The n e w e ng l a n d j o u r na l of m e dic i n e

review article

medical Education
Malcolm Cox, M.D., and David M. Irby, Ph.D., Editors

Educational Strategies to Promote Clinical

Diagnostic Reasoning
Judith L. Bowen, M.D.

C
linical teachers differ from clinicians in a fundamental way. From the Department of Medicine, Ore-
They must simultaneously foster high-quality patient care and assess the clin- gon Health and Science University, Port-
land. Address reprint requests to Dr. Bow-
ical skills and reasoning of learners in order to promote their progress toward en at the Department of Medicine, 3181
independence in the clinical setting.1 Clinical teachers must diagnose both the pa- S.W. Sam Jackson Park Rd., L-475, Port-
tient’s clinical problem and the learner’s ability and skill. land, OR 97239, or at [email protected].
To assess a learner’s diagnostic reasoning strategies effectively, the teacher needs N Engl J Med 2006;355:2217-25.
to consider how doctors learn to reason in the clinical environment.2-4 Medical stu- Copyright © 2006 Massachusetts Medical Society.
dents in a classroom generally organize medical knowledge according to the structure
of the curriculum. For example, if pathophysiology is taught according to organ sys-
tems, then the student’s knowledge will be similarly organized, and the recall will be
triggered by questions related to specific organ systems or other contextual clues. In
the clinical setting, the patient’s health and care are the focus. Clinical problems may
involve many organ systems and may be embedded in the context of the patient’s
story and questions. Thus, in the clinical setting, the student’s recall of basic science
knowledge from the classroom is often slow, awkward, or absent. Only after learners
make new connections between their knowledge and specific clinical encounters can
they also make strong connections between clinical features and the knowledge
stored in memory.5,6 This report focuses on how clinical teachers can facilitate the
learning process to help learners make the transition from being diagnostic novices
to becoming expert clinicians.

Di agnos t ic R e a s oning

There is a rich ongoing debate about our understanding of the complex process of
clinical diagnostic reasoning.2,3 In this report, some of the basic processes involved
in clinical reasoning, as understood according to current knowledge, are translated
into practical and specific recommendations for promoting the development of strong
diagnostic reasoning skills in learners. The recommendations are illustrated by a clini-
cal case presentation.
Clinical teachers observe learners gathering information from patients, medical
records, imaging studies, results of laboratory tests, and other health care providers.
On the basis of their observations, and through the discussion of clinical cases, teach-
ers draw conclusions about the learners’ performance, including their reasoning pro-
cesses. A hypothetical case provides an example of a conversation involving a patient,
two learners with different levels of expertise, and the clinical teacher (see Box). In
this case,7-9 a patient with knee pain makes an urgent visit to an ambulatory care
practice. A novice resident (with relatively little experience with this patient’s prob-
lem, which is gout) and an expert resident (who is familiar with this problem, hav-
ing seen other patients with gout) each independently interviews the patient, performs

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 The n e w e ng l a n d j o u r na l of m e dic i n e

an examination, presents the case to the precep- patient as seen through the resident’s eyes. On the
tor, and separately discusses the case with the basis of the case presentations by both the expert
preceptor. As becomes evident, the expert resident and the novice residents, the teacher may or may
has transformed the patient’s story into a mean- not have had a firm idea of what was wrong with
ingful clinical problem. The novice resident has the patient. Rather than offer an opinion, however,
also transformed the patient’s story, but less elabo- the teacher asked the expert resident to reason
rately. What the teacher hears from both resi- aloud about the case, thereby providing the teach-
dents differs substantially from what the patient er with additional clinical information about the
told them. patient as well as considerable insight into the
The expert resident brought two sets of skills resident’s clinical reasoning skills. The teacher
to the encounter with the patient. First, this resi- used the same strategy with the novice resident,
dent probably formed an early impression — a and although the result added little information
mental abstraction — of the patient’s story. Al- about the patient, the teacher learned something
though possibly unaware of this formulation, the about the novice resident’s limited clinical rea-
resident’s mental abstraction influenced his diag- soning.
nostic strategy. Guided by his early impression, the Key elements of clinical diagnostic reasoning
resident probably asked a series of questions, and are shown in Figure 1. The first step in diagnostic
the patient’s responses guided both further ques- reasoning, which is based on knowledge, experi-
tioning and the planning of a focused physical ence, and other important contextual factors,10 is
examination. The resident’s approach involved a always data acquisition. Data acquisition, depend-
search for information that could be used to dis- ing on the setting, may include elements of the
criminate among any number of diagnostic expla- history, the findings on physical examination, and
nations of the patient’s problem. The novice resi- the results of laboratory testing and imaging stud-
dent might not have formed a mental abstraction ies. Another early step is the creation of the men-
of the case and probably was not sure which ques- tal abstraction or “problem representation,”2,8,11
tions to pose to the patient. usually as a one-sentence summary defining the
Second, the expert resident’s clinical case pre- specific case in abstract terms. Clinicians may
sentation was a succinct summary of the findings, have no conscious awareness of this cognitive step.
providing the teacher with a clinical picture of the The problem representation, unless elicited in the

