Mark Lillicrap – Series 2 – Clinical Reasoning

[00:00:00] Cheryl: Welcome to the podcast from Cambridge University Medical Education Group, or CUMEG for short. This is a podcast from the University of Cambridge Clinical School, focusing on medical education. We discuss a range of topics that medical educators are dealing with. I'm your host, Cheryl France, head of CUMEG

Today I would like to introduce Dr Mark Lillicrap. Associate professor of Medical Education Practice at the University of Cambridge Clinical School and Honorary Consultant Rheumatologist.

Welcome, Mark. It's wonderful to have you with us today.

[00:00:37] Mark: Thanks, Cheryl. It's nice to be here.

[00:00:39] Cheryl: You've been kind enough to join us on a previous podcast, but if you don't mind, it would still be helpful if you could remind our listeners about your background and your current role.

[00:00:50] Mark: So as you just indicated, yes. I'm Associate Professor of Medical Education Practice here in Cambridge. I'm the Clinical Sub Dean for the curriculum. and I work heavily on organizing staff development particularly for junior doctors, but also for all our teachers across the board from allied health professionals, junior doctors, senior doctors, GP’s, secondary care and one of the areas that we discuss in those training sessions is what we're going to pick up today, which is about clinical reasoning.

My day job clinically is as a rheumatology consultant and so I also have to apply all this stuff day-to-day in practice as well.

[00:01:29] Cheryl: That's really helpful. Thank you for such a great introduction.

As you said, today we're going to be talking about clinical reasoning. It would be helpful to understand first of all, I think, the definition of clinical reasoning and how this may be taught to clinical students or medical students. So if you don't mind, can you give us a definition of clinical reasoning and why this is so important?

[00:01:55] Mark: Yes. Well, If I do the second part of your question first, why is clinical reasoning important? I think as we're going to see clinical reasoning underpins everything that we do in terms of clinical practice. So, you know, if you're sitting in a clinic seeing patients, clinical reasoning is the core of everything that you're doing.

There's multiple different definitions that are out there in the literature. The one I like is for Michelle Daniel and her group, Michelle Daniel, who's the Vice Dean for Education at University of California in San Diego. She, in her academic medicine paper, gives a lovely definition that gives a bit of the breadth and the depth of clinical reasoning. She describes it's a skill, a process, or an outcome wherein clinicians observe, collect, and interpret data to diagnose and to treat patients, it entails both conscious and unconscious cognitive operations and it's about interaction with contextual factors, including the patient's unique circumstances and the characteristics of the practice environment.

So quite a long wordy definition which I can unpick in terms of sort of three domains that we need to think about when it comes to clinical reasoning and four interactions that then occur within that sort of overall framework.

So what you want to think about is, first of all, you've got the patient. And so the first bit, which Michelle Daniels group picks up beautifully is you've got to be aware in terms of the patient is at the heart of everything that happens in terms of clinical reasoning. So you've got the patient in one domain. You've got the clinician and what you do as a clinician in terms of how you use your cognitive processes, which she again beautifully describes those conscious and unconscious cognitive operations.

You as the clinician are the second part of the sort of three interacting circles, and then the third circle is about the external evidence base, and that's manifested in terms of guidelines, it's in terms of scientific evidence, it's in terms of the investigations that we use. And so you've got a domain in terms of the external sort of developed expertise over generations. You've got the clinician themselves as the individual and then you've got the patient.

And so they are three areas, and then you've got four interactions that take place across those. The first interaction is between the clinician and the patient, and that's about how do you get the information from the patient? How do you know that you've got the right information to start your thinking process with? So the first step in any clinical reasoning is to make sure that you can observe and collect the data from the patient, and that's all about expertise in evidence-based history taking and examination so that you can define what is the problem that I'm dealing with here, or not so much that I'm dealing with here, but what the patient's dealing with. So defining the problem. So that's your first interaction between you and the patient.

The second interaction is then between you and the evidence. So having worked out what you think the problem is, your next step is to think, okay, so what does the evidence tell me? You know, how do investigations inform my thinking here? What does the guidance tell me I ought to do? And what that generally results in is, that gives you an idea as the clinician, what is the best solution for this problem. And so you can use your scientific expertise in order to define that.

The third interaction though that we need to be very conscious of is the patient interacts with that data as well. Patients come along, they've often looked up the evidence, same evidence base that we are going to look at in terms of they've Googled it, find out a little bit about what they think they are in a particular context. They have particular health beliefs. They've discussed it with family, with friends. So they come with their perspective, and we have to understand that the patient is interacting with that data in the third interaction.

