Internal medicine clerkship is where medical students (regardless of their interest) should learn the art of diagnostic reasoning. But we have very little training in how to teach it. Here is my approach: 👨🏫
#MedTwitter
1. The Rule of 3’s
2. The 3 C’s
3. 20-50-80
#MedTwitter
1. The Rule of 3’s
2. The 3 C’s
3. 20-50-80
The theory behind all of these methods is the simple (but heavily studied) finding that “errorful learning followed by corrective feedback” is incredibly powerful. This is the reason question banks are so useful. You are forced to pick an answer & get immediate feedback.
The Rule of 3’s ☘️
For the summary statement, the maximum number of items you can present are:
- Three past medical histories
- Three items from HPI
- Three objective findings (physical exam, labs, imaging)
Students must decide what supports their differential diagnosis
For the summary statement, the maximum number of items you can present are:
- Three past medical histories
- Three items from HPI
- Three objective findings (physical exam, labs, imaging)
Students must decide what supports their differential diagnosis
The point here isn’t for them to “nail it.” Each missed PMHx or overstated test result is a teaching point about risk factors for an acute illness or test characteristics. Support their learning with discrete numbers (ie. sensitivity/specificity or likelihood ratios).
The Three C’s ©️©️©️
For the differential, you must include at least one of each:
- Common
- Classic
- Can’t miss
Classic are the board exam answers for a syndrome
Can’t miss are the emergencies,malignancies, etc
Interestingly, I find “common” is the hardest for students
For the differential, you must include at least one of each:
- Common
- Classic
- Can’t miss
Classic are the board exam answers for a syndrome
Can’t miss are the emergencies,malignancies, etc
Interestingly, I find “common” is the hardest for students
So much of residency is learning how many different ways common things can present. I remember being convinced a patient had mesenteric ischemia, only for the CT to show constipation. Teach your students “common things are common” by always expecting it in their differential.
20-50-80 📈📉📊
First, don’t let the differential run into the plan. Have them commit to a single “most likely diagnosis”
Then, ask them to pick their certainty! They only have 3 options: 20% 50% 80%
The idea here is refining pretest probability for an illness script
First, don’t let the differential run into the plan. Have them commit to a single “most likely diagnosis”
Then, ask them to pick their certainty! They only have 3 options: 20% 50% 80%
The idea here is refining pretest probability for an illness script
Again, the learning here is best when the student is way off. You can ask a student why they chose a certain percentage (specific reasons) and then walk them through reasons it was higher/lower on your differential.
It’s true that experience is the best teacher for refining illness scripts, but that’s unhelpful advice for a learner at the beginning of their training. To take an active role in this process, you need to commit to a discrete probability & then see where you went right/wrong
I still do this myself. Sometimes I’ll even have my whole team state their pretest probability for an illness while waiting for a test. With every iteration (right or wrong), your brain refines its illness script. 📜
Thanks for reading!
@YaleIMed @YaleIM_Chiefs
Thanks for reading!
@YaleIMed @YaleIM_Chiefs
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