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Teaching Diagnostic Reasoning in the Digital Age: The Role of the Mentor

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Each case has its lesson—a lesson that may be, but is not always, learnt, for clinical wisdom is not the equivalent of experience. A man who has seen 500 cases of pneumonia may not have the understanding of the disease which comes with an intelligent study of a score of cases, so different are knowledge and wisdom.

William Osler, MD

The greatest difficulty in life and medicine is to convert knowledge into practical wisdom.

William Osler, MD

Mentoring is medicine’s greatest achievement.

Michael A. LaCombe, MD

 

The best mentors are seasoned clinicians who, over decades of insightful practice, have acquired exceptional diagnostic skills. On the basis of decades of insightful clinical experience, mentors also impart wisdom to their mentees. Osler, the role model for master teacher-clinician mentors, are the best teachers of the art of medicine and clinical diagnostic reasoning.

In the digital age, society has become enamored with speed. Information can be accessed in seconds. Instant information is substituted for thoughtful study and reflection.

In teaching clinical reasoning, instant information has important educational implications. Some learners believe information can replace real teacher teaching. However, the critical element in teaching is not simply information; meaningful learning occurs only via student–teacher interactions. Teaching clinical medicine requires more than instant information access.

Medical learners have become addicted to instant information and have become dependent on instant information to solve clinical problems. Today’s learners of medicine have overlooked an essential tenet of clinical problem solving, namely that information is not knowledge and knowledge is not clinical wisdom. Clinical wisdom comes only from thoughtful reflection derived from years of insightful experience.

Without accurate diagnosis, optimal therapy is a matter of chance. The value of the clinical syndromic approach is that it narrows diagnostic possibilities according to the relative diagnostic importance of characteristic findings in the differential diagnosis. Narrowed diagnostic possibilities permit selective diagnostic testing. Not only is the “order everything” approach excessive and needlessly expensive, but unexpected test results are often misleading, leading the unwary to order even more tests. Clinicians should always consider the clinical relevance of test results before embarking on non–clue-directed testing. Clinical judgment often takes a back seat to “shotgun testing.” To be clinically relevant, test results must be interpreted in clinical context. Unless interpreted in the clinical context, test results may be clinically misleading or irrelevant.

Today, in clinical medicine, most do not study. Because information is instant there is no need to remember, study, or correlate clinical findings. If information is instantly available, why acquire diagnostic reasoning skills? Thoughtful study is now often regarded as nonessential or quaint.

In life and medicine, speed comes at a cost. Today’s distracted physicians are hurried and harried, in large part owing to electronic medical record time-imposed limitations. The teacher-clinician mentor saves the mentee the time by imparting the lessons garnered from years of insightful clinical experience. The mentor saves the mentee learning time, but more importantly, imparts wisdom in the process.

Medicine has always been an art, and acquiring clinical excellence has always been difficult and time-consuming. Clinical diagnostic reasoning is best learned from an inspired teacher-clinician. A fortunate few will seek out teacher-clinician mentors to guide them. Instant information is a threat to teaching clinical diagnostic reasoning. I know of no more eloquent a mentoring story than this by Dr. LaCombe; the following text has been excerpted from his book, Bedside: The Art of Medicine.1

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-Burke A. Cunha, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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