So the fourth interaction is then back between you and the patient to what we call shared decision making. So, you take what you feel is what the best solution theoretically would be in this situation, but you then have to take into account the patient's perspective in terms of what is the most appropriate treatment for this patient with their multiple comorbidities within that particular context that they find themselves with, their particular perspective of what they feel will be appropriate, what's the most appropriate thing is for this patient in this context?

And that's the fourth component of reasoning, which is that shared decision making. So it's three areas, patient, clinician, external evidence base. It's four interactions, you and the patient for data collection, you and the evidence to work out best solution, patient and evidence so they have an understanding of what they think you have to access that. And then the fourth bid is the shared decision making in terms of the final interaction in clinical reasoning. And Michelle Daniel's group encapsulate that with that long wordy definition at the start. But hopefully it gives you a bit of an idea of some of the complexity and also why it is so fundamental to everything that we do as clinicians

[00:06:58] Cheryl: and it is complex.

So thank you for that. I think your breakdown of it using the definition. And I thought that definition was very good because it is complex and yes, it might be wordy, but it hit on a lot of the key points that you then described. In in more detail. And I think that's really important.

And there is a lot skill, observation, collecting of information, but then taking that with the knowledge that you've gained as a clinician over the years. So when we're thinking about that and teaching medical students how to do this, there's a lot for them to have to pull together in order to get that skill.

So it's not going to come right away so I imagine there's lots of different skills in that are taught at different times and then it's about pulling that together. Would I be correct?

[00:07:51] Mark: Yes. There are some core things that you need to cover. So I'm involved in a national group here in the United Kingdom, the UK Clinical Reasoning in Medical Education Group, which is shortened CReME.

Slightly frustrating name in that get crème brûlèe recipes if you try and Google that.

[00:08:09] Cheryl: Sounds lovely!

[00:08:09] Mark: But the UK Clinical Reasoning and Medical Education Group, and we published a consensus statement that looked at what are the core domains that you need to teach for somebody learning clinical reasoning.

And it links in with those definitions. And you are right. Sometimes we might do certain bits at a particular part of the course and will pick up other bits, but it's generally, it's a thread that you need to keep in mind.

So the first, 'what' you need to teach in terms of clinical reasoning is some concepts of clinical reasoning. We know that that doesn't necessarily improve your clinical reasoning if you just understand the concepts. But it does give you a shared language, and much of effective education is about having a shared language because you need to observe somebody doing something and they need to be able to articulate their thinking and so if you've got some shared concepts around what is going on in those cognitive processes, that enables you to discuss somebody's thinking process. So you need some understanding of clinical reasoning concepts. So things like, you know, system one, system two, pattern recognition, algorithmic thinking, those kind of general concepts. So you've got a bit of a shared understanding.

The second domain is around that interaction between you and the patient. You've got to have good evidence-based skills in history and examination so that you know that you can define the problem appropriately. And again, there's lots of different evidence around communication skills and how we effectively teach communication skills to enable us to be certain that we've got the patient story, that we've given the patient the time, and then we've used our examination to support what we found in there in the history. So that's that first interaction.

[00:09:50] Cheryl: Yeah, which is really important.

[00:09:51] Mark: Yeah. Second interaction is between the external evidence and you as the clinician. And so you've got to be able to choose and interpret diagnostic tests, and you've got to understand concepts like the sensitivity and specificity of tests. You've got to understand when a test is going to be useful in a particular context. And so again, you would teach that in as a slightly different skill in a slightly different context. But it's that third part of the clinical reason. The third, 'what' that you need to teach

The fourth bit is you've got to be able to then put all of that together and identify what is the problem that we're dealing with here. Because that then enables you to look at literature around what's the evidence for what we do in this situation. So you can define that what is the best management in this situation? And we know there are certain skills that you need to acquire in order to be effective at defining those problems and accessing the literature.

And then the fifth 'what' you need to be able to teach, is how you now communicate that back to the patient, having got an understanding of where they're coming from? So the fifth bit that we identified from the literature, the fifth domain that you need to teach, is shared decision making.

So five domains that constitute the overall skill of reasoning, clinical reasoning concepts, understanding what's going on in your brain, history and examination, choosing an interpreting diagnostic test, identifying problems and defining management and shared decision making. So they're the 'what' that you want to cover.

