Difficulties in Teaching Diagnostic Reasoning in the Digital Age: The Critical Role of the Teacher-Clinician Mentor

  • Burke A. Cunha
    Requests for reprints should be addressed to Burke A. Cunha, MD, MACP, Winthrop-University Hospital, Infectious Disease Division, 222 Station Plaza North (#432), Mineola, NY 1150.
    Infectious Disease Division, Winthrop-University Hospital, Mineola, NY

    State University of New York, School of Medicine, Stony Brook, NY
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      Each case has its lesson—a lesson that may be, but is not always, learnt, for clinical wisdom is not the equivalent of experience. A man who has seen 500 cases of pneumonia may not have the understanding of the disease which comes with an intelligent study of a score of cases, so different are knowledge and wisdom.William Osler, MDThe greatest difficulty in life and medicine is to convert knowledge into practical wisdom.William Osler, MDMentoring is medicine's greatest achievement.Michael A. LaCombe, MD
      The best mentors are seasoned clinicians who, over decades of insightful practice, have acquired exceptional diagnostic skills. On the basis of decades of insightful clinical experience, mentors also impart wisdom to their mentees. Osler, the role model for master teacher-clinician mentors, are the best teachers of the art of medicine and clinical diagnostic reasoning.
      In the digital age, society has become enamored with speed. Information can be accessed in seconds. Instant information is substituted for thoughtful study and reflection.
      In teaching clinical reasoning, instant information has important educational implications. Some learners believe information can replace real teacher teaching. However, the critical element in teaching is not simply information; meaningful learning occurs only via student–teacher interactions. Teaching clinical medicine requires more than instant information access.
      Medical learners have become addicted to instant information and have become dependent on instant information to solve clinical problems. Today's learners of medicine have overlooked an essential tenet of clinical problem solving, namely that information is not knowledge and knowledge is not clinical wisdom. Clinical wisdom comes only from thoughtful reflection derived from years of insightful experience.
      Without accurate diagnosis, optimal therapy is a matter of chance. The value of the clinical syndromic approach is that it narrows diagnostic possibilities according to the relative diagnostic importance of characteristic findings in the differential diagnosis. Narrowed diagnostic possibilities permit selective diagnostic testing. Not only is the “order everything” approach excessive and needlessly expensive, but unexpected test results are often misleading, leading the unwary to order even more tests. Clinicians should always consider the clinical relevance of test results before embarking on non–clue-directed testing. Clinical judgment often takes a back seat to “shotgun testing.” To be clinically relevant, test results must be interpreted in clinical context. Unless interpreted in the clinical context, test results may be clinically misleading or irrelevant.
      Today, in clinical medicine, most do not study. Because information is instant there is no need to remember, study, or correlate clinical findings. If information is instantly available, why acquire diagnostic reasoning skills? Thoughtful study is now often regarded as nonessential or quaint.
      In life and medicine, speed comes at a cost. Today's distracted physicians are hurried and harried, in large part owing to electronic medical record time-imposed limitations. The teacher-clinician mentor saves the mentee the time by imparting the lessons garnered from years of insightful clinical experience. The mentor saves the mentee learning time, but more importantly, imparts wisdom in the process.
      Medicine has always been an art, and acquiring clinical excellence has always been difficult and time-consuming. Clinical diagnostic reasoning is best learned from an inspired teacher-clinician. A fortunate few will seek out teacher-clinician mentors to guide them. Instant information is a threat to teaching clinical diagnostic reasoning. I know of no more eloquent a mentoring story than this by Dr. LaCombe; the following text has been excerpted from his book, Bedside: The Art of Medicine.
      • LaCombe M.A.
      Recent advances.
      “In a hospital cafeteria, two residents were arguing over lunch. Oblivious to … [an] unwinnable battle: what was the single most important discovery in the history of medicine? Understand that these were modern doctors with … a trendy impatience with history. … The first resident … argued for the discovery of antibiotics, and with a grand display of entitlement, he began his argument.