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Evidence based medicine: an approach to clinical problem-solving

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• Peer review
• William Rosenberg , clinical tutor in medicine a ,
• Anna Donald , senior house officer b
• a Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford OX3 9DU
• b Public Health and Health Policy, Anglia and Oxford Regional Health Authority, Oxford OX3 7LF
• Correspondence to: Dr Rosenberg.

Doctors within the NHS are confronting major changes at work. While we endeavour to improve the quality of health care, junior doctors' hours have been reduced and the emphasis on continuing medical education has increased. We are confronted by a growing body of information, much of it invalid or irrelevant to clinical practice. This article discusses evidence based medicine, a process of turning clinical problems into questions and then systematically locating, appraising, and using contemporaneous research findings as the basis for clinical decisions. The computerisation of bibliographies and the development of software that permits the rapid location of relevant evidence have made it easier for busy clinicians to make best use of the published literature. Critical appraisal can be used to determine the validity and applicability of the evidence, which is then used to inform clinical decisions. Evidence based medicine can be taught to, and practised by, clinicians at all levels of seniority and can be used to close the gulf between good clinical research and clinical practice. In addition it can help to promote self directed learning and teamwork and produce faster and better doctors.

Doctors must cope with a rapidly changing body of relevant evidence and maximise the quality of medical care despite the reduction in junior doctors' working hours and scarce resources. We are deluged with information, and although much of it is either invalid or irrelevant to clinical practice, an increasing amount comes from powerful investigations such as randomised controlled trials. Yet we continue to base our clinical decisions on increasingly out of date primary training or the overinterpretation of experiences with individual patients, 1 and even dramatically positive results from rigorous clinical studies remain largely unapplied. 2 Doctors need new skills to track down the new types of strong and useful evidence, distinguish it from weak and irrelevant evidence, and put it into practice. In this paper we discuss evidence based medicine, a new framework for clinical problem solving which may help clinicians to meet these challenges.

What is evidence based medicine?

Evidence based medicine is the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. For decades people have been aware of the gaps between research evidence and clinical practice, and the consequences in terms of expensive, ineffective, or even harmful decision making. 3 4 Inexpensive electronic databases and widespread computer literacy now give doctors access to enormous amounts of data. Evidence based medicine is about asking questions, finding and appraising the relevant data, and harnessing that information for everyday clinical practice.

Most readers will recognise that the ideas underlying evidence based medicine are not new. Clinicians identify the questions raised in caring for their patients and consult the literature at least occasionally, if not routinely. The difference with using an explicit, evidence based medicine framework is twofold: it can make consulting and evaluating the literature a relatively simple, routine procedure, and it can make this process workable for clinical teams, as well as for individual clinicians. The term “evidence based medicine” was coined at McMaster Medical School in Canada in the 1980s to label this clinical learning strategy, which people at the school had been developing for over a decade. 5

Evidence based medicine in practice

Evidence based medicine can be practised in any situation where there is doubt about an aspect of clinical diagnosis, prognosis, or management.

Four steps in evidence based medicine

Formulate a clear clinical question from a patient's problem

Search the literature for relevant clinical articles

Evaluate (critically appraise) the evidence for its validity and usefulness

Implement useful findings in clinical practice

SETTING THE QUESTION

A 77 year old woman living alone is admitted with non-rheumatic atrial fibrillation and her first bout of mild left ventricular failure, and she responds to digoxin and diuretics. She has a history of well controlled hypertension. An echocardiogram shows moderately impaired left ventricular function. She is an active person and anxious to maintain her independence. During the ward round on the following day a debate ensues about the risks and benefits of offering her long term anticoagulation with warfarin, and rather than defer to seniority or abdicate responsibility to consensus by committee, team members convert the debate into a question: “How does her risk of embolic stroke, if we don't give her anticoagulant drugs, compare with her risk of serious haemorrhage and stroke if we do?”

The questions that initiate evidence based medicine can relate to diagnosis, prognosis, treatment, iatrogenic harm, quality of care, or health economics. In any event, they should be as specific as possible, including the type of patient, the clinical intervention, and the clinical outcome of interest. In this example two questions are prepared for a literature search. One question relates to prognosis and her susceptibility: “How great is the annual risk of embolic stroke in a 77 year old woman with non-rheumatic atrial fibrillation, hypertension, and moderate left ventricular enlargement if she is not given anticoagulants?” The other question concerns treatment and asks, “What is the risk reduction for stroke from warfarin therapy in such a patient, and what is the risk of harming her with this therapy?”

FINDING THE EVIDENCE

The second step is a search for the best available evidence. To conduct searches on a regular basis, clinicians need effective searching skills and easy access to bibliographic databases. Increasingly the access can be proved by ward or surgery based computers, complemented by assistance in obtaining hard copies of articles, and enabled by librarians who teach searching skills and guide the unwary through the 25000 biomedical journals now in print. 6 7

Two sorts of electronic databases are available. The first sort is bibliographic and permits users to identify relevant citations in the clinical literature, using variations of Medline. The second sort of database takes the user directly to primary or secondary publications of the relevant clinical evidence—the rapidly growing numbers include the Cochrane Database of Systematic Reviews, Scientific American Medicine on CD-ROM, and the ACP Journal Club (a bimonthly supplement to the Annals of Internal Medicine which abstracts the relevant and rigorous articles on diagnosis, prognosis, treatment, quality of care, and medical economics from over 30 general medical journals). All these databases are, or soon will be, available on line from local, national, and international networks such as the internet.

For our patient, the searches were conducted with Medline and the Knowledge Finder searching software. “Atrial fibrillation” and “cerebrovascular disorders” were entered as major medical subject headings and “randomised controlled trial” as a publication type selected from the “dictionaries” menu. The search was performed twice, once with “prognosis” entered as a freetext search parameter and a second time with “therapy” included. The years 1990-4 were searched and 10 articles were identified, of which eight seemed to contain the relevant information (two on prognosis 8 9 and six reporting randomised trials of therapy 10 11 12 13 14 15 ). Five 10 11 12 13 14 were available in the library.

The search was repeated for 1992-4 with “review” as the publication type, and one recent article was identified. 16 The term “review” includes subjective reviews, systematic reviews, and meta-analyses. The newer term “meta-analysis” could have been used as a publication type to narrow the search but would have missed potentially useful reviews and systematic reviews, as well as meta-analyses that have not yet been classified as such in Medline.

The two articles on prognosis, four on therapy, and the review (in fact a meta-analysis) were then pulled from the library. The keyboard time taken for this search was 15 minutes. The ACP Journal Club, whose electronic version is currently being tested, has summarised these trials, and Cochrane reviews on the prevention and treatment of stroke will be available in 1995, but on this occasion we examined the evidence presented in conventional forms of clinical research publication.

While clinicians may make greater use of meta-analyses in the future, the ability to appraise critically publications of all types will remain an invaluable skill. Searches may fail to uncover well conducted and relevant meta-analyses and often it will be impractical for a busy clinician to conduct an independent systematic review of the literature each time a clinical question is generated. On these occasions the most effective strategy will be to seek out the best of the available literature and to appraise critically the evidence by using skills that can readily be learnt.