The Case as Seen by a Novice Resident and an Expert Resident.

Patient’s story: My knee hurt me so much last night, I woke up from sleep. It was fine when I went to bed. Now it’s
swollen. It’s the worst pain I’ve ever had. I’ve had problems like this before in the same knee, once 9 months ago
and once 2 years ago. It doesn’t bother me between times.
Novice resident’s presentation: My next patient Expert resident’s presentation: My next patient is a 54-year-old white
is a 54-year-old white man with knee pain. man with a sudden onset of pain in his right knee that awak-
It started last night. He does not report any ened him from sleep. He does not report any trauma and was
trauma. On examination, his vital signs are essentially asymptomatic when he went to bed. His history is re-
normal. His knee is swollen, red, and tender markable for two episodes of similar, severe pain 9 months
to touch. It hurts him a lot when I test his and 2 years ago. He is pain-free between episodes. He is afe-
range of motion. He’s had this problem brile today. His knee is swollen, tender to touch, and erythem-
twice before. atous.
Teacher’s inquiry: What do you think is causing this patient’s knee pain?
Novice resident’s response: It could be an in- Expert resident’s response: The patient has acute gout. He has had
fection. It could be a new onset of rheuma- multiple discrete episodes with abrupt onset of extremely se-
toid arthritis. It could be Lyme disease. vere pain involving a single joint with evidence of inflamma-
Since he doesn’t recall falling, I doubt it’s tion on examination. Before all his episodes, he is asymptom-
an injury. I don’t know whether osteoarthri- atic. I would have expected gout to affect the first metatarso-
tis ever presents like this, but he does have a phalangeal joint, but it can present in the knee. Nothing sug-
history of knee pain. gests any ongoing, chronic problem in the knee. I don’t see
any portal of entry to suggest acute infectious arthritis and he
looks quite well for that. His other joints are normal on exami-
nation. I doubt that he has a flare-up of osteoarthritis with
pseudogout or a systemic, inflammatory arthritis such as
rheumatoid arthritis.