[00:11:21] Cheryl: So not insignificant.

[00:11:23] Mark: Not insignificant, and constitutes a lot of what we do with our students.

[00:11:27] Cheryl: I can imagine, and I know that for different parts and times of the course throughout you are going to be teaching different aspects of that. So at some point, it's about starting to pull that together and helping them as a student to be able to manage each of those individual components to make the whole. So when we think about some of the individual bits, so for example, that shared decision making, I imagine that's something that you have to practice somehow and not necessarily on a patient in the first instance.

 So can you tell us a bit more about that is accomplished in the education setting.

[00:12:13] Mark: Yes. So, As you described, the key thing is you've got to have experience. So in order to learn from these various skills, you've got to be able to try them out. And we want to provide our students with the opportunity to try these things out in a safe setting. And that's where simulation is so important. So we'll often use actor simulated patients in order to allow our students to practice exactly these skills so that you can practice them in a safe environment.

So the first thing is that you've got to be able to do it and have the experience. The second thing is that you need to be observed. So the second element of teaching, the skill of reasoning is to observe people. Ideally in that safe simulated environment so you can see what they're doing and how they're doing it. So observation is the second key component.

 Then the third component is you've then got to articulate and discuss that. So that's where having a shared language becomes important. So you want your student having had an experience to now discuss it with you and articulate their thinking. What have I done well, what could I do a little bit differently? And you as the observer, are very often just what's described as the more knowledgeable other, the work of Russian educationalist called Le Vigotsky, you're just the more knowledgeable other who's providing a bit of scaffolding to help that student develop their ideas, develop their skills.

And then the fourth and final component is to reflect on that in order to now embed what you've done. And then you go back and you try it out again, and you gradually increase the complexity of that and then you start putting people in real life situations with real people in real clinical situations. Often the danger in education is that we then withdraw the observation and I think probably the key thing we need to keep in mind is you need to continue to observe people because otherwise you can't have that meaningful discussion and you can't keep going around that learning cycle.

So they're all elements that you need to keep in mind.

[00:14:19] Cheryl: and that's really useful to say, you know, it is about, everybody can use that check back sometimes actually have I done that quite right? And sometimes different scenarios, it's useful to just chat and say, Hmm, what could have gone differently? How could have we done better? And I think that's been really useful because when I think about clinical reasoning and a doctor patient relationship, quite often individuals think of the wise old doctor, you know, that's the one who kind of sits back and you know, he scratches their chin a bit and says, “Ooh, I think I know it's this” and intuitively almost they know because of the experience. So trying to get new doctors, newly trained doctors to have that experience is really important. So I think the way you've described it is really helpful to understand what can be done.

[00:15:13] Mark: Yes. And just picking up on that, so the evidence looks at different ways that people with more experience use slightly different strategies in terms of that cognitive processing. So what we know is experienced clinicians very often do this process of pattern recognition. What's the term type one processing. So you encounter a situation, but you've encountered it thousands of times before you unconsciously activate your networks, your frameworks, and you immediately make a decision that you know what's going on and you get your diagnosis very rapidly.

The danger of that system is it's subject to all sorts of unconscious biases and there's increasing literature showing that that's a key factor in diagnostic error because once you've made that decision, using that type of processing, you get a little kick of dopamine from your limbic system that gives you a feeling of satisfaction that you've made the right choice. What you need to do is to slow down. So experienced clinicians do exactly that. They make a decision quite quickly and it looks incredibly impressive, but that's because they're using decades of experience to deal with their problems. What happens for a less experienced person, an early year student or whatever, is they can't do that because they haven't got that bank to access.

So they have to use a different process of thinking, which is called algorithmic or hypothetical deductive reasoning where it's a much slower process. It's cognitively draining and it's really a bit boring. And in order to do that, you have to navigate your way through all the different components, put it together, use a variety of different sort of algorithmic processes using your scientific foundations to navigate your way, what's called system two processing.

So it's a much slower process. And it eventually builds into system one pattern recognition, but it's important that students are aware that what they see experienced clinicians doing is actually different to what they're doing, and they need to be reassured that that kind of way of reasoning will develop over time but you can't do that to start with. You've got to go through those basic processes in order to build those frameworks that you can access them unconsciously. But it, once you get that pattern recognition, you've then got to get into the habit of doing the slow stuff again and going back and checking. Am I using good algorithmic thinking to crosscheck my thinking to make sure that I'm not making errors. Of course, the quick way to that is to have a student with you in clinic because you can do the pattern recognition. You can ask them what they think and they're going to have to do the algorithmic thinking so the two of you can cross-check each other again, brings you back providing that you're talking about it's part of the process.

