Teaching Professional Attitudes and Basic Clinical Skills to Medical Students

Abstract

Clinical problems vary in complexity. At one extreme are “simple” questions, such as “What is the body mass index of this patient?” or “Does she have atrial fibrilla- tion?” The answers require examination, measurement, or calculation. At the other extreme are “complex” questions, such as “How should patients with asymptomatic gallstones be managed?” or “Should atrial fibrillation in a patient with a history of embolic stroke and gastrointestinal bleeding be treated by anticoagulants?” An- swers to such questions require predictions. The resolution of most clinical problems requires predictions that entail higher levels of uncertainty than examination, measurement, or calculation. Diagnosis is a categorization task that allows physicians to make prognostic predictions; choices of treatment are guided by predictions of the patient’s response. Uncertainty is per- vasive in clinical reasoning, as diagnostic aids are imperfect, and every interven- tion carries a defined risk. Yet, in the 1950s, uncertainty was only rarely discussed. Clinical reasoning was guided by pathophysiologic rationale and unsystematic ex- perience. Clinical decisions were believed to call for mastery of the “art of medi- cine,” which was a mystical process that eluded analysis and explication, and was somehow acquired by experience. Experience is certainly important. Some clinical skills indeed defy explication and are best taught by repeated exposure. Although uncertainty can be reduced, it cannot be eliminated, and there is no gold standard for clinical judgment. How- ever, in the second half of the twentieth century, observational studies revealed disturbingly high differences in clinical reasoning [1] and practice [2] even among experienced doctors. In 1953, Yerushalmy [3] reported that two competent radiolo- gists disagreed on the interpretations of chest X-rays in a third of the cases, and that a single interpreter disagreed with his previous readings in a fifth of the cases. In 1963 Schimmel [4] reported that out of a total of 1252 consecutive admissions to a university hospital, 16 patients had died as a consequence of medical interventions and, since then, the high rates of adverse reactions to treatment have been repeat- edly confirmed. Consequently, doctors are Hence the attempts to demystify clinical reasoning and decision-making with a view to permitting their rational analysis and reducing the frequency of medical errors. The purpose of this chapter is to briefly review these attempts and the dif- ficulties in learning and teaching clinical reasoning increasingly challenged to justify their decisions, and claims that the art of medicine eludes critical review are no longer acceptable. ©