Background: Clinical reasoning remains a central skill of the successful clinician. To improve or master these skills, it is essential to outline the cognitive steps that lead to success in eliciting, framing and then solving medical problems. In this era of increasingly hectic time schedules and duty hour restrictions, it is less common for the learner to hear a master clinician’s distinct steps used when solving problems. Moreover, since reasoning transpires largely at the subconscious level, it can be difficult for busy clinicians to articulate the steps in their thought process. Thus, more inexperienced learners are left to pick up reasoning in bits and pieces and to figure out their own way to “connect the dots” when faced with a patient problem. The clinical problem solving/diagnostic reasoning session is designed to provide a window into the master clinician’s thought process and reasoning strategies. The session serves as a valuable tool to learn and teach the process of hypothesis generation (eliciting the right question), problem representation (problem list), prioritized differential diagnosis and finally problem-solving strategies (pattern recognition and analytical reasoning).

Clinical Problem Solving Session Goal: to provide a mechanism for residents to learn the skills and to become more adept at clinical reasoning by listening to expert clinicians talk through process of making decisions and actively participating in discussion around a clinical problem.

Objectives: By making the thought process of a master clinician more transparent, the clinical reasoning session will:

1. highlight the intricacies of the diagnostic process.
2. help learners better understand how an experienced clinical formulates complex clinical decisions by combining prior experiences with evidence-based knowledge.
3. demonstrate history-taking, examination and diagnostic skills as a foundation for clinical reasoning.
4. teach the process of progressive problem solving.
5. outline the cognitive steps that lead to success in eliciting, framing and then solving medical problems.
6. engage learners in the diagnostic process.
7. allow master clinicians to serve as role models for less experienced learners.
8. help develop a collective espirit de corps while developing skills and confidence with the diagnostic reasoning process.

Clinical Problem Solving Session Format:

• The 55- minute session uses the “Stump the Professor” format.
• Those chosen to serve as master clinician will not have heard the case.

Activities:

Introduction to session by the facilitator (5 minutes)

• articulate goals and objectives of the session
• remind all participants that:< >diagnostic reasoning is not “magic” but rather a skill that is developed over timean individual does not need to know everything to participatethe session in about the process; getting the diagnosis right is relatively unimportantoutline session format

Presentation of case by the facilitator with responses/discussion by master clinicians (30 minutes)

• The clinical case will be presented in short segments rather than all at once. This allows for an infusion of information which allows for discussion breaks and gives the master clinician an opportunity to verbalize his/her thought process as well as to teach the process of progressive problem solving to the learners throughout the session.
• The clinician is expected to “think out loud” allowing the learners insight into the thought process of a master clinician.
• The master clinician is also expected to keep the audience engaged in solving the case throughout the presentation.
• Session participants are expected to be actively engaged in asking questions and sharing their reasoning.

  Discussion led by facilitator (15 minutes)

• comments on the process after the diagnosis is revealed.
• comments on the diagnosis from the audience.
• brief presentation of any new relevant knowledge on specific topics raised by the case.

Teaching points and wrap-up led by facilitator as well as completion of survey (5 minutes)

• teaching points will focus on physical diagnosis and diagnostic reasoning
• short survey to participants