Coffee Talks: How Physicians Balance Evidence-Based
Medicine With Clinical Experience
By Todd Felix, MD, Penn State University,
Department of Family Medicine, Hershey Medical Center
(CR) is the application of critical thinking to the formulation of a
differential diagnosis, diagnostic evaluation, and treatment plan for clinical
problems. Information mastery and evidence-based medicine (IM/EBM)
are the integration of clinical
expertise with the best available external clinical evidence. Obtaining and
critically appraising the evidence does not always equate with better decisions
in clinical care, though. The evidence should be linked to the clinician’s
expertise, clinical context or setting, and the patient’s individual
circumstances, values, and preferences.
While CR and IM/EBM
are, along with clinical experience and knowledge of the patient, essential for
the practice of medicine, few medical schools have CR training or a formal
IM/EBM curriculum through all 4 undergraduate
years. Recent data have shown that clinical reasoning skills
plateau after the second year of medical school, with a
lack of accelerated progress during the clinical years of training.1
faculty addressed this plateau in development of CR skills by establishing a 4-hour
case-based conference titled “Coffee Talks,” where third-year students bring
cases seen during their month-long family medicine clerkship back to a group of
12–14 students and several faculty at the end of their rotation. The typical
forum includes three to four experienced faculty with an EBM focus, seasoned
clinicians, and an EBM resource librarian. The thinking skills of medical students are
enhanced by faculty-led discussions of the cases in formulating a working
differential that is assessed and modified after each segment of the student’s
systematic case presentation. The discussions are focused around key points of
the differential, diagnostic decisions, and treatment regimens based on available
data presented by the student. Students identify key clinical questions that
arise during the discussion, and small teams of two to three students with an assigned
faculty member are then tasked to utilize EBM resources in answering the
identified questions. This is followed by a student-led discussion in the
larger forum that enables the students to recognize the cognitive skills
utilized daily by family physicians in the care of their patients.
Consider this scenario below as an example of how
CR and EBM may be incorporated into one of our Coffee Talks.
A toddler at a birthday party becomes short of
breath suddenly—already you are developing a differential diagnosis—the
challenge becomes how you would proceed with a diagnostic workup and treatment
plan quickly and efficiently.
Clinical reasoning has been defined as the
ability to ‘‘. . . sort through a
cluster of features presented by a patient and accurately assign a diagnostic
label, with the development of an appropriate
treatment strategy as the end goal.’’2 A seasoned clinician would likely use clinical intuition, considering allergy,
asthma attack, and foreign body as their top differentials. A medical student,
using a more analytical approach, may yield a more expansive differential,
perhaps pneumothorax, pneumonia, cardiac shunt, etc.
Regarding our case scenario, what if the child was
a known asthmatic?
move freely between pattern recognition and analytic reasoning as a given case
necessitates, although the majority of our thought process is intuition/pattern
recognition. Introducing Bayes theorem (pretest probability and likelihood
ratio) to students reinforces the value of determining the probability for a
given disease prior to testing and gives grounds to whether physicians will
test, treat, or observe. In our scenario above, our pretest probability would
likely be equal for the three diagnoses listed. The personal history of asthma
would increase the likelihood for allergy and asthma.
things being common, you start treatment for an acute asthma exacerbation—but what should be your initial management option
(albuterol, levalbuterol, racemic epi, steroids)?
The skill set to interpret medical data, search
valid resources, and apply this to clinical scenarios in real time is an
invaluable tool for students and residents. Specific training in application of
EBM in clinical care is often lacking during the clinical years of medical
student education. Role modeling an evidence-based approach is an important
part of teaching clinical reasoning. Without data, well-founded diagnoses and management decisions are
difficult to make and may become anecdotal exercises, which can leave students
puzzled by the decision-making process.
the patient worsens, so you reexamine the child and consider the birthday party
environment, realizing that there was peanut butter cake, and symptoms started
soon after ingestion.
frequently misdiagnose patients, despite significant improvements in diagnostic
technology, including advanced imaging techniques. Groopman estimates about 15% of all
people are misdiagnosed, possibly as high as 25%.3 Think of the last
radiographic diagnosis made that did not seem to fit the diagnosis. Regular discussions
are had with students and residents about the “pneumonia” admission without
cough, fever, or leukocytosis despite a positive CXR finding. Most doctors,
within the first 18 seconds of seeing a patient, will interrupt the patient’s
story and generate an idea/diagnosis, which can easily be influenced by the
cognitive bias of premature closure once a “diagnosis” is found.3
Our patient is
administered an Epi Pen and improves quickly, then discharged with a diagnosis
of peanut allergy. Oral desensitization therapy was reviewed with parents, who
elected to follow total avoidance based on evidence presented.
Our Coffee Talks attempt to prepare future physicians with the
tools necessary to practice in the ever-changing medical landscape. With
studies showing physicians have up to two questions for every three patient
visits and an average search time of less than 1 minute, developing information
mastery skills is vital to student education.4 By focusing on the
necessary clinical reasoning skills and appropriate use of information in a
systematic fashion, students will be better positioned to enter their medical
careers with a solid foundation. This unique forum has allowed for clinical
experience, student collaboration, critical thinking, information mastery, and
professionalism to be highlighted.
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al. Analysis of questions asked by family doctors regarding patient care. BMJ
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ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med 2011;86(3):307-13.
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