APPRAISING THE EVIDENCE

The third step is to evaluate, or appraise, the evidence for its validity and clinical usefulness. This step is crucial because it lets the clinician decide whether an article can be relied on to give useful guidance. Unfortunately, a large proportion of published medical research lacks either relevance or sufficient methodological rigour to be reliable enough for answering clinical questions. 17 To overcome this, a structured but simple method, named “critical appraisal,” developed by several teams working in North America and the United Kingdom, enables individuals without research expertise to evaluate clinical articles. Mastering critical appraisal entails learning how to ask a few key questions about the validity of the evidence and its relevance to a particular patient or group of patients. Its fundamentals can be learnt within a few hours in small tutorials, workshops, interactive lectures, and at the bedside by a wide range of users, including those without a biomedical background. This strategy has been developed for many different types of articles, and can be used to evaluate original articles about diagnosis, treatment, prognosis, quality of care, and economics as well as to evaluate reviews, overviews, and meta-analyses for their validity and applicability.

The table shows a typical set of critical appraisal questions for evaluating articles about treatment. Although they reflect common sense, the questions are not entirely self explanatory; some instruction is needed to help clinicians apply them to specific articles and individual patients. Self directed learning materials have been developed to help users apply different critical appraisal questions to the different sorts of clinical research articles on diagnosis, prognosis, therapy, quality of care, economic analysis, and screening. These materials include the JAMA series of user's guides and the text Clinical Epidemiology: A Basic Science for Clinical Medicine. 18 Week long training workshops in evidence based medicine are held in various venues, but we have found that even people with limited experience can readily learn how to practise evidence based medicine in the context of their own clinical practice. As with any other skill, expertise and speed come with practice, and experienced practitioners can learn to appraise critically most articles in under 10 minutes, transforming themselves from passive, opinion based spectators to active, evidence based clinicians.

Critical appraisal questions used to evaluate a therapy article 19 20

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This transformation is borne out in the critical appraisal of the evidence surrounding the management of the 77 year old woman with atrial fibrillation. The two articles on prognosis fulfil criteria for validity and applicability and reveal that our particular patient faces an 18% annual risk of stroke if left untreated. 8 9 Applying criteria given in the Users' guides to the medical literature: how to use an article about therapy or prevention, 19 20 we decided that the articles we have pulled provide valid and applicable evidence. We used them to obtain the relative risk reduction of stroke due to treatment with warfarin, which is 70%. The annual risk of stroke for our patient without treatment was used, in conjunction with relative risk reduction obtained from the prognosis articles, to calculate the absolute risk reduction (ARR) of stroke attributable to anticoagulation with warfarin. This figure, which is 0.13, was then used to calculate the “number needed to treat” (NNT=1/ARR) with warfarin to save one stroke. Thus treating eight patients (1/0.13) for one year will prevent one stroke. The annual rate of major haemorrhage in patients receiving warfarin is 1%, so one patient in every hundred taking warfarin will experience a major bleed each year, and we therefore can expect to prevent about 13 strokes in patients such as ours with warfarin for every major bleed we will cause through such treatment. Although the benefit:risk ratio seems acceptable in this instance, we know that bleeding rates vary between centres and a higher local risk of intracranial haemorrhage might lead other clinicians and patients to a very different decision. The evidence will not automatically dictate patient care but will provide the factual basis on which decisions can be made, taking all aspects of patient care into consideration.

ACTING ON THE EVIDENCE

Having identified evidence that is both valid and relevant, clinicians can either implement it directly in a patient's care or use it to develop team protocols or even hospital guidelines. They can also use evidence to revolutionise continuing medical education programmes or audit. In our experience, implementing the evidence is best learned through group discussions, either on ward rounds or in other meetings of the clinical team in which members explore ways of incorporating the evidence into a patient's clinical management.

At the weekly firm meeting the evidence extracted from the critically appraised literature on warfarin was presented in a summarised form as a critically appraised topic by a junior member of the team (table). During the subsequent ward round the team discussed the evidence with the patient and she decided to start taking warfarin. It was decided to set a target international normalised ratio of 1.5-2.0, and her general practitioner, who asked for a copy of the critically appraised topic to accompany the discharge letter, agreed to monitor her treatment.

Other requirements for practising evidence based medicine

Clear data presentation.

The ability to present published evidence quickly and clearly is crucial for clinical teams with little time and much information to absorb. 21 Medical journals have led the way here with structured abstracts to help readers quickly retrieve key information. Such clarity and quickness are equally important for clinicians when they present evidence to their team. A preset, one page, user friendly summary such as the one developed by doctors in training at McMaster University in Ontario (unpublished data) can help this process and was the model for the critically appraised topic that appears in the table.

Added advantages in practising evidence based medicine

For individuals

Enables clinicians to upgrade their knowledge base routinely

Improves clinicians' understanding of research methods and makes them more critical in using data

Improves confidence in management decisions

Improves computer literacy and data searching techniques

Improves reading habits

For clinical teams

Gives team a framework for group problem solving and for teaching

Enables juniors to contribute usefully to team

For patients

More effective use of resources

Better communication with patients about the rationale behind management decisions

SENIOR SUPPORT

Support from senior clinicians is critical to the success of introducing evidence based medicine. 22 Seniors who practice evidence based medicine are excellent role models for training newcomers and allocating questions according to the skills and time commitments of individual team members. Even when senior staff are themselves unfamiliar with evidence based medicine, their willingness to admit uncertainty, to encourage scepticism, and to be flexible can help the team to accommodate new evidence which may contradict previous assumptions and practice.

Does it work?

An evidence based approach to clinical care has been practised in many countries under various guises. In the structured form described above it attracts both support and criticism, often within the same hospital. The problem, ironically, is that the approach is difficult to evaluate. 23 It is a process for solving problems, and it will have different outcomes depending on the problem being solved. Trying to monitor all the possible outcomes would be impossible, especially since many are difficult to quantify. For example, a medical student who learns the importance of good research methodology through practising critical appraisal may later on carry out better research, but it would be hard either to quantify this or to link it directly to evidence based medicine.

None the less, evidence of the effectiveness of evidence based medicine is growing as it spreads to new settings. Short term trials have shown better and more informed clinical decisions following even brief training in critical appraisal, 24 and although graduates from traditional medical curriculums progressively decline in their knowledge of appropriate clinical practice, graduates of a medical school that teaches lifelong, self directed, evidence based medicine are still up to date as long as 15 years after graduation. 25 The review of the benefits and drawbacks of evidence based medicine that follows draws on our experience of teaching and practising evidence based medicine with clinicians and purchasers in Oxford.

An immediate attraction of evidence based medicine is that it integrates medical education with clinical practice. We have observed that students and doctors who begin to learn evidence based medicine become adept at generating their own questions and following them through with efficient literature searches. For example, learners quickly learn to pick out good review articles and to use resources such as the ACP Journal Club when they are appropriate to the question being asked. 26

Another advantage of evidence based medicine is that it can be learnt by people from different backgrounds and at any stage in their careers. Medical students carrying out critical appraisals not only learn evidence based medicine for themselves but contribute their appraisals to their teams and update their colleagues. At the other extreme, seasoned clinicians can master evidence based medicine and transform a journal club from a passive summary of assigned journals into an active inquiry in which problems arising from patient care are used to direct searches and appraisals of relevant evidence to keep their practice up to date.

The evidence based approach is being taken up by non-clinicians as well. Consumer groups concerned with obtaining optimal care during pregnancy and childbirth are evolving evidence based patient choice. The critical appraisal skills for purchasers project in the former Oxford region involves teaching evidence based medicine to purchasers who have no medical training so that it can inform their decisions on purchasing. 27

A third attraction of evidence based medicine is its potential for improving continuity and uniformity of care through the common approaches and guidelines developed by its practitioners. Shift work and cross cover make communication between health workers both more important and more difficult. Although evidence based medicine cannot alter work relationships, in our experience it does provide a structure for effective team work and the open communication of team generated (rather than externally imposed) guidelines for optimal patient care. It also provides a common framework for problem solving and improving communication and understanding between people from different backgrounds, such as clinicians and patients or non-medical purchasers and clinicians.

