Critical Thinking in Medicine: Reflections of a Third Year Student

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by Priya Parikh, Graduate Student, School of Medicine

“So, what is your assessment and plan for this patient?”

As a third year medical student, I am used to hearing this question during rounds when we present the patients we have been following to our residents and attending physician.  Early on in the year, this was a daunting question (okay it still usually is).  I’m just a student, how am I supposed to know what the patient has, and be able to support this with evidence and which labs/imaging/medications to give?

Well…that’s sort of the point. Third year is the first time as medical students we see and talk to patients every day in what we call “rotations.” We have six core rotations: psychiatry/neurology, internal medicine, obstetrics/gynecology, pediatrics, surgery, and family medicine. On each service, we are assigned to patients to talk to, to follow their progress, to keep track of their lab results, scans, and medications they are on. Then, we present this information at rounds to all of our superiors. It’s a whole new world compared to our first two years of medical school, in which we attend classes and study from books.

Making the transition from classes and books to real patients and patient care has been exciting, but difficult. This transition has made me reflect especially on how I think. Medicine is a vast, overwhelming field. Success is not only based on knowing the diseases and treatments, but on the development of critical thinking. Early on, seeing some of my attendings come up with diagnoses after only one sentence of my presentation inspired me to master the science of making a diagnosis. What I am quickly realizing, though, is that I will never know everything there is to know, regardless of which field I am working in. Instead, being able to reason through symptoms to come up with a diagnosis, and being able to sort out treatment options best suited for the patient’s needs and preferences, is the kind of skill that will lead to becoming a great physician. In my mind, critical thinking in medicine equals mastery of material PLUS formulation of perspective in the goal of the best treatment for our patients.

Sounds easy enough, right? Let’s first start by gathering all the evidence (patient’s symptoms, past medical history, current medications, physical exam), then exploring all the different possible diagnoses, then coming up with what we believe the diagnosis is and how we move forward with confirming our thoughts, then figuring out what options we have for treatment and which of these options best meets the patient’s needs. But what I struggle with is that this process is vastly different depending on the field. In internal medicine, it is sorting between the hundreds of reasons behind a patient presenting with abdominal pain and coming up with appropriate testing. In psychiatry, this process hinges more on being able to talk to the patient and building a rapport to really find out what is going on. On stroke team, clinical reasoning needs to be done quick, quick, quick as “time is brain.” In obstetrics, I need to be thinking about both mom and baby at all times. Thus, critical thinking can and does vary based on the kind of medicine being practiced, and requires development of different kinds of skills and considerations for each.

So how do we teach this kind of necessary critical thinking to medical students? As I look forward to a career in academic medicine and medical education, I am starting to reflect on my own medical education so far and how to foster this kind of thinking for future success. First and foremost, I believe that no lecture or textbook compares to direct patient care. Implementing early patient exposure as SLU does, including practicing physical examination and history taking on standardized patients and preceptorships starting in our second year, has been essential in developing critical thinking skills. Encouraging first and second year students to volunteer at clinical and medical outreach events can aid in this development too. Medicine is a process, and as a student, practicing clinical reasoning at every opportunity helps us to develop these skills.

In the classroom, implementing problem based learning and cases are worthwhile.  At SLU, we often times have group work in small teams in which we discussed a patient case with a fourth year medical student or faculty member, and went through the process from diagnosis to treatment. Adding this kind of activity on a more regular basis throughout classes benefits students in the transition to third year rotations. Another useful technique is mentorship. I have learned so much from residents and attendings who enjoy teaching and will go through their clinical reasoning when discussing patients so that I can compare my own thought process. Finding a mentor whose style you would like to emulate can be another great way to learn critical thinking skills.

These are just a few things I have been reflecting on, and it all comes down to finding ways to flex these critical thinking muscles, so that they become stronger on the wards and lead to a foundation of skills necessary to become a proficient physician. I am excited to see where the rest of third year takes me, and how my clinical reasoning skills develop and progress. One day, I hope to be teaching these skills to the next generation of aspiring physicians with a better understanding of how to best cultivate critical thinking.

To accompany our 2015-2016 theme of Thinking Critically, Thinking Creatively, fall contributors were asked to share their thoughts about two questions: 1) What does critical thinking look like in your field or discipline? And 2) How do you teach students to do it?

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