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 medical Education

teaching setting, is rarely articulated. Rather, the

teacher infers the learner’s problem representa-
tion from the learner’s presentation of the case.
For the case used as the example, the expert Knowledge Patient’s story
resident’s problem representation, had it been elic-
ited, might have been the following: “The acute
Data acquisition
onset of a recurrent, painful, monoarticular pro-
cess in an otherwise healthy middle-aged man.”
The problem representation illustrates the trans- Accurate “problem representation”
formation of patient-specific details into abstract
terms. “Last night” became “acute onset,” “I’ve Context
had problems like this before” became “recur- Generation of hypothesis
rent,” “same knee” became “monoarticular,” and
the patient’s age, sex, and medical history are
summarized as “otherwise healthy, middle-aged Search for and selection of illness script
man.” In this transformation, the characterization
of the problem facilitates the retrieval of pertinent
Experience Diagnosis
information from memory.7 The novice resident
may be less able than the expert resident to devel-
op an accurate problem representation.
When prompted by the teacher to reason about Figure 1. Key Elements of the Clinical Diagnostic Reasoning Process.
the case, the expert resident used abstract seman-
tic qualifiers to describe the case findings. Seman-
tic qualifiers are paired, opposing descriptors that
can be used to compare and contrast diagnostic vant information. Their content varies for each
considerations. The resident used several implied physician and among physicians. Some illness
pairs when considering hypotheses for a diagno- scripts are conceptual models, such as groups
sis of gout: multiple (not single) and discrete (not of diseases, whereas others are representational
continuous) episodes, abrupt (not gradual) onset, memories of specific syndromes. With experience,
severe (not mild) pain, and a single joint (not mul- clinicians also store memories of individual pa-
tiple joints). The use of such semantic qualifiers is tients, and the recollection of a particular patient
associated with strong clinical reasoning.7-9 often triggers the recall of relevant knowledge.14
To create a concise, appropriate problem rep- The defining and discriminating clinical features
resentation and to reason succinctly, the resident (Fig. 3) of a disease, condition, or syndrome be-
must have clinical experience with similar patients come “anchor points” in memory. In the future,
and must be able to recognize the information that recollection of such stored experiences expands
establishes gout as the diagnosis while ruling out the clinician’s ability to recognize subtle but im-
other possibilities. The way the clinical experience portant variations in similar cases.13
is stored in memory either facilitates or hinders When prompted to reason aloud, the novice
the ability to formulate the problem representa- resident listed possible causes of knee pain. The
tion. Expert clinicians store and recall knowledge expert resident, however, compared and contrasted
as diseases, conditions, or syndromes — “illness several relevant hypotheses — acute gout, infec-
scripts” — that are connected to problem repre- tious arthritis, osteoarthritis with pseudogout, and
sentations.2,4,12,13 These representations trigger rheumatoid arthritis — and included the discrimi-
clinical memory, permitting the related knowl- nating features of each possibility. Such reasoning
edge to become accessible for reasoning. Knowl- may represent the mental processes of searching
edge recalled as illness scripts has a predictable for and verifying an illness script, with the elimi-
structure: the predisposing conditions, the patho- nation of hypotheses for which the defining fea-
physiological insult, and the clinical consequenc- tures of a specific illness script are absent.2,4,12,13
es (Fig. 2). Such comparisons often take place in the expert
Constructed on the basis of exposure to pa- clinician’s mind during the data-acquisition phase
tients, illness scripts are rich with clinically rele- and form the basis of a focused strategy for ques-

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 The n e w e ng l a n d j o u r na l of m e dic i n e

to rule out these diagnostic considerations in a

Predisposing conditions conscious, analytic fashion.
Age ≥40 yr Both nonanalytic and analytic reasoning strat-
Male sex
Alcohol use egies are effective and are used simultaneously, in
Use of diuretics an interactive fashion.3 Nonanalytic reasoning, as
exemplified by “pattern recognition,” is essential
to diagnostic expertise,2-4,6,12,13 and this skill is
developed through clinical experience. Delibera-
tive analytic reasoning is the primary strategy
Pathophysiological insult
when a case is complex or ill defined, the clinical
Abnormal uric acid metabolism findings are unusual, or the physician has had
Precipitation of crystals in joint
Inflammation of the joint
little clinical experience with the particular disease
entity. Clinicians often unconsciously use multiple,
combined strategies to solve clinical problems,
suggesting a high degree of mental flexibility and
adaptability in clinical reasoning.3,4
By prompting the learner to reason aloud or
Clinical consequences eliciting the learner’s uncertainties, the clinical
Acute pain
Single joint, usually the first teacher can uncover the reasoning process used by
metatarsophalangeal joint the learner. In responses to the teacher’s questions
Recurrent
“What do you think?” or “What puzzled you?”
weak and strong diagnostic reasoning can be read-
Figure 2. Example of an Illness Script for Gout. ily distinguished.15 As was true of the novice resi-
dent in the case example, learners whose discus-
sion is poorly organized, characterized by long,
tioning the patient and for the physical examina- memorized lists of causes of isolated symptoms,
tion. Additional data gathering is purposeful: it is or only weakly connected to information from the
a search for the defining and discriminating fea- case are reasoning poorly.16 They do not connect
tures of each illness script under consideration. stored knowledge with the current clinical case
Clinicians familiar with the clinical presenta- because they lack either experience with such cases
tion of gout will recognize the pattern of symp- or basic knowledge.
toms and signs of gout in the expert resident’s Learners with strong diagnostic reasoning
case presentation. Such rapid, nonanalytic clinical skills often use multiple abstract qualifiers to dis-
reasoning is associated with experience with the cuss the discriminating features of a clinical case,
type of problem, in this case gout. The defining comparing and contrasting appropriate diagnos-
features for a diagnosis of gout are associated in tic hypotheses and linking each hypothesis to
memory as an illness script and, for some clini- the findings in the case. The discussion between
cians, are also associated with memories of indi- such a learner and the clinical teacher is often
vidual patients. Access to these memories is easily quite concise and may be so abbreviated that its
triggered when the clinical findings of gout are result, the diagnosis, appears to be a lucky guess.
present. The expert resident recognized the pat- In such situations, the teacher may need to ask
tern of symptoms and signs of gout and selec- additional questions that probe the learner’s rea-
tively accessed the illness script constructed on the soning or uncertainties to be sure that reasoning,
basis of experience. rather than luck, brought the diagnosis to light.
The novice resident’s clinical experience with Strong diagnosticians can readily expand on their
gout was limited; perhaps knowledge gained from thinking.15,16
prior cases of gout failed to be transferred to
memory. The novice resident used a slower, more
R ec om mendat ions
deliberate method of testing a hypothesis for this for Cl inic a l Te acher s
clinical problem, generating multiple plausible
hypotheses for acute arthritis. Additional data Clinical teachers can use several strategies to pro-
gathering would be useful either to confirm or mote the development of strong diagnostic rea-

