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INTRODUCTION

To a medical student who requires hours to collect a patient’s history, perform a physical examination, and organize that information into a coherent presentation, an experienced clinician’s ability to decide on a diagnosis and management plan in minutes may seem extraordinary. What separates the master clinician from the novice is an elusive quality called “expertise.” The first part of this chapter provides an overview of our current understanding of expertise in clinical reasoning, what it is, and how it can be developed.

The proper use of diagnostic tests and the integration of the results into the patient’s clinical assessment may also be equally bewildering to students. Hoping to hit the unknown diagnostic target, novice medical practitioners typically apply a “shotgun” approach to testing. The expert, in contrast, usually focuses her testing strategy to specific diagnostic hypotheses. The second part of the chapter reviews basic statistical concepts useful for interpreting diagnostic tests and quantitative tools useful for clinical decision-making.

Evidence-based medicine (EBM) constitutes the integration of the best available research evidence with clinical judgment as applied to the care of individual patients. The third part of the chapter provides an overview of the tools of EBM.

BRIEF INTRODUCTION TO CLINICAL REASONING

Clinical Expertise

Defining “clinical expertise” remains surprisingly difficult. Chess has an objective ranking system based on skill and performance criteria. Athletics, similarly, have ranking systems to distinguish novices from Olympians. But in medicine, after physicians complete training and pass the boards, no further tests or benchmarks identify those who have attained the highest levels of clinical performance. Of course, physicians often consult a few “elite” clinicians for their “special problem-solving prowess” when particularly difficult or obscure cases have baffled everyone else. Yet despite their skill, even master clinicians typically cannot explain their exact processes and methods, thereby limiting the acquisition and dissemination of the expertise used to achieve their impressive results. Furthermore, clinical virtuosity appears not to be generalizable, e.g., an expert on hypertrophic cardiomyopathy may be no better (and possibly worse) than a first-year medical resident at diagnosing and managing a patient with neutropenia, fever, and hypotension.

Broadly construed, clinical expertise includes not only cognitive dimensions and the integration of verbal and visual cues or information but also complex fine-motor skills necessary for invasive and noninvasive procedures and tests. In addition, “the complete package” of expertise in medicine includes the ability to communicate effectively with patients and work well with members of the medical team. Research on medical expertise remains relatively sparse overall, with most of the work focused on diagnostic reasoning, and much less work focused on treatment decisions or the technical skills involved in the performance of procedures. Thus, in this chapter, we focus primarily on the cognitive elements of clinical reasoning.

Because clinical reasoning takes place in the heads of doctors, it is therefore not ...

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