Journal Club

Borleffs JCC, Cursters EJFM, van Gijn J, ten Cate, OTJ. "Clinical Reasoning Theater": A New Approach to Clinical Reasoning Education. Acad Med 2003: 78:322-325.

This interesting article describes a formalized methodology that is used in the authors' medical school to aid in teaching basic science students about clinical reasoning skills. The method is quite simple and all the more exquisite because of this. Creating two "scenes" in which the action takes place, faculty members interview a real patient (scene 1) then take a "timeout" to describe their thinking and interact with the students to decide on the next questions to ask or actions to take (scene 2). It is a dynamic process, oscillating between the two scenes. The method can be used for history-taking, physical examination, ordering and reviewing diagnostic tests, and providing therapeutic interventions. Actively involving the students holds their attention and, if reflection is added, should help them identify their own skills and gaps.

In reviewing this article, I would like to go back to a format we used when thinking about an evidence-based journal club. We used three questions to decide whether to review an article. The first question is about impact - does this affect learning? While the authors of this study don't measure impact at all, I can see where this method would lend itself to investigation. The clinical reasoning of students could be measured before, during and after this intervention. I'd also be interested in hearing about whether the clinical faculty at this institution think the students arrive better prepared and more skilled in the clinical reasoning process since using this format. The second question asks whether the article focuses on a common problem. My answer is absolutely. I know that in the last few years, the whole concept of how we explicitly teach clinical reasoning has become increasingly important to me. Patients are with us for such a short period of time that we are more concerned with making sure we get things done than in explaining to the novices we have the privilege of trying to teach. The third question deals with change. If the article shows an affect on learning, could it change your practice? Once again, I would have to answer in the affirmative. Many of us are faced with escalating time pressures and some are struggling with patient numbers. In addition, if you think about patient safety and trying to allow learners to practice more in settings where patients are less at risk, this is a wonderful model. First, as the paper points out, more students can experience this type of demonstration than can comfortably fit around a bed. What they don't mention, and what may very well be equally advantageous is that one or two faculty members could focus on this type of training, freeing up others to deal with those patient care and time pressures.

So, for anyone struggling with how to teach this vital skill, how to improve efficiency, or how to stretch patients or faculty, this is a paper to read. I know that I have already thought about how to incorporate something like this in our clerkship, making sure to also look at the impact and evidence of its effectiveness. Being involved in fourth year student education, this article also gave me a great idea for a selective that could focus on integrating basic and clinical sciences without overwhelming faculty members. If anyone else has similar interests, I'd be happy to figure out a collaborative study comparing and contrasting variations on the model. It is a thought-provoking article and, with the likely diffusion of the ACGME competencies into our clerkships, a timely one addressing patient care and medical knowledge.

(This is a great follow up to having George Bordage with us at the last meeting. The challenge is - how good are the faculty in thinking out loud - and in describing their strategies of reasoning? Do you have a seminar on clinical reasoning in your clerkship? How do you measure clinical judgment in your medical students? Steve Miller)