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 medical Education

soning skills. The recommendations that follow

are drawn from research on how doctors rea- Defining
feature
son.1-4,6,8,9,11-15,17,18 Although experienced clinical
teachers will recognize the validity of some of
these recommendations, many of the ideas still
need empirical testing in the clinical teaching en- Discriminating
vironment. features

Experience with patients is essential for es- Gout Infection

tablishing new connections in memory between Episodic Monoarticular Discrete
Recurrent Single episode
learned material and clinical presentations, for Male sex Patient is febrile
developing illness scripts, and for developing the and ill
ability to reason flexibly with the use of analytic Problem
representation
reasoning and pattern recognition.3 As learners
listen to patients’ stories, learn to transform these Chronic
stories into case presentations, develop their own
illness scripts, and learn to reason about clinical
information, teachers can use case-specific in- Defining
Osteoarthritis
feature
structional strategies to help learners strengthen Multiple joints involved
Discriminating
features
their skills (Table 1). Long-term decline in functioning

Articulating Problem Representations

Failure to generate an appropriate problem repre-
sentation can result in the random generation of Figure 3. Defining and Discriminating Features of a Set of Diagnostic
hypotheses that are based on isolated findings in Hypotheses for Acute Arthritis.
the case. When the case presentation or discussion The problem representation is “acute onset of a recurrent, painful, mono-
articular process in an otherwise healthy middle-aged man.” Defining fea-
is disorganized, the clinical teacher can prompt the tures are descriptors that are characteristic of the diagnoses (e.g., gout,
learner to create a one-sentence summary of the septic arthritis, osteoarthritis). Discriminating features are descriptors that
case with the use of abstract terms.9 However, are useful for distinguishing the diagnoses from one another.
teaching learners to articulate problem represen-
tations as an isolated teaching strategy is insuffi-
cient.9 Rather, problem representation must be tory and physical examination for the consider-
connected to the type of clinical problem — a con- ation of appropriate diagnostic possibilities.17
nection that facilitates the learner’s retrieval of per-
tinent information from memory. Strategies for Comparing and Contrasting
In the teaching environment, several learners Novice learners often generate numerous possible
with different levels of expertise may be involved diagnoses for any given case. To prioritize such a
in the same case, and eliciting the learners’ vari- lengthy list, they should be encouraged to com-
ous problem representations will help the clini- pare and contrast possible diagnoses on the basis
cal teacher to understand their different perspec- of the relationship among the actual clinical data
tives and learning needs. In complex, ill-defined on the case, typical presentations for each diagnos-
clinical cases, more than one problem represen- tic possibility, and the relative probabilities of dif-
tation may need to be considered. The discussion ferent diagnoses.17,18 Forcing learners to prioritize
of the different problem representations will help the list of diagnostic possibilities and explain their
novice learners to appreciate the complexity of the justifications helps them to create linkages between
case as well as their own early, limited under- the clinical findings in the case and relevant di-
standing. agnoses, bolstering their ability to develop perti-
Teachers should articulate their own problem nent illness scripts.
representations to demonstrate the type of abstract The development of elaborate illness scripts
summary they seek from learners. Teachers can and pattern recognition involves knowledge of
then reason aloud, linking the summary statement the typical presentation of a problem as well as
to their own illness scripts and highlighting the the many atypical presentations or variations on
discriminating features clinicians seek in the his- the typical one. It is important for novice learners

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 2222
Table 1. Strategies for Diagnosing a Learner’s Skills and Addressing Problems in Clinical Reasoning.

