Teaching clinical reasoning to undergraduate medical students

Abstract

In the 1950s, teaching programs focused on the biomedical sciences; clinical decisions were left to expert intuition rather than rational analysis. During the past few decades, efforts have been made to understand the mental strategies employed by physicians during clinical decision making, and the reasons for errors that result from human bounded rationality. This chapter describes the recent shift in approach to clinical reasoning and practice-from intuitive to scientific. Today, medical students are offered courses in epidemiology, evidence-based medicine and medical economics. They are taught to generate diagnostic hypotheses, suggest information that would support or refute these hypotheses, and apply Bayes’ theorem for diagnostic reasoning and evidence-based principles for treatment choices. The author believes, however, that medical education is still in a state of transition from the determinism of the biomedical sciences to the uncertainty of clinical practice. To overcome the intellectual and emotional barriers to this transition, medical students must come to terms with two apparently incompatible conceptions: the cause-effect descriptive approach based on deterministic thinking, and one that views clinical practice as consisting of prescriptive decisions based on probabilistic estimates. Students must accept that clinical uncertainty is pervasive. To this end, clinical preceptors should openly share their thought processes-and their doubts-in clinical training.