Thinking louder: Teaching clinical reasoning in the hospital using structured frameworks

Early in one of our (A.O.'s) careers, a hospital medicine team was making morning rounds and entered the room of a patient with a complex clinical presentation and substantial diagnostic uncertainty. The patient was visibly frustrated, as they felt like nothing was happening to move their care forward and find an explanation for their symptoms. The attending physician's mind went to the many conversations about the patient's care with many different specialists as well as among the core care team in the last few days and then stammered “We've been thinking a lot about you!” The patient responded, “Well, you need to think louder!” Clinical reasoning is the foundation of good medical care, and much of the work of hospitalists relates to clinical reasoning. Clinical reasoning is a broad term that encompasses many different cognitive and sociotechnical aspects and includes diagnostic reasoning, management reasoning, and prognostic reasoning. The science of clinical reasoning has continued to expand and deepen in recent years, and many different theories are commonly used to understand the processes by which clinicians and clinical teams make decisions.1 This includes expansion beyond theories focused completely on individual cognition, such as dual process theory, to theories that account for how reasoning unfolds within teams and clinical environments, such as ecological psychology and distributed cognition.2, 3 While such theories are important for research, education, and systems design, the most important thing that hospitalists caring for patients and teaching in the hospital need to know and do with respect to clinical reasoning is how to talk about it. Teaching of clinical reasoning often occurs implicitly in the form of questions posed by the clinician educator: What's the worst thing this could be? What is the most likely diagnosis in this case? Does this presentation fit your illness script for [the working diagnosis]? What else could this be? Can all the findings be explained by the [working diagnosis]? Although the clinician educator intuitively knows why these questions are important, their significance is obscure, opaque, or altogether an obfuscation to many learners. Using the aforementioned patient's words, we need to “think louder.” One of the challenges to sharing our thinking out loud with learners and the rest of the care team, including patients and their loved ones, is finding a natural scaffold for sharing often non-linear, experience-based, and idiosyncratic cognitive processes. Studies of teachers of clinical reasoning consistently demonstrate that master clinician educators are distinguished by how clearly they make their thinking visible to others.4 Making one's reasoning explicit can feel awkward, particularly when conclusions are provisional or evolving. This is where structured frameworks can help clinicians overcome the activation energy and imposter syndrome that exists when sharing one's thinking out loud. In this issue of the Journal of Hospital Medicine, Brumfield and colleagues describe the “5L framework,” a stepwise scaffold for discussing diagnostic reasoning at the bedside that serves to make the implicit more explicit, and therefore louder, among team members.5 The framework begins by asking what is lethal, directing attention to time-sensitive conditions that must be considered even when they are unlikely: What's the worst thing this could be? It then turns to what is likely, drawing attention to base rates and disease prevalence: What is most likely? What is logical asks whether the working diagnosis fits the patient's presentation and clinical course: Does this presentation fit your illness script for [condition X]? What is lurking shifts focus to diagnoses that remain plausible but have not yet been fully considered and may require targeted testing: What else could this be? Finally, what is lingering asks clinicians to name what still feels unresolved and whether further input or follow-up is needed: Can all the findings be explained by our working diagnosis? By giving clinicians a shared set of prompts, this framework (and others like it), affects which questions are raised and which concerns stay quiet. When a learner asks about an unaddressed symptom or what still feels unresolved, it becomes easier discuss uncertainty. This keeps attention on how diagnostic decisions are being made. While this framework has not been evaluated in rigorous studies, it remains a valuable contribution to the literature as an accessible and easily recalled approach to discussing clinical reasoning. Similar but distinct point-of-teaching tools have been developed and published in the past, including SNAPPS and the One Minute Preceptor.6 Although these tools differ in structure, each gives clinicians a scaffold for sharing their reasoning out loud and inviting learners into that process. While well designed, prospective studies comparing the effectiveness of these tools are needed, it is probably more important that educators just start using one. Thinking is a hospitalist's most important procedure, and it is imperative that we use tools that allow us to render this procedure visible. The authors declare no conflicts of interest.