How to get Good at Clinical Problem Solving
Practicing the Art of Diagnostic Reasoning
Recently we introduced how to approach differential diagnoses for patient presentations, but how do we master the art of diagnostic reasoning and clinical problem solving? It’s a combination of:
Knowledge
Experience
Reflection
Practice
#1 Knowledge: having foundational knowledge for common disease processes is a good place to start. This learning can be achieved through school lectures or seminars (e.g. pathophysiology, anatomy) and continued education opportunities (e.g. medical blogs, podcasts, books, conferences, etc.). To identify a disease process in clinical practice, we first need to know it exists. There’s a lot to know – both common, and rare disease entities, and no one expects us to know everything (especially when we start out!) Learning is an iterative, lifelong process. Break it up. Listen to a podcast on your drive to work, read a blog for 5 minutes on a weekend morning – whatever gets the job done. It is impossible to learn everything we need to know for clinical practice in school - we will learn for the rest of our lives!
#2 Experience: A great way to solidify knowledge is by anchoring (more on this later!) Let’s say you learn about knee pathology during a class lecture, then you assess a patient presenting with knee pain – you’re able to apply what you’ve learned. You’ve studied your differentials for knee pain and feel confident ruling in and ruling out diagnoses through your history and physical exam. The act of anchoring theoretical knowledge in a real patient scenario elevates your approach to knee pain.
In contrast, let’s say you see a patient presenting with vertigo – you are less comfortable with this symptom. You haven’t learned much about it yet. In this scenario, the skill of reflection comes into play.
#3 Reflection: this skill is key in refining our diagnostic reasoning skills. If we see a presenting concern that we a) know nothing about, or b) haven’t seen in a long time – that’s okay! It’s good to be honest with ourselves. We can consult a colleague or a specialist. We can go home and read around the case. What causes vertigo? What were the patient’s symptoms? Was anything missed on the history or physical exam? Were any diagnostic tests necessary? What are the red flags for vertigo? How was the differential diagnosis organized? We can simultaneously learn about the theoretical knowledge of what causes vertigo and can reflect on our clinical case – this is another way to anchor knowledge.
When faced with a less familiar clinical scenario, we can read about it, listen to a podcast, talk with a colleague. We can reflect on what differential approach makes sense for vertigo – systems approach? Mechanism approach? Anatomic approach? Case-based reflection is an excellent way to improve our diagnostic reasoning skills.
#4 Practice: practice makes us better (but never perfect because that’s impossible in medicine). If we make a conscious effort to learn, open ourselves up to experience, and reflect, our diagnostic reasoning skills will naturally improve. After reflecting on vertigo and your differential diagnosis, the next time you see a patient with vertigo you can feel more confident working through the possible causes of vertigo.
Key Take Home Point:
The art of diagnostic reasoning involves building our knowledge, anchoring knowledge in clinical scenarios to make sense of it, reflecting on our experiences (our strengths, our weaknesses), and practicing good habits.
Stay tuned for up-coming posts on problem representation/illness scripts, and presenting great differential diagnoses!
Resources for Case-based Learning:
The Curbsiders Internal Medicine Podcast: https://thecurbsiders.com/
EM Basic podcast (emergency medicine): http://embasic.org/
The Pediatric Emergency Playbook: https://pemplaybook.org/
Harrison’s Podclass: available on Spotify and other apps