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The Pediatric Forum |

Aunt Minnie: Will Inexperienced Trainees Recognize Her?

Larrie W. Greenberg, MD
Arch Pediatr Adolesc Med. 1999;153(8):893. doi:.
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The commentary by Cunningham et al,1 as an example of "out of the box" thinking as an alternative way to teach in the ambulatory setting in this era of managed care, was interesting and entertaining, and the authors are to be commended. I do, however, have reservations about adopting this technique either personally or for instructing others as a faculty development teaching tool for the following reasons:

  • An innovation such as this needs to be examined and studied as a randomized controlled trial or through qualitative analysis to be certain that learner behavior and outcome is at least as effective as that resulting from traditional teaching.

  • In a recent article, Irby2 states that "physicians develop an exhaustive knowledge base of medicine" through experiencing a variety of clinical cases, and knowledge then develops into tighter connections and is retained in memory as "illness scripts." Irby goes on to state that effective instruction emerges from the complicated interaction between understanding the learner and comprehending the subject matter. Grum et al3 also emphasizes the importance of previous clinical experience and having the learner exposed to large volumes of patients. The process of understanding the interplay between learner and content, in my extensive work in faculty development, takes in-depth instruction and practice for faculty to learn. The authors do not mention how they've marketed this teaching approach to their faculty, and how well the latter has adapted it. Finally, Norman et al4 also have studied the pattern recognition phenomenon in students and reported that medical students have difficulty recognizing common and classic physical signs from photographs, most of which are self-evident to more experienced clinicians. In a recentdiscussion of pattern recognition with second-semester third-year clerks on a pediatrics rotation, I asked what the blurring of the right heart border on a posteroanterior radiograph indicated to them regarding location of the infiltrate and only some of the class knew the correct answer. I'm assuming that those who didn't know the answer hadn't had enough or any exposure to this principle.

    In fact, this process of pattern recognition and developing the contextual relationship between content and learner takes time. Whereas we can expect medical students to start this developmental process during their clinical experiences, faculty need to be realistic and ask themselves what the "gold standards" should be regarding this process. The article doesn't address this nor has the literature definitively studied this.

  • The authors propose that trainees present a chief complaint and presumptive diagnosis when presenting a case (30 seconds); Irby similarly calls for a "distilled summary" of the case. Whereas a short, efficient presentation is very important to maintain patient flow in an ambulatory setting, the preceptor must know enough about the learner's assessment of the patient and, as importantly, how he or she arrived at this assessment. As an extension of the "1-minute preceptor" that has been popularized as a teaching technique, I have suggested and teach 2 additional steps not mentioned in the original article; namely, to be aware of the learner's previous experience with the kind of case he or she is presenting and, after the preceptor-learner interaction, to identify student or resident learning objectives that would improve performance with the next case.5

  • The chief complaint doesn't always reflect the patient's hidden agenda and may be a detractor for an inexperienced trainee. Once the hidden agenda is identified, the preceptor needs to dissect what information the learners garnered and used in their decision-making and to instruct them in what issues were critical in arriving at a correct diagnosis, perhaps not related to the chief complaint.

  • It has been stated repeatedly that 80% to 90% of diagnoses can be made from history alone. For an experienced clinician, many of these will come through pattern recognition and not problem-solving. For the inexperienced trainee, this will evolve through meticulous history-taking and astute descriptions of findings. As preceptors, we should be challenging learners to put forward hypotheses about patients and test them, determining what in the history and/or physical examination is compatible with their assessment. If the learner were taught to develop hypotheses prior to the interaction with the preceptor, it would save significant time.

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