Journal Club: February 2013

Developing a Unified List of Physicians’ Reasoning Tasks During Clinical Encounters

Goldszmidt, Mark MD, MHPE; Minda, John Paul PhD; Bordage, Georges MD, PhD

About Reasoning During Clinical Encounters

The process of clinical reasoning has long been a focus of research and commentary. The landmark work of Elstein and colleagues in the late 1970’s identified reasoning as a hypothetico-deductive process in a clinical setting. Others have identified reasoning as a process of pattern recognition, the development of illness scripts, or the accretion of concepts and patient experience into explanatory semantic structures. Expertise in reasoning has also been found to be context specific, so that an expert becomes a neophyte when faced with a patient for clinical problem outside of the expert’s specialized skills. Although some suggestions for teaching have emerged from this work, the pedagogy of clinical reasoning is not well developed.

Article Summary

The authors conclude that the majority of studies in clinical reasoning have focused on how doctors reason – the process of reasoning, rather than on what a physician reasons about – the tasks of reasoning. This study attempted to identify a list of reasoning tasks, using both a review of the literature and a survey of a group of international experts. Twenty-four reasoning tasks were identified within four broad categories of framing the counter, diagnosis, management, and self-reflection. The primary use of this list is the development of a vocabulary of reasoning tasks that may help frame the pedagogy of reasoning, and focus future research in the field.

Questions

  1. Does the list of reasoning tasks identified in this study fit within your own perceptions of those tasks?
  2. How generalizable is this list across specialties or types of patients?
  3. What is the role of self-reflection in improving reasoning?
  4. What pedagogy can be developed in light of these tasks?
  5. How would you know if instruction on these tasks resulted in better reasoning skills?

Further reading

Bordage G and Lemieux M. Semantic Structures and diagnostic thinking of experts and novices. Acad Med. 1991;66: S70-72.

Charlin B, Boshuizen HP, Custers EJ, and Feltovich PJ. Scripts and clinical reasoning. Med Educ. 2007 Dec;41(12):1178-84

Schmidt HG, Norman GR, and Boshuizen HP. A cognitive perspective on medical expertise: theory and implication. Acad Med. 1990;65:611-21. Erratum in: Acad Med 1992;67:287.

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