Sir William Osler’s familiar quote “Medicine is a science of uncertainty and an art of probability” captures well the complex nature of clinical medicine. Although the science of medicine is often taught as if the mechanisms of the human body operate with Newtonian predictability, every aspect of medical practice is infused with an element of irreducible uncertainty that the clinician ignores at her peril. Clinical medicine has deep roots in science, but it is an imprecise science. More than 100 years after the practice of medicine took its modern form, it remains at its core a craft, to which individual doctors bring varying levels of skill and understanding. With the exponential growth in medical literature and other technical information and an ever increasing number of testing and treatment options, twenty-first century physicians who seek excellence in their craft must master a more diverse and complex set of skills than any of the generations that preceded them. This chapter provides an introduction to three of the pillars upon which the craft of modern medicine rests: (1) expertise in clinical reasoning (what it is and how it can be developed); (2) rational diagnostic tests, use and interpretation; and (3) integration of the best available research evidence with clinical judgment in the care of individual patients (evidence-based medicine or EBM and the tools of EBM).
BRIEF INTRODUCTION TO CLINICAL REASONING
Defining “clinical expertise” remains surprisingly difficult. Chess has an objective ranking system based on skill and performance criteria. Athletics, similarly, have ranking systems to distinguish novices from Olympians. But in medicine, after physicians complete training and pass the boards (or get recertified), no tests or benchmarks are used to identify those who have attained the highest levels of clinical performance. Physicians often consult a few “elite” clinicians for their “special problem-solving prowess” when particularly difficult or obscure cases have baffled everyone else. Yet despite their skill, even such master clinicians typically cannot explain their exact processes and methods, thereby limiting the acquisition and dissemination of the expertise used to achieve their impressive results. Furthermore, clinical virtuosity appears not to be generalizable, e.g., an expert on hypertrophic cardiomyopathy may be no better (and possibly worse) than a first-year medical resident at diagnosing and managing a patient with neutropenia, fever, and hypotension.
Broadly construed, clinical expertise includes not only cognitive dimensions involving the integration of disease knowledge with verbal and visual cues and test interpretation but also potentially the complex fine-motor skills necessary for invasive procedures and tests. In addition, “the complete package” of expertise in medicine requires effective communication and care coordination with patients and members of the medical team. Research on medical expertise remains sparse overall and mostly centered on diagnostic reasoning, so in this chapter, we focus primarily on the cognitive elements of clinical reasoning.
Because clinical reasoning occurs in the heads of clinicians, ...