Cultivating Clinical Acumen Through Mindful Experience

We have probably all seen a senior clinician who just knows. They have that 6^th sense that allows them to navigate a difficult, complex patient case with ease. They just seem to do the right thing at the right time, whether it is making a diagnosis or balancing a complex treatment plan with several competing factors. They have clearly developed clinical acumen.

 I have often heard senior clinicians bemoan that their juniors do not have clinical acumen. However, I’ve rarely heard any of them explain what clinical acumen is, let alone how to acquire it. Some clinicians speak as if clinical acumen is something that we are just supposed to intuitively understand, without explicit guidance. I disagree.

In my experience with bedside teaching, I have found that teachers can cultivate clinical acumen in their trainees.   

What do we mean by clinical acumen? I think this definition will suffice: the ability to navigate a clinical situation effectively and efficiently. 

So how does a clinician learn to navigate a clinical situation effectively and efficiently?

By going through clinical experiences mindfully and actively try to learn from them.

When trainees go through our experiences mindfully, they learn faster and develop clinical acumen more quickly.  

How can they be mindful? One, simple way is to have trainees analyze recent, clinical experiences and then ask them questions such as:

• What might they have done differently?
• What could they do to make things go smoother next time?
• If a variable changed, how would they have managed the situation differently?

By answering questions like this, the trainees run thought experiments, mental simulations that allow them to test ideas and plan for future situations. The results of these thought experiments help them prepare for similar situations in the future. By encouraging trainees to analyze these experiences in this way, we allow them to learn without having to be in every possible scenario. 

A trainee can do such an analysis themselves, and I encourage mine to do so. However, I tend to ask questions like the ones above during a patient presentation, when making decisions on patient care, and when debriefing after treating a patient. When the experience is more fresh, I find that there is better learning. When I have brought trainees through this process often and consistently, they start developing navigating clinical situations well very quickly. With these kinds of teaching processes, I have seen even very junior trainees start to develop acumen in just a few short weeks.

If you want to learn more about this and other clinical decision making processes, you can check out my book: A Guide to Clinical Decision Making

What Should Go in Your Medical Decision Making Section - A Few Principles to Guide You

A common question that comes from many clinicians from trainees to seasoned attendings is: 

“What do I put in my medical decision making section?”

If you ask 10 different clinicians, you will likely get 10 different answers. There is no, one, standard method for making a medical decision making/assessment and plan section. However, we can rely on a few principles for guidance on how to make a reasonable and logical medical decision making section.

Keep in mind your diagnosis(es) from the beginning of your chart.

Your MDM section is where you pull everything together. You must lay out the groundwork in the other parts of the chart first. Start thinking about your MDM section long before that actual section in your chart starts.

The details of the patients’ history and physical exam are important. These details come in the form of pertinent positives and pertinent negatives.

For example, if your assessment is that the patient has bruising to the extremity and not a fracture, be sure specific details that support your conclusion are in your history and physical. These can include details such as:

• no point tenderness
• minimal swelling
• full range of motion with minimal pain 
• mild tenderness 
• diffuse tenderness

Focus on what you think the diagnosis(es) is

The remaining diagnosis(es) from your original differential should be the focus on your chart. As above, support this conclusion with details you have gathered. If you have done this, you can just put down your diagnosis without further explanation.

You can simply write something such as “Findings are suspicious for pulmonary embolism” and that should be all you need if the rest of your chart includes details like

• recent 10 hour plane flight
• left leg swelling
• pleuritic chest pain
• feels anxious
• tachycardic

Minimize how much you list other diagnoses you have already determined are low-probability

In the MDM section, I often read lengthy lists and explanations as to why several diagnoses are not present. Proving the low probability of another diagnosis is the job of the preceding sections of the chart. Repeating what you have already said is unnecessary. 

Demonstrate that during your investigations to get to your final diagnosis(es), you checked on a few details to consider alternate diagnoses. For example, when you already have a compelling story for another diagnosis, you would not need to mention pulmonary embolism if you have already included details such as:

• no tachycardia
• no leg swelling
• no OCP use
• no recent surgery

Spell out your plan based on your diagnoses.

Often I have seen clinicians list diagnoses and then their described plans veer off in a completely different direction. It is as if they are now addressing an unmentioned diagnosis. 

Keep your plan consistent with your diagnosis. If you state something inconsistent with your stated diagnoses, you should consider changing your stated diagnosis, or question whether you really want to do what you state that you plan.

For example, if you have listed pulmonary embolism and costochondritis as your remaining differential diagnoses and then also order blood cultures, you should amend your differential diagnosis to include whatever infection you are assessing for.

If you’re interested in learning more about this or similar topics, check out my book: The Handbook of Medical Charting

How do You Maximize Clinical Experience?

 

Most American, medical students come out of medical school having passed 2 USMLE’s, accumulated well over 3,000 hours of clinical experience, evaluated hundreds of patients, and assisted with scores of procedures. They then enter residency where they are treated as if they know nothing. 

Most of these students slog through medical school rotations and later residency, picking up pearls along the way. With these pearls, they stitch together what will eventually become their way of practicing. They do this under the watchful eyes of attending physicians who often bemoan of how the younger generation does not get “it”. No one ever defines what “it” is. Few of these attending physicians remember that their own teachers also said the exact same thing about them. 

I will not pretend to know all aspects and permutations of “it”. However, sometimes “it” is the lack of a framework with which to understand the information and experiences that the student is thrown into.

A framework in this case is a mental structure that gives the student direction, a guiding principle (or set of principles) for how to make their knowledge function in real life. With a lot of experience, most physicians gain these mental frameworks in a mass-volume, brute-force kind of way through residency. 

However, to make frameworks explicit from the outset is a powerful tool in maximizing learning from clinical experience.

For example, in emergency medicine: 

You can tell a trainee, 

“Go see a patient and present their case to me”.

Alternatively, you can give them a framework that can guide them, 

“Think of the 3 most dangerous conditions your patient could have. Make sure they do not have any of them.”

With the second, the trainee has guiding principles to help focus their efforts. Despite being broadly worded, the second method gives a direction that can guide the trainee’s actions.

You could put more detail into this framework if you thought your trainee needed more explicit direction.

Building on our previous example, 

“Find out what the patient’s real chief complaint is. Determine if they have any of the 3 most emergent conditions for their chief complaint. Present their case to me with a plan that focuses on what diagnostics and therapeutics you want to do. Be prepared to explain why we are doing each point in your plan.”  

With a little reflection, a teacher in any other specialty could give equivalent types of frameworks to their trainees.

When they have a good framework, the trainees’ attention and efforts focus on the important aspects of a patient’s case. Trainees that do this learn more from each patient interaction, grow more quickly as clinicians, grasp advanced lessons in patient care more quickly, and can take better care of their patients. 

So clinical teachers, please consider what frameworks you might use with your trainees to maximize their learning. Give your trainees the guiding concepts that will focus their efforts and help them grow faster as clinicians. 

If you’re interested in learning more about using cognitive frameworks to help your trainees, please consider checking out my book: A Guide to Clinical Decision Making