown in Figure, Box A. Discussion of a differential diagnosis follows, and participants are asked for their top three diagnoses (5 minutes). A Venn diagram is drawn around the problem representation.Next we highlight illness scripts or mental models of diseases that include the predisposing conditions, pathophysiology, and clinical manifestations. Knowledge of illness scripts are used to search for defining and discriminating features of diseases. The group discusses their illness scripts for each diagnosis and propose where specific findings should be placed in the Venn diagram (15 minutes). Reaching a working diagnosis is accomplished by finding the best match between the problem representation and the selected illness script.In the second half of the workshop, we introduce concepts of therapeutic reasoning. For simplicity, the group is informed that this case is either miliary tuberculosis or sarcoidosis, and asked how they would treat this patient, discussing risks and benefits in the presence and absence of each disease. Due to uncertainty in the diagnosis, deciding between treatment options (e.g., RIPE therapy, steroids, or both) can be difficult. The concept of the treatment threshold is introduced (Box B)—the probability of disease at which the benefits and harms of either starting or withholding treatment “break even.” Treatment is given or withheld at disease probabilities above and below this threshold, respectively. Decisions on further testing is dependent on this treatment threshold. Testing is done when the result can change the probability of disease to cross the treatment threshold (i.e., change management), and determines the test-treatment thresholds (Box C).
Conclusions: We present a structured workshop to teach concepts of clinical reasoning through visual aids that can be adapted to any clinical scenario. Our preliminary data show that interns find this workshop to be highly educational and the visual aids to be extremely effective. Most found these concepts to be very important or essential to patient care and teaching learners. After this session, participants felt more confident in their medical decision making. We believe using visual aids significantly enhances learners’ conceptualization of a problem representation, illness scripts, the treatment threshold, and test-treatment thresholds.
