April 21, 2021, by mszrm4

Learning strategies in #MedEd

Dr Nicola Cooper is a consultant physician and clinical associate professor in medical education, and chair of the UK Clinical Reasoning in Medical Education group (CReME)

Diagnostic error is the most common, costly and dangerous of medical mistakes (Tehrani, 2013) and has been identified as a high priority patient safety problem by the World Health Organization (WHO, 2015). It’s been found that, while system-related errors are important contributors, cognitive errors, such as failure to synthesise all the available information correctly or failure to use the physical examination findings or test results appropriately, contribute to the majority of diagnostic errors. Doctors frequently had all the information available to make the right diagnosis, but made the wrong diagnosis (Graber et al, 2005).

In recognition of this, the influential Institute of Medicine published a report, ‘Improving Diagnosis in Health Care’, which found that: ‘Inaccurate or delayed diagnoses persist throughout all settings of care and continue to harm an unacceptable number of patients … improving the diagnostic process is not only possible, but also represents a moral, professional and public health imperative’ (IoM, 2015). The report concluded that while most people will experience at least one diagnostic error in their lifetime, stakeholders in quality measurement and patient safety have largely neglected the issue. Among its recommendations are that educators should ensure that curricula and training programmes across the career trajectory explicitly address performance in the diagnostic process and employ educational approaches that are aligned with evidence.

The diagnostic process (a.k.a. clinical reasoning) can be defined as, ‘A skill, process, or outcome wherein clinicians observe, collect and interpret data to diagnose and treat patients. It entails both conscious and unconscious cognitive operations interacting with contextual factors’ (Daniel et al, 2019). There is a consensus that medical schools and postgraduate training programmes worldwide rarely teach clinical reasoning in a way that is explicit, systematic and consistent with what is known (Rencic et al, 2017). This is a problem, given its importance in clinical practice.

Studies in medicine have consistently shown that those considered to be experts are distinguished not by their superior problem-solving skills, nor by their enhanced capacity for memory retrieval, but by the content and organisation of their knowledge. From an expertise point of view, there is no such thing as a skill called, ‘How to take a history’ – since it is knowledge and experience that dictates what questions are asked and how the answers are interpreted. In medical education, short courses aimed at teaching the general process of clinical reasoning seem to fail at reducing diagnostic error (although interesting new avenues for research are being explored) whereas teaching aimed at building knowledge and understanding leads to improvements in diagnostic accuracy (Schmidt & Mamede, 2015). Since medicine requires a large body of organised and retrievable knowledge (and that’s before you realise you need to look something up) this leads to the question: how can we teach in a way that makes learning ‘stick’?

In fact, there is a wealth of evidence from learning scientists and others about the best teaching and learning strategies we can employ in medical education – but we are often slow to adopt these. We collated some in a recent literature review:

  • Strategies that build understanding (e.g. self-explanation, use of concrete examples to explain abstract concepts, elaboration)
  • Retrieval practice (e.g. promoting effortful recall of information before being told the answer, spacing things out instead of learning ‘all in one go’ and then moving on, mixing things up – or interleaving – topics)
  • Structured/guided reflection (e.g. comparing and contrasting findings one would expect in different diseases with similar presentations)
  • Structuring knowledge around problem-specific concepts (e.g. having a diagnostic ‘decision-tree’ underpinned by relevant basic science, clinical knowledge and evidence)
  • Practicing with as many ‘real’ cases as possible in as many different contexts as possible – with coaching and feedback
  • Moving from low complexity, low fidelity tasks with high instructional support in the early years moving to high complexity, high fidelity tasks with minimal instructional support by final year at medical school – i.e. working as part of a clinical team by the time of graduation.

There’s a vast literature behind these strategies. I have seen medical students’ performance significantly improve by changing how they study and how they learn, adopting some of these strategies. Teachers can adopt them too. Now we need to spread the word!

If you want to find out more, visit www.learningscientists.org and search out their book, ‘Understanding how we learn: a visual guide’ (Weinstein & Sumeracki, 2019), or check out http://creme.org.uk/resources.html

Dr Nicola Cooper is a consultant physician and Clinical Associate Professor in Medical Education, and chair of the UK Clinical Reasoning in Medical Education group (CReME)

Join us on the Nottingham MedEd course: https://www.nottingham.ac.uk/pgstudy/course/taught/medical-education-mmedsci

Key references

  • Tehrani ASS, Lee HW, Mathews SC, Shore A, Makary MA, Pronovost PJ, Newman-Toker DE. (2013). 25-year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf; 0: 1-9
  • Graber ML. (2013). The incidence of diagnostic error in medicine. BMJ Qual Saf; 22(Suppl2): ii21–ii27.
  • Daniel M, Rencic J, Durning S, et al. (2019). Clinical reasoning assessment methods: a scoping review and practical guidance. Acad Med; 94(6): 902–912.
  • Rencic J, Trowbridge RL, Fagan M, Durning S. (2017). Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. J Gen Intern Med; 32(11): 1242–1246. Schmidt HG & Mamede S. (2015). How to improve the teaching of clinical reasoning: a narrative review and a proposal. Medical Education; 49; 961–973. World Health Organization. (‎2016)‎. Diagnostic errors. World Health Organization. http://www.who.int/iris/handle/10665/252410
  • Institute of Medicine. Improving diagnosis in health care. Washington, DC, 2015. The National Academies Press. https://doi.org/10.17226/21794
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