Evidence based medicine can help providers make better use of limited resources by enabling them to evaluate clinical effectiveness of treatments and services. Remaining ignorant of valid research findings has serious consequences. For example, it is now clear that giving steroids to women at risk of premature labour greatly reduces infant respiratory distress and consequent morbidity, mortality, and costs of care, 28 and it is equally clear that aspirin and streptokinase deserve to be among the mainstays of care for victims of heart attack.

Disadvantages

Evidence based medicine has several drawbacks. Firstly, it takes time both to learn and to practise. For example, it takes about two hours to properly set the question, find the evidence, appraise the evidence, and act on the evidence, and for teams to benefit all members should be present for the first and last steps. Senior staff must therefore be good at time management. They can help to make searches less onerous by setting achievable contracts with the team members doing the searches and by ensuring that the question has direct clinical usefulness. These responsibilities of the team leader are time consuming.

Establishing the infrastructure for practising evidence based medicine costs money. Hospitals and general practices may need to buy and maintain the necessary computer hardware and software. CD-ROM subscriptions can vary from £250 to £2000 a year, depending on the database and specifications. But a shortage of resources need not stifle the adoption of evidence based medicine. The BMA provides Medline free of charge to members with modems, and Medline is also available for a small fee on the internet. Compared with the costs of many medical interventions (to say nothing of journal subscriptions and out of date texts), these costs are small and may recover costs many times their amount by reducing ineffective practice.

Inevitably, evidence based medicine exposes gaps in the evidence. 4 This can be frustrating, particularly for inexperienced doctors. Senior staff can help to overcome this problem by setting questions for which there is likely to be good evidence. The identification of such gaps can be helpful in generating local and national research projects, such as those being commissioned by the York Centre for Reviews and Dissemination. 29

Another problem is that Medline and the other electronic databases used for finding relevant evidence are not comprehensive and are not always well indexed. At times even a lengthy literature search is fruitless. For some older doctors the computer skills needed for using databases regularly may also seem daunting. Although the evidence based approach requires a minimum of computer literacy and keyboard skills, and while these are now almost universal among medical students and junior doctors, many older doctors are still unfamiliar with computers and

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Problem Solving in Clinical Medicine

American Medical Association Chicago

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.

Reaching a secure diagnosis is a formidable task for the medical student, which consumes many hours of history taking, physical examination, and scanning of laboratory test data. The experienced clinician who instructs students appears to arrive at a diagnosis by intuition with relative ease and only a small expenditure of time. Actually the skilled diagnostician uses a highly developed system of quickly testing hypotheses that might fit the case under consideration and eliminates all but the most probable diagnosis by careful questioning and by astute observation. This skill, or perhaps we should call it art, can be developed early in one's medical career through proper instruction, and that is what Paul Cutler's book is all about. In eight short chapters he describes the process and lays down the rules for becoming a good diagnostician. These chapters are followed by 65 case presentations that any physician will encounter in a primary

Barclay WR. Problem Solving in Clinical Medicine. JAMA. 1979;242(4):374. doi:10.1001/jama.1979.03300040056037

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Principles and Practice of Case-based Clinical Reasoning Education: A Method for Preclinical Students [Internet].

Chapter 1 introduction.

Olle ten Cate .

Affiliations

Published online: November 7, 2017.

This chapter introduces the concept of clinical reasoning. It attempts to define what clinical reasoning is and what its features are. Solving clinical problems involves the ability to reason about causality of pathological processes, requiring knowledge of anatomy and the working and pathology of organ systems, and it requires the ability to compare patient problems as patterns with instances of illness scripts of patients the clinician has seen in the past and stored in memory.

The purpose of the book, supporting the teaching of clinical reasoning before students enter the clinical arena, faces the paradoxical problem of the lack of clinical experience that is so essential for building proficiency in clinical reasoning. So where to start if students are to be best prepared for first clinical encounters?

The method of case-based clinical reasoning is summarized and explained in its potential to provide early rudimentary illness scripts through elaboration and systematic discussion of the courses of action between the initial presentation of the patient and the final steps of clinical management. Meanwhile, the method requires student to apply knowledge of anatomy, physiology, and pathology.

The CBCR method has been applied successfully in several medical schools over a period of decades, and support for its validity is provided.

This chapter provides a general background and summarizes the CBCR method.

Clinical reasoning is a professional skill that experts agree is difficult and takes time to acquire, and, once you have the skill, it is difficult to explain what you actually do when you apply it—clinical reasoning then sometimes even feels as an easy process. The input, a clinical problem or a presenting patient, and the outcome, a diagnosis and/or a plan for action, are pretty clear, but what happens in the doctor’s mind in the meantime is quite obscure. It can be a very short process, happening in seconds, but it can also take days or months. It can require deliberate, painstaking thinking, consultation of written sources, and colleague opinions, or it may just seem to happen effortless. And “reasoning” is such a nicely sounding word that doctors would agree captures what they do, but is it always reasoning? Reasoning sounds like building a chain of thoughts, with causes and consequences, while doctors sometimes jump at a conclusion, sometimes before they even realize they are clinically reasoning. Is that medical magic? No, it’s not. Laypeople do the same. Any adult witnessing a motorcycle accident and seeing a victim on the street showing a lower limb in a strange angle will instantly “reason” the diagnosis is a fracture. Other medical conditions are less obvious and require deep thinking or investigations or literature study. Whatever presentation, doctors need to have the requisite skills to tackle the medical problems of patients that are entrusted to their care. No matter how obscure clinical reasoning is, students need to acquire that ability. So how does a student begin to learn clinical reasoning? How must teachers organize the training of students?

Case-based clinical reasoning (CBCR) education is a design of training of preclinical medical students, in small groups, in the art of coping with clinical problems as they are encountered in practice. As will be apparent from the description later in this chapter, CBCR is not identical to problem-based learning (Barrows and Tamblyn 1980 ), although some features (small groups, no traditional teacher role) show resemblance. While PBL is intended as a method to arrive at personal educational objectives and subsequently acquire new knowledge (Schmidt 1983 ), CBCR has a focus on training in the application of systematically acquired prior knowledge, but now in a clinical manner. It aims at building illness scripts—mental representations of diseases—while at the same time supports the acquisition of a diagnostic thinking habit. CBCR is not an algorithm or a heuristic to be used in clinical practice to efficiently solve a new medical problem. CBCR is no more and no less than educational method to acquire clinical reasoning skill. That is what this book is about.

The elaboration of the method (Part II and III of the book) is preceded in Part I by chapters on the general background of clinical reasoning and its teaching.

• What Is Clinical Reasoning?

Clinical reasoning is usually defined in a very general sense as “The thinking and decision -making processes associated with clinical practice” (Higgs and Jones 2000 ) or simply “diagnostic problem solving” (Elstein 1995 ).

For the purpose of this book, we define clinical reasoning as the mental process that happens when a doctor encounters a patient and is expected to draw a conclusion about (a) the nature and possible causes of complaints or abnormal conditions of the patient, (b) a likely diagnosis, and (c) patient management actions to be taken. Clinical reasoning is targeted at making decisions on gathering diagnostic information and recommending or initiating treatment. The mental reasoning process is interrupted to collect information and resumed when this information has arrived.

