• 1.

    Croskerry P. Clinical cognition and diagnostic error: Applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract 2009; 14 (Suppl 1):2735. doi: 10.1007/s10459-009-9182-2

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med 2013; 368:24452448. doi: 10.1056/NEJMp1303712

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Rencic J, et al. Clinical reasoning education at US medical schools: Results from a national survey of internal medicine clerkship directors. J Gen Intern Med 2017; 32:12421246. doi: 10.1007/s11606-017-4159-y

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Connor DM, et al. Clinical reasoning as a core competency. Acad Med 2020; 95:11661171. doi: 10.1097/ACM.0000000000003027

  • 5.

    Tonelli M, et al. Comparison of the complexity of patients seen by different medical subspecialists in a universal health care system. JAMA Netw Open 2018; 1:e184852. doi: 10.1001/jamanetworkopen.2018.4852

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Warburton KM, et al. Comprehensive assessment of struggling learners referred to a graduate medical education remediation program. J Grad Med Educ 2017; 9:763767. doi: 10.4300/JGME-D-17-00175.1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Warburton KM, Mahan JD. Coaching nephrology trainees who struggle with clinical performance. Clin J Am Soc Nephrol 2018; 13:172174. doi: 10.2215/CJN.07270717

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Beyond Medical Knowledge: A Framework to Improve Clinical Reasoning in Nephrology Training

  • 1 Suzanne M. Boyle, MD, MSCE, is an Associate Professor of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, at the Lewis Katz School of Medicine at Temple University, Philadelphia, PA, and is the William and Sandra Bennett Clinician Educator Grant Recipient for 2021. Stephen M. Sozio, MD, MHS, MEHP, is an Associate Professor of Medicine, Division of Nephrology, at Johns Hopkins University School of Medicine, Baltimore, MD, and is an Associate Professor of Epidemiology with Johns Hopkins Bloomberg School of Public Health and Chair of the American Society of Nephrology Data Subcommittee. Andrew S. Parsons, MD, MPH, is an Assistant Professor of Medicine and Public Health, Section Hospital Medicine, at the University of Virginia School of Medicine and is Director of Clinical Reasoning Coaching with the University of Virginia, Charlottesville, VA. Karen M. Warburton, MD, is an Associate Professor of Medicine, Division of Nephrology, with the University of Virginia School of Medicine, Charlottesville, VA; Director of Graduate Medical Advancement; and Director of the Clinician Wellness Program.
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Clinical reasoning is the process by which clinicians gather, interpret, and synthesize data to arrive at a diagnosis and make management decisions. Research in this field aims to: 1) understand decision-making under conditions of uncertainty and 2) promote systematic approaches to reasoning that minimize cognitive bias and reduce medical error (1, 2). Although most early-stage clinicians develop reasoning skills through repeated clinical exposure, many benefit from more explicit instruction (Figure 1) (3, 4).

Figure 1.
Figure 1.

Clinical decision-making pathway

Citation: Kidney News 13, 10/11

These steps are informed by non-analytical and analytical processes. The non-analytical process is typically fast and unconscious and relies on pattern recognition via illness scripts (stored memories of specific signs/symptoms with associated diagnoses that are refined over time), which makes it prone to cognitive bias. The analytical process is conscious and deliberate and is more often used by novices or by experienced clinicians as a check against cognitive bias.

Yet, to our knowledge, clinical reasoning curricula are largely absent from fellowship training programs. For many reasons, nephrology trainees would benefit from dedicated clinical reasoning instruction. Nephrology patients are among the most medically complex—often with compromised immune systems, cardiovascular comorbidities, and complicated electrolyte abnormalities—and are often cared for by multiple providers (5). These characteristics create high-stakes clinical scenarios that are vulnerable to cognitive bias. Clinical reasoning deficits are common and underrecognized in graduate medical learners, including nephrology fellows, and may be mistaken for knowledge or organizational deficiencies (6, 7). Struggling fellows are often advised to focus on knowledge acquisition when the root cause of their struggle is not lack of knowledge but, rather, effective application of knowledge (6, 7). This is illustrated by a recent survey of nephrology training program directors, which revealed that approximately 40% of fellows who required remediation had clinical reasoning deficits (6).

The successful nephrology educator's toolkit requires clinical reasoning assessment and coaching resources. In such, our team is developing Reasoning Evaluation in Nephrology Education (RENE), a web-based resource to assess and coach clinical reasoning skills in nephrology fellows (Figure 2). Through support from the William and Sandra Bennett Clinical Scholars Program, we will validate exercises that assess fellows' clinical reasoning. We will also provide a framework for nephrology educators to provide feedback to fellows and coach those with deficits. Unlike traditional assessment tools, such as board certification examinations, the reasoning assessment tool will measure a fellow's ability to synthesize data to make clinical decisions. We hope to engage the nephrology community in the creation and implementation of this novel educational resource.

Figure 2.
Figure 2.

Components of reasoning evaluation in nephrology education (RENE)

Citation: Kidney News 13, 10/11

References

  • 1.

    Croskerry P. Clinical cognition and diagnostic error: Applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract 2009; 14 (Suppl 1):2735. doi: 10.1007/s10459-009-9182-2

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med 2013; 368:24452448. doi: 10.1056/NEJMp1303712

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Rencic J, et al. Clinical reasoning education at US medical schools: Results from a national survey of internal medicine clerkship directors. J Gen Intern Med 2017; 32:12421246. doi: 10.1007/s11606-017-4159-y

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Connor DM, et al. Clinical reasoning as a core competency. Acad Med 2020; 95:11661171. doi: 10.1097/ACM.0000000000003027

  • 5.

    Tonelli M, et al. Comparison of the complexity of patients seen by different medical subspecialists in a universal health care system. JAMA Netw Open 2018; 1:e184852. doi: 10.1001/jamanetworkopen.2018.4852

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Warburton KM, et al. Comprehensive assessment of struggling learners referred to a graduate medical education remediation program. J Grad Med Educ 2017; 9:763767. doi: 10.4300/JGME-D-17-00175.1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Warburton KM, Mahan JD. Coaching nephrology trainees who struggle with clinical performance. Clin J Am Soc Nephrol 2018; 13:172174. doi: 10.2215/CJN.07270717

    • Crossref
    • Search Google Scholar
    • Export Citation
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