‘There is no doubt that the dawn of the antibiotic era is indisputably the beginning of modern medicine. [Antibiotics] … gave physicians more to do than simply monitor the dying patient. …[T]heir discovery has spawned the … discipline of infectious disease…’ Eminently pleased with himself, he leaned back in his chair. But for meager academic salaries, he might have considered an infectious disease fellowship…The second resident … prided himself on his intuitive leaps and lateral thinking. He could hardly settle for any such simplistic solution … Antibiotics are important and have their place, but … No, my friend, you miss the obvious. He went on his own rebuttal.The discovery of the computer is the Rosetta stone for medicine. Regard the computer’s applications in medical research. … He had won and he knew it. And the second resident now sat back smugly…At the end of their table sat an old man in a long white coat. To this elderly physician the first resident appealed. What do you think, sir? he asked condescendingly. What would you consider medicine’s greatest achievement?You’re both correct as far as you go, which isn’t very far. … And the correct answer to your question may be found … in your asking me … and in my compulsion to answer you, or rather, history’s compelling me to do so. … Alzheimer’s, thought the first resident. Korsakoff’s, thought the second…The mentor, whispered the old man. What? both residents asked in unison. The old gentlemen stared off as though addressing some imaginary audience, and began.The mentor is medicine’s single greatest achievement … It started … long before Hippocrates … but just stop and consider Hippocrates himself. There he is, sitting there in his robe, surrounded by colonnades … Through observation, by sheer power of thought, he’s trying to make a science out of what had been only magic and religion. Pretty soon he finds he has a group of young people sitting around him as well, all wanting to learn what he, Hippocrates, knows what is important. So he teaches them all he knows, which is what you’re supposed to do when you’re a mentor.And then he sends them out into the world. They teach others in turn, each of them becoming a mentor for students, as Hippocrates had been for them. And everywhere they go, teaching students, treating patients, he is right there at their elbows, making sure they do it the right way, and with style. And so it goes through history … well, you know history as well as I do. Clearly they didn’t, so the old man continued.‘Look at what happens with this mentor business. You have teachers, each with students numbering in the thousands, all linked with each other down through the ages—forming a vast, dendritic coalescence of medical knowledge. Why, you have to be proud just to belong to it, pieces of wisdom yourself! You begin to think of yourself as some living page out of a grand medical textbook.”And what happens to those young doctors when they are adrift in the world? Do their mentors desert them? Not in their life! A student meets a patient with congestive heart failure, and old man Withering is right there, telling him how much foxglove to use. Or your young doctor is dealt a baffling case, with Sydenham is sitting on her shoulder, making sure she takes down the history correctly…And so it’s been for me these long years. I’ve carried my mentor everywhere. If I get sloppy, I wonder, “What would he think of me now?” And if I’m in a tight spot clinically, he prods me back to the literature. … When I’m asked to teach, I do so willingly because that is what he did. When I begin to doubt myself, I remember his belief in me. And if I am ready to quit, I can see him standing there before me in his long white coat, with stern look and stethoscope, and I go on.What has he been for me, this mentor of mine? He’s been like a father to me, but more than a father. He has been a companion in medicine, to help me through the loneliness that medicine can bring and to share with me the joy that medicine can be. My mentor has, through me and those of my students, cared decently and compassionately for countless patients.…Yes sir, the mentor is medicine’s best invention. All of us doctors need one. That’s what it’s all about. I hope you boys have one yourselves.’The old man stopped, looked off, and smiled at some distant memory. The residents at the next table had tuned to listen to him as well. The old man got up to leave, nodding to them all. He had a gleam in his eye, and a radiance about him. Was this madness, wondered the residents, or some forgotten brilliance? He straightened his shoulders, and turned with a quote to the residents at the next table: ‘Observation, reason, human understanding, courage—these make the physician.’Now the old man turned back to the two residents, nodded to them, and turned to walk away. With a hand to his breast, the old man gave a slight bow, turned, and shuffled away. Bewildered, the residents watched him leave, wondered who he was, and why it was that they had never had time for him before.”
      Although clinical wisdom is acquired only after years of thoughtful, study-based, insightful clinical experience, master diagnosticians are best positioned to teach clinical diagnostic reasoning to mentees. Accessing instant information and populating data in the electronic medical record leaves little time to perfect clinical diagnostic reasoning skills. If teacher-clinician mentors are unavailable, mentees can still learn diagnostic reasoning from master diagnosticians by reading and studying their works (eg, Osler). Master teaching-clinicians are fast disappearing, and soon only a few will remain. Students of medicine at all levels should seek out teacher-clinician mentors to teach them diagnostic reasoning while there is still time.


        • LaCombe M.A.
        Recent advances.
        in: LaCombe M.A. Bedside: The Art of Medicine. University of Maine Press, Orono, ME2010: 57-61

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