It is well established that clinicians have a range of mental approaches to apply. Somewhat simplified, they are categorized in two thinking systems, sometimes subsumed under the name dual-process theory (Eva 2005 ; Kassirer 2010 ; Croskerry 2009 ; Pelaccia et al. 2011 ). Based in the work of Croskerry ( 2009 ) and the Institute of Medicine (Balogh et al. 2015 ), Fig. 1.1 shows a model of how clinical reasoning and the use of System 1 and 2 thinking can be conceptualized graphically.

A model of clinical reasoning (Adapted from Croskerry 2009)

The first thinking approach is rapid and requires little mental effort. This mode has been called System 1 thinking or pattern recognition , sometimes referred to as non-analytical thinking. Pattern recognition happens in various domains of expertise. Based on studies in chess, it is estimated that grand master players have over 50,000 patterns available in their memory, from games played and games studied (Kahneman and Klein 2009 ). These mental patterns allow for the rapid comparison of a pattern in a current game with patterns stored in memory and for a quick decision which move to make next. This huge mental library of patterns may be compared with the mental repository of illness scripts that an experienced clinician has and that allows for the rapid recognition of a pattern of signs and symptoms in a patient with patients encountered in the past (Feltovich and Barrows 1984 ; Custers et al. 1998 ). See Box 1.1 .

Box 1.1 Illness Script

An illness script is a general representation in the physician’s mind of an illness. An illness script includes details on typical causal or associated preceding features (“enabling conditions”); the actual pathology (“fault”); the resulting signs, symptoms, and expected diagnostic findings (“consequences”); and, added to the original illness script definition (Feltovich and Barrows 1984 ), the most likely course and prognosis with suitable management options (“management”). An illness script may be stored as one comprehensive unit in the long-term memory of the physician. It can be triggered to be retrieved during new clinical encounters, to facilitate comparison and contrast, in order to generate a diagnostic hypothesis.

A mental matching process can lead to an instant recognition and generation of a hypothesis, if sufficient features of the current patient resemble features of a stored illness script.

Next to this rapid mental process, clinicians use System 2 thinking: the analytical thinking mode of presumed causes-and-effects reasoning that is slow and takes effort and is used when a System 1 process does not lead to an acceptable proposition to act. Analytic, often pathophysiological, thinking is typically the approach that textbooks of medicine use to explain signs and symptoms related to pathophysiological conditions in the human body. Both approaches are needed in clinical health care, to arrive at decisions and actions and to retrospectively justify actions taken. The two thinking modes can be viewed on a cognitive continuum between instant recognition and a reasoning process that may take a long time (Kassirer et al. 2010 ; Custers 2013 ). In routine medical practice, the rapid System 1 thinking prevails. This thinking often leads to correct decisions but is not infallible. However, the admonition to slow down the thinking when System 1 thinking fails and move to System 2 thinking may not lead to more accurate decisions (Norman et al. 2014 ). In fact, emerging fMRI studies seem to indicate that in complex cases, inexperienced learners search for rule-based reasoning solutions (System 2), while experienced clinicians keep searching for cases from memory (System 1) (Hruska et al. 2015 ).

• How to Teach Clinical Reasoning to Junior Students?

It is not exactly clear how medical students acquire clinical reasoning skills (Boshuizen and Schmidt 2000 ), but they eventually do, whether they had a targeted training in their curriculum or not. Williams et al. found a large difference in reasoning skill between years of clinical experience and across different schools (Williams et al. 2011 ). Even if reasoning skill would develop naturally across the years of medical training, it does not mean that educational programs cannot improve.

One way to approach the training of students in clinical reasoning is to focus on things that can go wrong in the practice of clinical reasoning and on threats to effective thinking in clinical care. Box 1.2 shows the most prevalent errors and cognitive biases in clinical reasoning (Graber et al. 2005 ; Kassirer et al. 2010 ). See also Chap. 3 .

Box 1.2 Summary of Prevalent Causes of Errors and Cognitive Biases

Errors (graber et al. 2005 ; kassirer et al. 2010 ).

Lack or faulty knowledge

Omission of, or faulty, data gathering and processing

Faulty estimation of disease prevalence

Faulty test result interpretation

Lack of diagnostic verification

Biases (Balogh et al. 2015 )

Anchoring bias and premature closure (stop search after early explanation)

Affective bias (emotion-based deviance from rational judgment)

Availability bias (dominant recall of recent or common cases)

Context bias (contextual factors that mislead)

In general, diagnostic errors are considered to occur too often in practice (McGlynn et al. 2015 ; Balogh et al. 2015 ), and it is important that student preparation for clinical encounters be improved (Lee et al. 2010 ). In a qualitative study, Audétat et al. observed five prototypical clinical reasoning difficulties among residents: generating hypotheses to guide data gathering, premature closure, prioritizing problems, painting an overall picture of the clinical situation, and elaborating a management plan (Audétat et al. 2013 ), not unlike the prevalent errors in clinical practice as summarized in Box 1.2 . Errors in clinical reasoning pertain to both System 1 and System 2 thinking and cognitive biases causing errors are not easily amenable to teaching strategies. An inadequate knowledge base appears the most consistent reason for error (Norman et al. 2017 ). A number of authors have recommended tailored teaching strategies for clinical reasoning (Rencic 2011 ; Guerrasio and Aagaard 2014 ; Posel et al. 2014 ). Most approaches pertain to education in the clinical workplace. Box 1.3 gives a condensed overview.

Let students

• Maximize learning by remembering many patient encounters.
• Recall similar cases as they increase experience.
• Build a framework for differential diagnosis using anatomy, pathology, and organ systems combined with semantic qualifiers: age, gender, ethnicity, and main complaint.
• Differentiate between likely and less likely but important diagnoses.
• Contrast diagnoses by listing necessary history questions and physical exam maneuvers in a tabular format and indicating what supports or does not support the respective diagnoses.
• Utilize epidemiology, evidence, and Bayesian reasoning.
• Practice deliberately; request and reflect on feedback; and practice mentally.
• Generate self-explanations during clinical problem solving.
• Talk in buzz groups at morning reports with oral and written patient data.
• Listen to clinical teachers reasoning out loud.
• Summarize clinical cases often using semantic qualifiers and create problem representations.

One dominant approach that clinical educators use when teaching students to solve medical problems is ask them to analyze pathophysiologically, in other words to use System 2 thinking. While this seems the only option with students who do not possess a mental library of illness scripts to facilitate System 1 thinking, those teachers teach something they usually do not do themselves when solving clinical problems This teaching resembles the “do as I say, not as I do” approach, in part because they simply cannot express “how they do” when they engaged in clinical reasoning.

In a recent review of approaches to the teaching of clinical reasoning, Schmidt and Mamede identified two groups of approaches: a predominant serial-cue approach (teachers provide bits of patient information to students and ask them to reason step by step) and a rare whole-task (or whole-case) approach in which all information is presented at once. They conclude that there is little evidence for the serial-cue approach, favored by most teachers and recommend a switch to whole-case approaches (Schmidt and Mamede 2015 ). While cognitive theory does support whole-task instructional techniques (Vandewaetere et al. 2014 ), the description of a whole-case in clinical education is not well elaborated. Evidently a whole-case cannot include a diagnosis and must at least be partly serial. But even if all the information that clinicians in practice face is provided to students all at once, the clinical reasoning process that follows has a serial nature, even if it happens quickly. Schmidt and Mamede’s proposal to first develop causal explanations, second to encapsulate pathophysiological knowledge, and third to develop illness scripts (Schmidt and Mamede 2015 ) runs the risk of separating biomedical knowledge acquisition from clinical training and regressing to a Flexnerian curriculum. Flexner advocated a strong biomedical background before students start dealing with patients (Flexner 1910 ). This separation is currently not considered the most useful approach to clinical reasoning education (Woods 2007 ; Chamberland et al. 2013 ).