[00:18:10] Cheryl: Yes, and I would agree. I mean, I’m giggling because I often think, you know, we have this amazing teaching hospital on our doorstep and I think that patients are quite lucky because they get the two and I've often thought, well the medical students are learning lots of different things so they can bring a different perspective to each patient potentially. Then, as I said before, the wise old doctor. So I think that is interesting the way you've brought that together and saying it is good to have these checks and balances in place; probably for both.

[00:18:42] Mark: Yes. And, you know, yes. As you say that sort of idea that the wise old doctor, that the key thing is that that doctor also has to be able to articulate their thinking in a more logical way than just saying, well, it's, you know, I've got that gut feeling that's what's going on. And that ability to articulate things, is really helpful for teaching because that helps a student to understand that's why you are thinking that way and having those frameworks that guide people can be very helpful.

[00:19:14] Cheryl: That is really useful to understand. And so some of this clinical reasoning, is this taught throughout the course or does that come on more as the student has matured and is looking to almost finish the course in the last few years?

[00:19:31] Mark: In general, I think it should be starting from day one.

[00:19:35] Cheryl: Okay.

[00:19:37] Mark: So it's why we go into medicine. You know, the reason we go into medicine is because we want to make a difference in terms of patients with suffering various illnesses. So we want to make a difference. And actually clinical reasoning is how you make a difference. It's how you pull everything together. And so I think it needs to start right from the beginning so you get an understanding of why you are doing the things that you are doing and why at the end of the day that's going to make a difference to the quality of care that you're going to be able to provide to somebody. So yes, it does have to start from day one, but it has to build as we go through.

Coming back to the consensus paper that we published through the UK Clinical Reasoning Group, CReME again, we came up with sort of six strategies that you need to think about when you are planning, how you're going to deliver reasoning teaching.

So we mentioned the five, 'what's’ you need to teach? We then looked at what does the literature tell us of the 'how' to teach. So the first thing is you've got to have strategies that progressively build understanding. And what's reassuring about the findings from the consensus paper when we looked at all the literature, they mapped to what we often call the educational pearls in how adults learn you know, people like Kolb's Reflective experiential learning cycle, Sean's reflective practice, labour and then constituted learning. All those things that you cover in a sort of staff development program, like a postgraduate certificate. You see, when you look at the literature, the ‘how’ to do it maps beautifully today.

So the first thing you've got to structure, you've got to have structures that build understanding. You've got to map it to a learning cycle. You've got to keep spiralling back through things in order to learn things.

The second thing is that for effective clinical reasoning, you've got to have strategies that employ structured reflection. So again, I said earlier, you've got to have an opportunity for somebody to reflect on what they've done in order they can work out, what am I doing well, what can I do differently? You've got to practice with cases in real world settings. Again, coming back to what we discussed earlier, it's all very well doing it in simulated setting, in that sort of nice, safe environment. But the real clinical world is messy, and you've got to have the opportunity to try that in the real world where things don't go quite as you anticipate that they're going, to other stuff's happening. And you've got to be able to adapt to that. And you've got to have a framework for your reasoning that is robust enough that it works in all those messy other places that you that you find things.

Fourth thing we identified is you've got to structure it around problem specific concepts. And so problem based learning becomes really important here in terms of how you develop your reasoning because you need to, when you're interacting with that evidence, how you as the clinician interact with the evidence, we know that that works best if you are thinking orientates around problems. So you want to have a problem based kind of approach. You want to employ strategies that employ what's called retrieval practice. So, you need gaps and then you need to do it again. And that comes back to these concepts of the spiral curriculum in that, you know, once you've been through the experiential learning cycle, you want to come back to it again and again.

And then the final thing, picking up on where your questions started, you've got to have strategies that differ according to the stage of learning. So what you want is to start early with basics and gradually increase the complexity as you go through so that somebody activates their network, their construct, their framework, their neural networks in terms of how they think. To start with, at a simple level, just to make sure I've got the, I've got the core foundations nicely embedded, and then I come back to it and I stretch it a little bit more and I use it in a slightly more complex way, and then I stretch it and I work out where it's not working, where things are going wrong. And then you learn from that, and then you go back round again, and you gradually build a robust reasoning framework by keep revisiting these things time and again.

