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“ We’re pretty sure it’s the West Nile virus.”. Assessment of Diagnostic Reasoning and Clinical Thought Chart Stimulated Recall. Clinical Judgment/Reasoning. The cognitive engine that drives problem-solving and decision-making.

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clinical judgment reasoning
Clinical Judgment/Reasoning
  • The cognitive engine that drives problem-solving and decision-making.

students.pdf clinical reasoning definition

critical thinking
Good Thinking


Interest in gaining more information

Seeking alternatives


Willing to invest energy in thinking the matter through


Possess the cognitive ability

“Bad Thinking” – “cognitive misers”

Chose to take mental shortcuts, engage in heuristic thinking,

without interest in “good thinking”

Critical Thinking

Krupat 2011

clinical judgment reasoning1
Clinical Judgment/Reasoning
  • Internal process
  • Trainees and faculty need ways to externalize this process
  • Programs need to identify assessment methods that document growth and competency in this skill
key elements of diagnostic reasoning
Key Elements of Diagnostic Reasoning

Patient’s story


Data acquisition

Accurate “problem representation”


Generation of hypothesis


Search for and selection - illness script


Bowen JL. NEJM; 2006: 2217

clinical reasoning
Clinical Reasoning
  • Graber¹ adverse event study:
    • Most errors combination of individual and systems factors
    • Average 5.9 system +/- cognitive error per case
  • “Cognitive factors”:
    • 320 cognitive factors in 74 cases
    • 45 due to faulty data gathering
    • 264 due to faulty synthesis (problem representation)

¹ Arch Intern Med. 2005; 165: 1493.

problem representation
Problem Representation
  • Non- analytical - The behavior of experts
    • Pattern Recognition illness scripts
    • Heuristics
      • The rapid non-analytic mental shortcuts that humans use to recognize and categorize things.
  • Analytical - The work of early learners
    • Hypothesis based deductive reasoning
    • The default when a pattern is not apparent

Illness script





Clinical presentation

No clear


Hypothesis based

Deductive reasoning


You evaluate a 78-year-old male with a 2-week history of joint pain beginning after cardiac catheterization. Both knees and one wrist are red, painful, and swollen. X-ray is pending. No fever, weight loss or malaise, and recent labs reveal an ESR of 50. Past medical history includes CAD and hypothyroidism.
processed problem representation
Processed Problem Representation

78-year-old (ELDERLY) male for evaluation of a 2-week (SUBACUTE) history joint pain. Symptoms began 1 week after a cardiac catheterization (RECENT MEDICAL INTERVENTION). Both knees and one wrist (OLIGO-ARTICULAR). He has no fever, weight loss, or malaise (NON-SYSTEMIC). Recent labs are significant for an ESR of 50 (INFLAMMATORY).

pattern illness script
Pattern – illness script



Recent medical






  • Availability
    • Diagnose disease that are familiar or striking
      • HTN is due to pheochromocytoma
  • Recency
    • Diagnosis is proposed because it was recently seen
      • I just read about ----
  • Anchoring
    • Weight data that supports your diagnosis more than data that does not
the art of clinical questioning
The Art of Clinical Questioning
  • Promoting/Probing Clinical Reasoning
    • Minimize overuse of recall questions
    • Use compare and contrast learning
    • Avoid “what am I thinking now?”
    • Encourage identification of key features of an illness
chart stimulated recall
Chart-Stimulated Recall
  • Uses the medical record as a reference point for structured clinical questioning
  • Specifically targets clinical reasoning
  • Developed by the ABEM
  • High correlation between examiners
  • Reliable enough with 3 cases for pass/fail determinations
  • Ultimately dropped by ABEM because of cost and time requirement
chart stimulated recall1
Chart Stimulated Recall


  • Conducted by medical faculty
  • Faculty development needed
  • Ideally, the medical record is reviewed in advance to identify specific questions
chart stimulated recall2
Chart Stimulated Recall
  • Benefits
    • Inexpensive and easy to teach
    • Uses patients/clinical scenarios familiar to the trainee (context of care)
    • Allows examiner to assess problem solving and interpretation skills
    • Adaptable to multiple learner levels
small group exercise

Small Group Exercise

Review this resident note. The resident is on a one month geriatric rotation.

Are there opportunities to explore the resident’s diagnostic reasoning?

  • Recall
    • What, how, why?
      • What is the significance of dip stick positive hematuria in the absence of RBCs?
  • Analysis/synthesis
    • Demonstrate reasoning
      • There are multiple causes for falls in the elderly, what features of this presentation suggest volume loss/anemia as opposed to drug side effect?
  • Application
    • Apply knowledge/skills/attitudes to a specific presentation
      • In the setting of renal insufficiency with a history of diabetes, new NSAID use, and and polymyosiitis, how would you distinguish determine etiology?

Overall Note:


Organization ____________________________________


Internal Consistency - Identify any disconnects in the history and physical.

donobedian framework
Donobedian Framework
  • Schematic representation of a system
  • Every system has a structure and a process that processes that produce an outcome

S + P = O

  • You need to consider each of these components in your assessment system!
donobedian framework1
Donobedian Framework

S + P = O

Night float MR + CSR = Evaluation of trainee clinical thought/diagnostic reasoning and a documented educational experience on night float rotation