Training students in the skill of clinical reasoning is evidently a difficult task, and Schuwirth rightly once posed the question “Can clinical reasoning be taught or can it only be learned?” (Schuwirth 2002 ). Since the work of Elstein and colleagues, we know that clinical reasoning is not a skill that is trainable independent of a large knowledge base (Elstein et al. 1978 ). There simply is not an effective and teachable algorithm of clinical problem solving that can be trained and learned, if there is no medical knowledge base. The actual reasoning techniques used in clinical problem solving can be explained rather briefly and may not be very different from those of a car mechanic. Listen to the patient (or the car owner), examine the patient (or the car), draw conclusions, and identify what it takes to solve the problem. There is not much more to it. In difficult cases, medical decision-making can require knowledge of Bayesian probability calculations, understanding of sensitivity and specificity of tests (Kassirer et al. 2010 ), but clinicians seldom use these advanced techniques explicitly at the bedside.

These recommendations are of no avail if students do not have background knowledge, both about anatomical structures and pathophysiological processes and about patterns of signs and symptoms related to illness scripts. When training medical students to think like doctors, we face the problem that we cannot just look how clinicians think and just ask students to mimic that technique. That is for two reasons: one is that clinicians often cannot express well how they think, and the second is simply that the huge knowledge base required to think like an experienced clinician is simply not present in students.

As System 1 pattern recognition is so overwhelmingly dominant in the clinician’s thinking (Norman et al. 2007 ), the lack of a knowledge base prohibits junior students to think like a doctor. It is clear that students cannot “recognize” a pattern if they do not have a similar pattern in their knowledge base. It is unavoidable that much effort and extensive experience are needed before a reasonable repository of illness scripts is built that can serve as the internal mirror of patterns seen in clinical practice. Ericsson’s work suggests that it may take up to 10,000 hours of deliberate practice to acquire expertise in any domain, although there is some debate about this volume (Ericsson et al. 1993 ; Macnamara et al. 2014 ). Clearly, students must see and experience many, many cases and construct and remember illness scripts. What a curriculum can try to offer is just that, i.e., many clinical encounters, in clinical settings or in a simulated environment. Clinical context is likely to enhance clinical knowledge, specifically if students feel a sense of responsibility or commitment (Koens et al. 2005 ; Koens 2005 ). This sense of commitment in practice relates to the patient, but it can also be a commitment to teach peers.

System 2 analytic reasoning is clearly a skill that can be trained early in a curriculum (Ploger 1988 ). Causal reasoning, usually starting with pathology (a viral infection of the liver) and a subsequent effect (preventing the draining of red blood cell waste products) and ending with resulting symptoms (yellow stains in the blood, visible in the sclerae of the eyes and in the skin, known as jaundice or icterus), can be understood and remembered, and the reasoning can include deeper biochemical or microbiological explanations (How does it operate the chemical degradation of hemoglobin? Which viruses cause hepatitis? How was the patient infected?). This basically is a systems-based reasoning process. The clinician however must reason in the opposite direction, a skill that is not simply the reverse of this chain of thought, as there may be very different causes of the same signs and symptoms (a normal liver, but an obstruction in the bile duct, or a normal liver and bile duct, but a profuse destruction of red blood cells after an immune reaction). So analytic reasoning is trainable, and generating hypotheses of what may have caused the symptoms requires a knowledge base of possible physiopathology mechanisms. That can be acquired step by step, and many answers to analytic problems can be found in the literature. But clearly, System 2 reasoning too requires prior knowledge. So both a basic science knowledge base and a mental illness script repository must be available.

The case-based clinical reasoning training method acknowledges this difficulty and therefore focuses on two simultaneous approaches (1) building illness scripts from early on in the curriculum, beginning with simple cases and gradually building more complex scripts to remember, and (2) conveying a systematic, analytic reasoning habit starting with patient presentation vignettes and ending with a conclusion about the diagnosis, the disease mechanism, and the patient management actions to be taken.

Summary of the CBCR Method

When applying these principles to preclinical classroom teaching, a case-based approach is considered superior to other methods (Kim et al. 2006 ; Postma and White 2015 ). Case-based clinical reasoning was designed at the Academic Medical Center of University of Amsterdam in 1992, when a new undergraduate medical curriculum was introduced (ten Cate and Schadé 1993 ; ten Cate 1994 , 1995 ). This integrated medical curriculum with multidisciplinary block modules of 6–8 weeks had existed since 10 years, but was found to lack a proper preparation of students to think like a doctor before entering clinical clerkships. Notably, while all block modules stressed the knowledge acquisition structured in a systematic way, usually based on organ systems and resulting in a systems knowledge base, a longitudinal thread of small group teaching was created to focus on patient-oriented thinking, with application of acquired knowledge (ten Cate and Schadé 1993 ). This CBCR training was implemented in curriculum years 2, 3, and 4, at both medical schools of the University of Amsterdam and the Free University of Amsterdam, which had been collaborating on curriculum development since the late 1980s. After an explanation of the method in national publications (ten Cate 1994 , 1995 ), medical schools at Leiden and Rotterdam universities adopted variants of it. In 1997 CBCR was introduced at the medical school of Utrecht University with minor modifications and continued with only little adaptations throughout major undergraduate medical curriculum changes in 1999, 2006, and 2015 until the current day (2017).

CBCR can be summarized as the practicing of clinical reasoning in small groups. A CBCR course consists of a series of group sessions over a prolonged time span. This may be a semester, a year, or usually, a number of years. Students regularly meet in a fixed group of 10–12, usually every 3–4 weeks, but this may be more frequent. The course is independent of concurrent courses or blocks. The rationale for this is that CBCR stresses the application of previously acquired knowledge and should not be programmed as an “illustration” of clinical or basic science theory. More importantly, when the case starts, students must not be cued in specific directions or diagnoses, which would be the case if a session were integrated in, say, a cardiovascular block. A patient with shortness of breath would then trigger too easily toward a cardiac problem.

CBCR cases, always titled with age, sex, and main complaint or symptom, consist of an introductory case vignette reflecting the way a patient presents at the clinician’s office. Alternatively, two cases with similar presentations but different diagnoses may be worked through in one session, usually later in the curriculum when the thinking process can be speeded up. The context of the case may be at a general practitioner’s office, at an emergency department, at an outpatient clinic, or at admission to a hospital ward. The case vignette continues with questions and assignments (e.g., What would be first hypotheses based on the information so far? What diagnostic tests should be ordered? Draw a table mapping signs and symptoms against likelihood of hypotheses ), at fixed moments interrupted with the provision of new findings about the patient from investigations (more extensive history, additional physical examination, or new results of diagnostic tests), distributed or read out loud by a facilitator during the session at the appropriate moment. A full case includes the complete course of a problem from the initial presentation to follow-up after treatment, but cases often concentrate on key stages of this course. Case descriptions should refer to relevant pathophysiological backgrounds and basic sciences (such as anatomy, biochemistry, cell biology, physiology) during the case.

