The Introduction to Clinical Reasoning (ICR) course aims to teach students the way experienced clinicians approach making a diagnosis. Diagnosing patients accurately and efficiently is an essential ability for all physicians, but the process can be complicated. Becoming an expert clinician is a long process that requires a great deal of work, patience, and dedication. This course will provide practical, tangible instruction on how to think like a doctor and improve one’s diagnostic skills. It will also introduce approaches and algorithms for many of the common clinical presentations that students will encounter frequently over the course of clinical rotations.

Goals and Competencies

Please read the below list of learning goals and competencies for the course. Be sure to ask one of the course directors if you are unsure as to the meaning or significance of an objective.

Goals

1. Improve your non-analytic reasoning (pattern recognition) skills by developing accurate mental constructs for common diseases (illness scripts) so that you can make correct diagnoses.
2. Improve your analytic reasoning skills as such strategies will further improve your diagnostic abilities.
3. Recognize pitfalls in the diagnostic process and reduce your rate of diagnostic error.

Competencies

By the end of the course, you should become competent in the using the knowledge, skills, and attitudes listed below.

Knowledge

1. Describe the basic steps of the diagnostic process (see section on “Illness Scripts and Diagnosis” below).
2. Recognize the dual process model of clinical reasoning and the interplay between non-analytic reasoning and analytic reasoning.
3. Identify the epidemiology, symptoms, signs, and laboratory/imaging findings of the covered common diseases.
4. Construct the common differential diagnoses for the covered chief concerns.
5. Describe the concept of non-analytic reasoning (pattern recognition) and its role in diagnostic reasoning.
6. Define illness script.
7. Define heuristic and four major types (availability, representativeness, anchoring, and premature closure).
8. Explain how pre-test probability is estimated by gestalt or prediction rules.
9. Evaluate the impact of pre-test probability on the utility of a given diagnostic test.
10. Define likelihood ratio.
11. Describe the concept of post-test probability.
12. Describe the concepts of threshold to test and threshold to treat.

Skills

1. Translate patient words into medical terminology.
2. Construct illness scripts for common diseases using epidemiology, symptoms, signs, and laboratory/imaging findings.
3. Formulate an accurate problem representation.
4. Create a complete key features list based on the history, physical, laboratory results, and imaging findings.
5. Determine pre-test probabilities for diseases on the differential diagnoses.
6. Find likelihood ratios for the tests that are being considered and apply them to calculate post-test probability.
7. Always identify life/function threatening diagnoses prior to choosing a working diagnosis.
8. Consistently search for clinical data that are at odds with the leading diagnosis.
9. Defend the choice of the working diagnosis with epidemiological, clinical, and pathophysiological evidence.
10. Apply pathophysiology to improve understanding of patient presentations (causal reasoning).
11. Apply pathophysiology to aid in the memorizing and understanding of the diagnosis and treatment of common diseases (causal reasoning).
12. Apply the concepts of thresholds to test and treat to case-based examples; specifically describe how post-test probability, risks, and benefits all factor into testing and treatment decisions.
13. Develop algorithms for approaching common chief concerns.
14. Use comparison and contrast routinely in analyzing differential diagnoses.
15. Apply primary evidence from the literature to the diagnosis and management of patients.
16. Demonstrate the ability to search for, appraise, and apply evidence in the literature to inform decisions based on one’s own needs and interests

Attitudes

1. Recognize the critical nature of epidemiology in diagnosis.
2. Recognize how pre-test probability determines whether a test is worth performing.
3. Recognize the importance of knowing likelihood ratios for determining the value of tests.
4. Recognize the value of employing a hypothesis-driven (active) mental approach to the history, physical, and data.
5. Recognize the importance of repetitive mental practice in considering the differential diagnoses for given symptoms and of illness scripts in enhancing the ability to recall diagnoses in appropriate clinical settings.
6. Recognize the need for self-directed learning and the necessity of pursuing further knowledge based on one’s own needs and interests.

Overview of Course Content

Clinical reasoning is the cognitive and physical (e.g., physical examination) process through which doctors determine a diagnosis and management approach for a given patient. In this course, we will focus primarily on diagnostic reasoning or making the correct diagnosis. The key mental skill in making the right diagnosis is categorization. Becoming a good diagnostician requires clinicians to learn how to categorize and distinguish between the various manifestations of disease in determining the correct diagnosis.

The practical term for what is at the center of the doctor’s search for the correct diagnosis is the differential diagnosis. Creating a differential diagnosis is the process of creating a list of possible causative diseases that may account for the patient presentation.  The likelihood of each disease is then considered by weighing the evidence (e.g., symptoms, signs, labs, imaging) that supports each possibility. Great diagnosticians are famous for having a vast repository of differential diagnoses for common and uncommon symptoms and you should work towards building your own diagnostic warehouse. The course will serve to help you build both your ability to form a differential diagnoses and to recognize the key distinguishing factors that help differentiate one disease from another.

An Important Note on this Syllabus

Unlike other courses, the syllabus for ICR is built over the course of time.  With each session, more material will be added to the syllabus and will be available on Canvas.  A unified syllabus will be available on Canvas at the end of the course with individual sections available on the respective session pages as they are released.