When we studied ward attending rounds, the thought process represented the top attribute that learners valued. Learners can learn facts from textbooks, but using those facts requires experience and role modeling.
I have given many lectures on clinical reasoning, and I have attended many lectures on clinical reasoning. These lectures can entertain, but one lecture does little to help our colleagues and our learners.
We must structure case conferences as a primary way to teach and learn. Lectures may help occasionally, but often the information in a lecture leaves our memory quite rapidly. But a case discussion gives the story bones on which to attach the meat!
Many years ago I had GI distress and hives after a seafood lunch. For years I thought I had developed a scallop allergy. Then I heard a similar case presented with a diagnosis of scombroid. That one case made my diagnosis, and has helped me make several more diagnoses.
At our institution, we address case conferences in several ways. The majority of our morning reports use case presentations with a clinician discussing the case as it unfolds. Residents often rate these conferences as the number two learning opportunity in residency (after daily rounds). At our grand rounds, while we often have pure lectures, we do have occasional clinicopathological conferences (CPCs) that remain quite popular. Our noon conference has both CPCs and clinical problem solving (CPS). We do CPS every month with one attending physician presenting patients to another attending physician. The discussion focuses on the thought process. Residents and students love this conference.
But for me, the best conference is Tinsley conference (named after our hero — Tinsley Harrison — our Osler-like influence). At Tinsley, the chief residents choose the most interesting patients from our teaching service (also named after Dr. Harrison) and present it to a room full of students, residents and attending physicians. In this conference, the faculty do most of the talking. We have many subspecialists who attend regularly. Thus, we have general internists and a variety of subspecialists helping to dissect the details of the presentation. I always learn a great deal.
We must model clinical reasoning. Patient stories provide the bones, and the discussion provides the meat. The meat sticks because it attaches to the bones. When done properly these conferences help us all improve as clinicians.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
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