The sessions are led by three (sometimes two) students of the group. They are called peer teachers and take turns in this role over the whole course. Every student must act as a peer teacher at multiple sessions across the year. Peer teachers have more information in advance about the patient and disclose this information at the appropriate time during the session, in accordance with instructions they receive in advance. In addition, a clinician is present. Given the elaborated format and case description, this teacher only acts as a consultant, when guidance is requested or helpful, and indeed is called “consultant” throughout all CBCR education.

Study materials include a general study guide with explanations of the rules, courses of action, assessment procedures, etc. (see Chap. 10 ): a “student version ” of the written CBCR case material per session, a “peer teacher version” of the CBCR case per session with extra information and hints to guide the group, and a full “consultant version” of the CBCR case per session. Short handouts are also available for all students, covering new clinical information when needed in the course of the diagnostic process. Optionally, homemade handouts can be prepared by peer teachers. The full consultant version of the CBCR case includes all answers to all questions in detail, sufficient to enable guidance by a clinician who is not familiar with the case or discipline, all suggestions and hints for peer teachers, and all patient information that should be disclosed during the session. Examples are shown in Appendices of this book.

Students are assessed at the end of the course on their knowledge of all illnesses and to a small extent on their active participation as a student and a peer teacher (see Chap. 7 ).

• Essential Features of CBCR Education

While a summary is given above, and a detailed procedural description is given in Part II, it may be helpful to provide some principles to help understand some of the rationale behind the CBCR method.

Switching Between System-Oriented Thinking and Patient-Oriented Thinking

It is our belief that preclinical students must learn to acquire both system-oriented knowledge and patient-oriented knowledge and that they need to practice switching between both modes of thinking (Eva et al. 2007 ). In that sense, our approach not only differs from traditional curricula with no training in clinical reasoning but also from curricula in which all education is derived from clinical presentations (Mandin et al. 1995 , 1997 ).

By scheduling CBCR sessions spread over the year, with each session requiring the clinical application of system knowledge of previous system courses, this practice of switching is stimulated. It is important to prepare and schedule CBCR cases carefully to enable this knowledge application. It is inevitable, because of differential diagnostic thinking, that cases draw upon knowledge from different courses and sometimes knowledge that may not have been taught. In that case, additional information may be provided during the case discussion. Peer teachers often have an assignment to summarize relevant system information between case questions in a brief presentation (maximum 10 min), to enable further progression.

Managing Cognitive Load and the Development of Illness Scripts

Illness scripts are mental representations of disease entities combining three elements in a script (Custers et al. 1998 ; Charlin et al. 2007 ): (1) factors causing or preceding a disease, (2) the actual pathology, and (3) the effect of the pathology showing as signs, symptoms, and expected diagnostic findings. While some authors, including us, add (4) course and management as the fourth element (de Vries et al. 2006 ), originally the first three, “enabling conditions,” “fault,” and “consequences,” were proposed to constitute the illness script (Feltovich and Barrows 1984 ). Illness scripts are stored as units in the long-term memory that are simultaneously activated and subsequently instantiated (i.e., recalled instantly) when a pattern recognition process occurs based on a patient seen by a doctor. This process is usually not deliberately executed, but occurs spontaneously. Illness scripts have a temporal nature like a film script, because of their cause and effect features, which enables clinicians to quickly take a next step, suggested by the script, in managing the patient. “Course and management” can therefore naturally be considered part of the script.

A shared explanation why illness scripts “work” in clinical reasoning is that the human working memory is very limited and does not allow to process much more than seven units or chunks of information at a time (Miller 1956 ) and likely less than that. Clinicians cannot process all separate signs and symptoms, history, and physical examination information simultaneously—that would overload their working memory capacity, but try to use one label to combine many bits of information in one unit (e.g., the illness script “diabetes type II” combines its enabling factors, pathology, signs and symptoms, disease course, and standard treatment in one chunk). If necessary, those units can be unpacked in elements (Figs. 1.1 and 1.2 ).

One information chunk in the working memory may be decomposed in smaller chunks in the long-term memory (Young et al. 2014)

To create illness scripts stored in the long-term memory, students must learn to see illnesses as a unit of information. In case-based clinical reasoning education, students face complete patient scripts, i.e., with enabling conditions (often derived from history taking) to consequences (as presenting signs and symptoms). Although illness scripts have an implicit chronology, from a clinical reasoning perspective, there is an adapted chronology of (a) consequences → (b) enabling conditions → (c) fault and diagnosis → (d) course and management, as the physician starts out observing the signs and symptoms, then takes a history, performs a physical examination, and orders tests if necessary before arriving at a conclusion about the “fault.” To enable building illness script units in the long-term memory, students must start out with simple, prototype cases that can be easily remembered. CBCR aims to develop in second year medical students stable but still somewhat limited illness scripts. This still limited repository should be sufficient to quickly recognize the causes, symptoms, and management of a limited series of common illnesses, and handle prototypical patient problems in practice if they would encounter these, resonating with Bordage’s prototype approach (Bordage and Zacks 1984 ; Bordage 2007 ). See Chap. 3 . The assessment of student knowledge at the end of a CBCR course focuses on the exact cases discussed, including, of course, the differential diagnostic considerations that are activated with the illness script, all to reinforce the same carefully chosen illness scripts. The aim is to provide a foundation that enables the addition in later years of variations to the prototypical cases learned, to enrich further illness script formation and from there add new illness scripts. We believe that working with whole, but not too complex, cases in an early phase in the medical curriculum serves to help students in an early phase in the medical curriculum to learn to recognize common patterns.

Educational Philosophies: Active Reasoning by Oral Communication and Peer Teaching

A CBCR education in the format elaborated in this book reflects the philosophy that learning clinical reasoning is enhanced by reasoning aloud. The small group arrangement, limited to no more than about 12 students, guarantees that every student actively contributes to the discussion. Even when listening, this group size precludes from hiding as would be a risk in a lecture setting.

Students act as peer teachers for their fellow students. Peer teaching is an accepted educational method with a theoretical foundation (ten Cate and Durning 2007 ; Topping 1996 ). It is well known that taking the role of teacher for peers stimulates knowledge acquisition in a different and often more productive way than studying for an exam (Bargh and Schul 1980 ). Social and cognitive congruence concepts explain why students benefit from communicating with peers or near-peers and should understand each other better than when students communicate with expert teachers (Lockspeiser et al. 2008 ). The peer teaching format used in CBCR is an excellent way to achieve active participation of all students during small group education. An additional benefit of using peer teachers is that they are instrumental in the provision of just-in-time information about the clinical case for their peers in the CBCR group, e.g., as a result of a diagnostic test that was proposed to be ordered.

Case-based clinical reasoning has most of the features that are recommended by Kassirer et al.: “First, clinical data are presented, analyzed and discussed in the same chronological sequence in which they were obtained in the course of the encounter between the physician and the patient. Second, instead of providing all available data completely synthesized in one cohesive story, as is in the practice of the traditional case presentation, data are provided and considered on a little at a time. Third, any cases presented should consist of real, unabridged patient material. Simulated cases or modified actual cases should be avoided because they may fail to reflect the true inconsistencies, false leads, inappropriate cues, and fuzzy data inherent in actual patient material. Finally, the careful selection of examples of problem solving ensures that a reasonable set of cognitive concepts will be covered” (Kassirer et al. 2010 ). While we agree with the third condition for advanced students, i.e., in clerkship years, for pre-clerkship medical students, a prototypical illness script is considered more appropriate and effective (Bordage 2007 ). The CBCR method also matches well with most recommendations on clinical reasoning education (see Box 1.3 ).