And so again, it links very much with the educational pearls that you cover, but you see how they're then applicable in practice, in clinical reasoning.

[00:23:56] Cheryl: Which is quite nice with being able to take that full circle and say, here's the theory but actually in practice, this is how it works and it does work and this is why and I think that's interesting. When you talked again about going back into the real world, because you're right, it is messy. It isn't always straightforward and clean cut and that's part of the importance of trainee doctors having that opportunity to be in different settings and to see lots of different patients with different needs, and like you said previously as well, lots of different comorbidities. How do you decide what's best in that shared environment with that clinical reasoning at the end to say this is what's best for this patient because, but it may not have been for a different person.

[00:24:42] Mark: Yeah. And that brings you back to that wise old clinician. That wise old clinician very often uses pattern recognition. But actually when you find yourself in a messy, real world scenario, one of the things good expert clinicians do is they drop back onto their more cognitive analytical processes. And so it's fine when everything's straightforward and it's as you expect, pattern recognition works well. You've got insight into things that I can use to cross-check that, talking to students in clinic. But actually sometimes there's complex situations. It's messy. It's the real world. And what you see that wise clinician doing at that point is dropping back and using more scientific, analytical kind of processes. Going back into that hypothetical deductive reasoning strategy, because that's what we do when we find ourselves in positions where we feel uncertain.

And having that insight is part of what makes a good clinician, having that insight, I need to pause here. I actually need to take a bit of time here. Something's not right. An American author who describes it as that pebble in my shoe. Having that awareness that something just doesn't feel quite right here. I need to move to a slower thinking strategy here.

And my experience with that is, when you find yourself in that situation, having students with you sitting in your clinic with you who you can bounce things off, is actually incredibly helpful. So I think sometimes we perceive that, you know, having students with you in a clinic is it is time consuming. It's going to use up your time. Things are going to run slightly less efficiently. But actually, at times, I think they also improve the quality of your diagnostic thinking. Nobody who I'm aware of has yet done that study to show that having students with you in clinic reduces diagnostic error but I think it would be a very interesting study to look at.

[00:26:37] Cheryl: It would be, and I think on the other side, as a patient, this is a good advert to say, yes. You want the students in there because they are offering something different. So it's a positive all the way around.

[00:26:49] Mark: Absolutely. Yes.

[00:26:50] Cheryl: So I think that's good to note as well, because sometimes I think some patients are a bit reluctant when you think, no, actually this is a really good thing.

[00:26:58] Mark: Yes, absolutely.

[00:26:59] Cheryl: Particularly, when we're talking about this clinical reasoning.

Mark, this has been really interesting to chat to you today. There's been a lot of information. It's quite complex.

[00:27:09] Mark: Yes.

[00:27:10] Cheryl: I was going to ask if there's any, you know, major points that you want to pull out of today. It seems so complex. There's a lot that we've talked about. Do you have anything specific that you would say? Actually, if there's one thing you want to take away or three things you want to take away today, this is it.

[00:27:28] Mark: If you, yes. I would say if there's something that you, as an educator want to take away from this, the key thing is observe your student. Get them doing things in real life. Observe them doing it, and then talk to them because that's how people learn. And very often we miss out that observation step. We might send a student off to do something and then come back. But actually, effective teaching in this situation is going to involve observation. And I would compare it in many ways to a sports coach. You know, as the educator you need to be watching exactly what your trainee, your student is doing so that you can have those meaningful discussions and you can help them reflect.

You wouldn't expect, you know, a tennis coach to just have the player come to talk to them afterwards about what went on in the match. You would've expected them to watch what's gone on and then have a meaningful discussion about it. And I think sometimes in medical education, we miss out the observation and that reduces the quality of the discussions. So that will probably be the key thing that I would take away from this. Observe your trainees and students.

[00:28:41] Cheryl: That's really helpful. Thank you. And it is a good point there, but there were so many good points today. It was really helpful and interesting to learn more about clinical reasoning.

It is complex, but I really appreciate how you broke that down for us to help us understand more about what is involved in that practice and as medical educators how to get the most from that situation.

So Mark, thank you so much for being with us again today.

[00:29:08] Mark: Thank you. It's been an enjoyable discussion. Thank you.

[00:29:10] Cheryl: Thank you.

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Until next time, I'm your host, Cheryl France, and thank you once again for listening.