Skill Clue in Case Presentation Diagnosis Educational Strategy Example of Strategy

Data acquisition Presentation lacking impor- Learner has not identified what is Go to the bedside, examination room, or “I’d like you to watch me take the history and ex-
and reporting tant information. important, obtained important medical record and model the acqui- amine this patient. Look for things I do that
information, or both. sition of important findings; request are particularly useful in eliciting information.
that the learner revise the presenta- Then let’s discuss your observations.”
The

tion accordingly.
Problem repre- Disorganized presentation, Learner has no experience with this Go to the bedside, examination room, or “Now that we’ve reviewed the important find-
sentation discussion, or both. clinical problem or lacks a con- medical record and elicit or confirm ings, let’s think together about how they point
ceptual approach to it. important findings; think aloud with to acute arthritis as the likely problem. I’m
the learner, linking important findings considering acute arthritis because. . . .”

n engl j med 355;21

to your own problem representation.
Summary statement only Learner has not identified a prob- Instruct the learner regarding the impor- “Concise, accurate problem representation is a
loosely related to the lem representation, lacks a coher- tance of the problem representation; critical entry point to differential diagnosis.
case. ent understanding of the case, ask for a summary statement (if nec- Can you give me a one- or two-sentence sum-
or both. essary, compare and contrast it with mary of this case? Here’s how I think it might
your own). be put together. . . .”

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Generation of Multiple diagnoses generat- Learner has not identified a prob- Ask the learner to list all important find- “What are the main findings? Can you summa-
n e w e ng l a n d j o u r na l

hypothesis: ed in a random order lem representation or formulated ings from the case, create a problem rize these in abstract terms in one or two sen-
of

Search for and with no attempt to prior- illness scripts for the diagnostic representation based on selected tences? What are the diagnostic consider-
selection of itize them. considerations. findings, and prioritize diagnostic ations for patients with acute arthritis? Which
illness script considerations that identify discrimi- cause of acute arthritis is most likely to be
nating features for each consideration. correct in this case? Why?”
Discussion of differential di- Learner has not formulated illness Ask the learner to support his or her di- “What are your main and alternative diagnoses?

november 23, 2006

m e dic i n e

agnosis not linked to scripts for the diagnostic consid- agnosis using findings from the case; What features of the case helped you to dis-

Copyright © 2006 Massachusetts Medical Society. All rights reserved.

findings from the case. erations or is unable to compare then ask for at least one additional criminate between them?”
and contrast relevant illness plausible diagnosis and have learner
scripts. compare it with alternative diagnostic

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possibilities. If necessary, provide
your own analysis of the case.
 Cognitive feed- Far-fetched diagnosis. Learner has a poor understanding Ask the learner to describe the prototypi- “What is the classic presentation for your diag-
back of the case or lacks a sense of cal presentation for this particular di- nosis? What findings in this case fit the typical
relative probability. agnosis, to be followed by a compari- presentation? Are there enough key features
son with the findings in this case; present to continue with this line of reasoning?
identify additional data that would be What else do we need to know about this pa-
needed to rule in the diagnosis. tient?”
Developmental Presentation or reasoning Learner has not created an “anchor” Ask the learner about his or her experi- “Have you taken care of other patients with
stage below the expected prototype in memory, has too lit- ence with this type of case or problem; acute arthritis? What do you remember about
level for a common prob- tle experience with this type of assign the learner patients who have those patients? I want you to read about the
lem. problem to create illness scripts, common problems and prototypical typical presentation of gout and compare it
or both. presentations; instruct the learner with the typical presentation of infectious ar-
when reading about the case to com- thritis. Identify key and discriminating features
pare the primary diagnosis with at for both diagnoses. Tomorrow, tell me what
least one other consideration, identi- you have learned.”

n engl j med 355;21

fying relevant key and discriminating
features; and have learner follow up to
explain what was learned. Determine
whether the learner’s difficulty is an
isolated or recurring one.
Contextual con- Disorganized presentation More than one problem represen- Elicit some plausible problem represen- “Tell me how your primary diagnosis is support-