Chapter 4 of this book describes six prerequisites for clinical reasoning by medical students in the clinical context: having clinical vocabulary, experience with problem representation, an illness script mental repository, a contrastive learning approach, hypothesis-driven inquiry skill, and a habit of diagnostic verification. The CBCR approach helps to prepare students with most of these prerequisites.

Indications for the Effectiveness of the CBCR Method

The CBCR method finds its roots in part in problem-based learning (PBL) and other small group active learning approaches. Since the 1970s, various small group approaches have been recommended for medical education, notably PBL (Barrows and Tamblyn 1980 ) and team-based learning (TBL) (Michaelsen et al. 2008 ). In particular PBL has gained huge interest in the 1980s onward, due to the developmental work done by its founder Howard Barrows from McMaster University in Canada and from Maastricht University in the Netherlands, which institution derived its entire identity to a large part from problem-based learning. Despite significant research efforts to establish the superiority of PBL curricula, the general outcomes have been somewhat less than expected (Dolmans and Gijbels 2013 ). However, many studies on a more detailed level have shown that components of PBL are effective. In a recent overviews of PBL studies, Dolmans and Wilkerson conclude that “a clearly formulated problem, an especially socially congruent tutor, a cognitive congruent tutor with expertise, and a focused group discussion have a strong influence on students’ learning and achievement” (Dolmans and Wilkerson 2011 ). These are components that are included in the CBCR method.

While there has not been a controlled study to establish the effect of a CBCR course per se, compared to an alternative approach to clinical reasoning training, there is some indirect support for its validity, apart from the favorable reception of the teaching model among clinicians and students over the course of 20 years and different schools. A recent publication by Krupat and colleagues showed that a “case-based collaborative learning” format, including small group work on patient cases with sequential provision of patient information, led to higher scores of a physiology exam and high appreciation among students, compared with education using a problem-based learning format (Krupat et al. 2016 ). A more indirect indication of its effectiveness is shown in a comparative study among three schools in the Netherlands two decades ago (Schmidt et al. 1996 ). One of the schools, the University of Amsterdam medical school, had used the CBCR training among second and third year students at that time (ten Cate 1994 ). While the study does not specifically report on the effects of clinical reasoning education, Schmidt et al. show how students of the second and third year in this curriculum outperform students in both other curricula in diagnostic competence.

CBCR as an Approach to Ignite Curriculum Modernization

Since 2005, the method of CBCR has been used as leverage for undergraduate medical curriculum reform in Moldova, Georgia, Ukraine, and Azerbaijan (ten Cate et al. 2014 ). It has proven to be useful in medical education contexts with heavily lecture-based curricula—likely because the method can be applied within an existing curriculum, causing little disruption, while also being exemplary for recommended modern medical education (Harden et al. 1984 ). It stimulates integration, and the method is highly student-centered and problem-based. While observing CBCR in practice, a school can consider how these features can also be applied more generally in preclinical courses. This volume provides a detailed description that allows a school to pilot CBCR for this purpose.

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Diagnostic Schemas: Form and Function

• Perspective
• Published: 14 November 2022
• Volume 38 , pages 513–516, ( 2023 )

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• Michael Cammarata MD   ORCID: orcid.org/0000-0001-8311-924X 1 &
• Gurpreet Dhaliwal MD 2 , 3  

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Diagnostic schemas are frameworks that depict organized clinical knowledge and serve as a bridge between problem representation and differential diagnosis generation. Schema-based problem solving is increasingly used among clinician educators and is widely featured in digital media. We examine the origins of schemas and their theoretical background, review existing literature on their applications in medicine, and explore their utility for learners and teachers.

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A first-year medicine resident has just evaluated a 75-year-old man with shortness of breath. She arrives at the correct diagnosis — a heart failure exacerbation — but her preceptor is not sure she has an organized approach to reasoning through the clinical problem of dyspnea. The preceptor asks if she has a “schema” for shortness of breath and the resident gives her preceptor a puzzled look.

Diagnostic schemas are frameworks that depict organized clinical knowledge and serve as the bridge between problem representation and differential diagnosis in the clinical reasoning process. In recent years, the term “schema” has been increasingly used in clinical and educational settings. This adoption reflects the integration of cognitive psychology into clinical instruction, 1 as well as the influence of textbooks, 2 medical educators, 3 , 4 case reports, 5 and digital media 6 , 7 , 8 that have introduced schemas into the clinical reasoning vernacular. In this paper, we explore how diagnostic schemas (hereafter referred to as “schemas”) can serve as powerful tools for both teacher and learners.

THE HISTORY OF SCHEMAS

The word “schema” originates from the Greek word for “shape” or “plan” and has long been in the lexicon of philosophy and psychology. 9 The eighteenth century German philosopher Immanuel Kant introduced the term “schema” to describe structures that organize thinking and give form to abstract concepts. 10 In the second half of the twentieth century, psychologist Jean Piaget defined schemas as “mental representations” that organize a unit of knowledge. 11 He proposed that with age and experience, a child will acquire and retrieve increasingly complex schemas, such as what constitutes a chair (object schema) or how to order food in a restaurant (action schema). Schema theory emerged in the 1970s and posited that an individual’s knowledge is represented in memory as the sum of their schemas, and that the mind has schemas for all things, including people, objects, and abstract concepts. 9

HOW SCHEMAS WORK

When the human mind encounters a problem, it activates knowledge to arrive at a solution. 12 Enumerating a list of all solutions for a complex problem is cognitively taxing and inconsistent between episodes . Activating a schema is a more feasible and reproducible first step when solving a problem. A schema “chunks” isolated pieces of knowledge into units that are easier to manage in long-term memory. 13 In clinical problem solving, a schema transforms a long list of potential diagnoses into more manageable groups of diagnoses. 3

For the resident in the introductory case, recalling all relevant causes of dyspnea would be mentally taxing and haphazard. But sequentially considering several categories of dyspnea — pulmonary, cardiac, hematologic, neuromuscular, and metabolic — is a reproducible approach to solving dyspnea that can structure her differential diagnosis generation (Fig. 1 ). Schema-based problem solving differs from hypo-theticodeductive reasoning, which is characterized by sequential hypothesis generation fueled by incoming data. 14

Simplified dyspnea schema.

Diagnostic schemas are distinct from diagnostic checklists which ensure consideration of a lengthy differential diagnosis or enforce a diagnostic “time out” with metacognition. 15 , 16 Schemas also differ from mnemonics 17 , which are memory aids that facilitate recall without connecting to an underlying knowledge structure or meaning (e.g., MUDPILES for anion gap metabolic acidosis).