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siderations of a complex and ill- tation is possible, there is a risk tations; ask the learner to identify and ed by the clinical findings. Choose a reason-
defined clinical problem. of premature closure (learner defend primary and secondary diag- able alternative diagnosis and tell me why it
medical Education

may be making a lucky guess), or noses, using key and discriminating does not fit the clinical findings.”
both. features of the case; articulate your (Repeat this procedure for each plausible prob-
own problem representations and lem representation.)
clinical reasoning.
Evidence of varying levels of Within the group, there is likely to Elicit problem representations from two Ask the group: “Does anyone have a different

november 23, 2006

understanding. be a broad range of case experi- or three other learners present; ask problem representation?” Ask each learner:
ence (the stage of training may questions to assess each learner’s lev- “What questions do you have about this
only partially predict the learner’s el of expertise; ask more senior learn- case?” Ask the senior resident: “Tell us your
ability to reason about a case). ers to reason aloud; articulate your primary diagnosis and how it is supported by
own problem representation and clinical the clinical findings. Did you consider any

Copyright © 2006 Massachusetts Medical Society. All rights reserved.

reasoning. other diagnosis, and if so, how did you rule
it out?”

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 The n e w e ng l a n d j o u r na l of m e dic i n e

to begin by creating in memory an anchor proto- Encouraging useful Reading Habits

type of the typical presentation, rather than giving Learners should be encouraged to read about their
equal consideration to a number of undifferenti- patients’ problems in a way that promotes diagnos-
ated possibilities.17,19 Early in their training, medi- tic reasoning, rather than to read about topics in
cal students should be assigned to evaluate pa- a rote-memorization fashion, without context. The
tients with common problems — ideally, problems organization of knowledge stored in memory fa-
for which there are prototypical presentations. cilitates the recall of key concepts for application
After the features of the prototype have been so- to the next relevant clinical case.5 To enhance their
lidified in memory, additional clinical exposure to organization of knowledge and their understand-
similar problems can offer a basis for comparison ing, novice learners should read about at least two
with the prototypical case, providing learners with diagnostic hypotheses at the same time (e.g., gout
an appreciation of atypical or subtle findings.18,19 and infectious arthritis), comparing and contrast-
ing the similarities and discriminating features.
Varying Expectations According to Clinical teachers should encourage reading that
Developmental Level promotes conceptualization rather than memori-
The teacher’s expectation of evidence of strong rea- zation and provides learners with an opportunity
soning should vary according to the stage of train- to share what they have learned, testing what has
ing of the learner, but the learner’s developmental been understood well enough to be explained19
level is often related more to the extent of clinical and reinforcing the importance of self-directed
experience with the case at hand than to the year learning.
of training. First-year residents, for example, may Some medical textbooks are better organized
have clinical reasoning skills that are as advanced than others to encourage learning by comparing
as those of senior residents when it comes to com- and contrasting diagnostic considerations.23 The
mon clinical problems that they saw frequently judicious use of the original literature, even by
as medical students.20 Thus, although the stage of novices, can be an effective clinical learning tool,
training is somewhat helpful to the teacher in de- especially when it provides important new orga-
termining expectations of and roles for learners, nizing principles or pathophysiological insights
specific questioning strategies are necessary to that have yet to permeate textbooks. Learners
probe the understanding and elicit the uncertain- should be encouraged to identify progressively
ties of learners at any level.15 Several different strat- broader and more complex issues, explore them
egies can be used, but open-ended questions are more deeply, and apply the principles of evidence-
especially useful for assessing the learner’s clini- based medicine in arriving at answers.
cal reasoning ability.21,22 Using this or other simi- In summary, clinical teachers can promote the
lar frameworks, clinical teachers can evaluate a development of diagnostic reasoning while simul-
learner’s performance on the basis of the expected taneously diagnosing both the patient’s disorder
performance at different developmental levels. and the learner’s abilities. To do so, however, they
must have an appreciation of clinical learning
Providing Cognitive Feedback theory and practice and an accurate understand-
The clinical teacher should provide the learner with ing of the clinical problem in question. Such an
specific cognitive feedback. The teacher should undertaking requires that the teacher accompa-
point out diagnostically meaningful information ny the learner to the bedside or examination room
in the data on the case, identify redundant or ir- and perform an independent assessment of the
relevant findings, and highlight the discriminat- patient and, at the same time, assess the develop-
ing features, including their relative weight or im- mental stage and clinical reasoning ability of the
portance for drawing conclusions as to the correct learner. Ensuring the quality of patient care and
diagnosis.17 When a learner suggests a possible but modeling professionalism while promoting diag-
not plausible diagnostic consideration, the teacher nostic reasoning skills constitute the true art of
can ask the learner to describe the key features of clinical teaching.
a prototypical case and then to compare the pro- No potential conflict of interest relevant to this article was re-
totype with the findings in the case at hand.16 ported.

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 medical Education

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