In cognitive psychology, both illness scripts (encapsulated knowledge about a single disease) 18 and frameworks to approach a problem are considered types of schemas (i.e., structured representations of knowledge in memory). However, in the clinical reasoning literature, schemas have come to refer to the latter, even though the two forms are closely linked in learning and problem solving. 3

SCHEMAS IN MEDICINE

Schemas were introduced into undergraduate medical education at the University of Calgary in the 1990s. 14 The goal was to promote organized problem solving by providing students with schemas for common clinical problems. This differed from the more widespread approach of teaching about diseases and leaving learners to construct their own idiosyncratic approaches to diagnosis through observation and trial and error. Three decades later, schemas continue to form an integral part of the University of Calgary medical program. 3

Several studies have demonstrated that schemas organize learning and guide problem solving, reduce cognitive load (the amount of working memory resources used in a learning or workplace task 19 ), and mitigate premature closure among medical students. 20 In a randomized trial of second year medical students learning with a cardiopulmonary simulator, schema-based instruction was associated with improved discrimination between diagnoses and greater diagnostic accuracy compared to standard instruction. 21 Another study showed that medical students who used a diagnostic schema to conceptualize metabolic alkalosis maintained expert-type (deep rather than superficial) knowledge structures longer than students who did not use schemas. 22 Other studies of medical students demonstrated that schemas were associated with greater diagnostic accuracy with EKGs, 23 electrolyte and acid-base problems, 24 congenital heart disease cases, 25 and gastroenterology conditions. 26

In a study of clerkship students, Coderre et al. demonstrated that learners with problem-specific schemas had better diagnostic performance on cases of dyspnea, chest pain, anemia, and abnormal liver function than students with generic knowledge structures. The higher performing students organized differential diagnoses according to clinically relevant categories for a specific problem, such as approaching dyspnea by chest X-ray results, as opposed to more generic categories that can be applied to all problems (e.g., VINDICATE mnemonic). 27

Although a schema-based approach to knowledge construction and problem solving has not been widely adopted in medical schools, schemas are being embraced by learners and teachers in digital education resources like podcasts and social media. 6 , 28

SCHEMA FORM

A diagnostic schema is a hierarchal conceptual framework with a branching connection between upper and lower levels. Schemas can be formed for any data point, such as a symptom (e.g., dyspnea), sign (e.g., jaundice), imaging result (e.g., ground-glass opacities), or lab value (e.g., hypercalcemia). 5 Practical schemas have higher-level categories with parallel construction (e.g., organ-based or mechanisms) that narrow to subsidiary categories and eventually terminate at individual diagnoses. 13 The initial branch points and overall layout often reflect the practical considerations and resources available when solving a specific problem in the typical clinical setting (Table 1 ).

IS THERE ONE RIGHT SCHEMA?

There is no gold standard schema for any problem because there are multiple successful pathways to addressing the same issue. 29 Some schemas are widespread (e.g., pre-, intra-, and post-renal approach to acute kidney injury [AKI]), while others have multiple widely used iterations and variations (e.g., anemia analysis based on erythrocyte size, kinetics, or sites of production and destruction).

Schemas should be practical and may vary by clinical environment. For example, an emergency medicine clinician approaching chest pain may prefer an initial branch point that identifies or excludes coronary artery disease–related chest pain, rather than an approach considering five anatomic compartments in parallel.

Schemas will mature and grow in complexity based on clinical experience. For instance, a student will gradually develop a more nuanced understanding of AKI and elaborate the tripartite approach by expanding the intrarenal category to include glomerular, tubular, interstitial, and vascular etiologies. Each category will expand further during residency.

Schemas will evolve as knowledge of disease mechanisms improves. For instance, inflammatory disease currently categorized by patterns of presentation (e.g., symmetric vs asymmetric arthritis) may eventually be organized by the underlying cytokines driving inflammation (e.g., IL-6 mediated). 30 A traditional cancer of unknown origin schema may shift from pursuing the tissue of origin (e.g., sarcoma or GI adenocarcinoma) to classifying the underlying malignancy according to genetic profiles and driver mutations. 31

SCHEMAS AS A LEARNING TOOL

Using schemas as the scaffold for knowledge in memory promotes a systematic approach to problem solving. 3 Learners can practice retrieving schemas by routinely using them as a bridge between problem representation and differential diagnosis generation.

Most learners begin by adopting available schemas for common problems. This is an effective starting point, but downloading and saving schemas alone does not equate with knowledge and comprehension. 32 Repeatedly writing and recalling schemas for common problems draws on learning sciences principles like retrieval practice, elaboration, and dual coding, which improve memory and understanding. 33 , 34 Regardless of whether a schema is borrowed or built, it should be rehearsed and revised so that it evolves with clinical experience and captures a successful approach to the clinical problem. These efforts can be aided by a paper or electronic schema repository 35 which features easy modification 36 and rapid accessibility (e.g., as a reference before seeing new patients to focus history of present illness questions).

When presenting their assessment of a patient, learners should demonstrate their organized approach to a problem by articulating their schema. After accurately labeling the patient’s primary problem, such as thrombocytopenia, the learner should briefly elaborate the relevant schema in a succinct sentence (e.g., “thrombocytopenia is caused by decreased production, increased consumption, or sequestration”). The schema, which is agnostic to any patient, can then guide the construction of a prioritized differential diagnosis, which is specific to each patient. Inevitably, certain categories or classifications will be forgotten with initial recall efforts, but with increased practice, the major categories will become familiar, and attention can be turned to deeper branch points in the algorithm.

Learners can also access their schemas when a patient’s trajectory is not evolving as anticipated. When the pursuit of an infection in a febrile ICU patient is unrevealing, a learner can use their schema to shift their attention to alternative categories of disease. Like a map guiding a lost traveler, schemas can provide direction when the diagnosis remains uncertain.

SCHEMAS AS A TEACHING TOOL

One of the challenges of teaching clinical reasoning is making implicit knowledge explicit for learners. By regularly elaborating schemas, instead of lengthy differential diagnoses, teachers can simplify their representation of how doctors approach a problem. When teachers can draw schemas or narrate their structure in a memorable way, the resulting visual simplification gives learners a foothold into a complex topic from which they can build. 37

Teachers can promote the development of schemas by encouraging their integration into learners’ presentations. Teachers may set expectations that learners name the problem and then succinctly articulate a schema for the problem before their elaboration of the prioritized differential diagnosis. In the opening case, the learner arrived at the diagnosis of acute heart failure without a brief description of the schema for the presenting symptom. Even if the diagnosis was correct, the teacher had no reassurances that the learner could reason through the clinical problem of dyspnea for the next patient. Hearing her schema for dyspnea (“dyspnea is primarily caused by pulmonary, cardiac, hematologic, ...”) would have helped the preceptor confirm that the learner arrived at the right diagnosis with a comprehensive understanding of the problem. Conversely, analysis of her schema may reveal a gap in the learner’s understanding of how to approach dyspnea (e.g., conflation of hypoxemia with dyspnea), which would serve as a launching point for teaching and discussion.

Educators must determine where to intervene along the reasoning process. 38 Schemas have more educational utility when learners would benefit from an overview of the approach to a problem rather than the details of specific diagnoses. This may occur when reframing a case, after an accurate problem representation, or in the process of generating a differential diagnosis. When patients are incorrectly framed or have multiple interacting problems, the discussion may be better centered around points other than the diagnostic schema. For example, in some contexts, analyzing the illness script or management script 39 for atrial fibrillation will be more relevant than reviewing the diagnostic schema for tachycardia.

Diagnostic schemas are powerful tools to organize knowledge and facilitate clinical problem solving. What began in the minds of psychologists and philosophers has been carried into the realm of diagnostic reasoning by clinician educators. Schema-based instruction provides learners with a structured approach to knowing and learning that starts during training and can continue throughout a career in medicine.

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Cammarata, M., Dhaliwal, G. Diagnostic Schemas: Form and Function. J GEN INTERN MED 38 , 513–516 (2023). https://doi.org/10.1007/s11606-022-07935-1

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