Advice please on critical thinking

[Roy G Biv]

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Hello, I'm a 4th year medical student soon to be going into residency. I received some comments from attendings during one of my medicine rotations that I need to think/learn how to think. I realize that I will learn a lot during intern year, but I've been feeling kind of bummed from the comments and is starting to worry that I won't do well during residency. I want to do better, but I don't know how to improve my clinical reasoning ability/critical thinking. I would appreciate any advice.

Thank you.

 

[bashwell]

The first piece of "critical thinking" advice is to ask whether what the attending(s) said was true or not. In other words, was the comment that you need to learn how to "think" based on good evidence that you weren't doing so? Did the attending give you specific examples of where you weren't "thinking" at a level appropriate to a 4th year med student? And, if so, did they give you constructive feedback on how you can improve or was it just plain criticism with no other substance? I ask because some attendings can be arses.

 

[Roy G Biv]

Thanks for the response. There were two instances. One was after I gave a short presentation on a topic and failed to have a more in depth analysis on the papers I presented. I was told that my analysis of the papers was superficial and that I needed to think about them instead of just repeating the authors' conclusions. The other was a patient on the wards who presented with new neurological symptoms. I mentioned in my plan that I wanted to get a CT or MRI, but I wasn't sure what might be causing the problems. I was then told by the attending that in medicine we need people who will think and then he turned to the resident for their opinion. I wasn't given any further feedback. I should have asked specifically, but I guess in the heat of the moment, I didn't know what to think and just kind of stood there.

 

[hmockingbird]

Thanks for the response. There were two instances. One was after I gave a short presentation on a topic and failed to have a more in depth analysis on the papers I presented. I was told that my analysis of the papers was superficial and that I needed to think about them instead of just repeating the authors' conclusions. The other was a patient on the wards who presented with new neurological symptoms. I mentioned in my plan that I wanted to get a CT or MRI, but I wasn't sure what might be causing the problems. I was then told by the attending that in medicine we need people who will think and then he turned to the resident for their opinion. I wasn't given any further feedback. I should have asked specifically, but I guess in the heat of the moment, I didn't know what to think and just kind of stood there.

For the articles, when I have gone to journal clubs we usually talk about the validity of the conclusions by identifying any flaws in the study, whether we agree, etc. I'm sure you could find something online or maybe from a mentor to help you think through various aspects of evaluating a study -- we use a guided set of questions in my residency and I think it's really helpful to go through articles systematically like this at least until you get confident with it. Maybe that is more what they are looking for?

For the other I think maybe he meant he wanted you to have a reason for getting the CT/MRI (what are you looking for or what do you want to rule out) and/or a differential (I'm not sure what else you included in your presentation). Next time if you don't know, you can always ask your resident to help you go through a differential or google it/look on UptoDate/etc. I used the app Diagnosaurus a lot in med school, and also honestly the first aid book for CS is good for broad differentials. When you present, give a mini-analysis of why you think each diagnosis is or is not likely. E.g. "I feel like the symptoms of slurred speech and a droopy arm are concerning for a stroke, so I would like to get a head CT to rule this in or out." or "The patient did not bite his tongue and become incontinent, and was not post-ictal, so I don't think this spell is concerning for a seizure." Even if you are not sure what it is, going through everything you think does NOT fit will show your attending that it's more "the patient's story doesn't fit well with a bunch of known diseases" than them thinking you don't know the differential or didn't bother coming up with one. Don't worry, you will get better at this with time and be able to work on your differentials/plans in residency!

 

[Beezlebub]

uptodate/harrison's IM

critical thinking - integrate info; block out irrelevant info; localize on key points

 

[FlameBroiledDoc]

The good news is that by midway through internship, your thinking changes and you naturally acquire the skills your supervisors want you to demonstrate. You'll find that you won't need to take such comprehensive histories, and will be generating differential diagnoses and investigation plans automatically.

 

[LUCPM]

Learning how to think will come with time. The fact that you are worrying about it now is a pretty good indication that you will do just fine.

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[caffeinemia]

The good news is that by midway through internship, your thinking changes and you naturally acquire the skills your supervisors want you to demonstrate. You'll find that you won't need to take such comprehensive histories, and will be generating differential diagnoses and investigation plans automatically.

that's if internship is doing what it's supposed to do. I find that pgy2 year is really when it starts kicking in for a lot of residents these days. I'm slightly weirded out by it when I start talking to junior residents. am i just being harsher on the younger residents and was i probably pretty ****ty as an intern? damn.

 

[FlameBroiledDoc]

that's if internship is doing what it's supposed to do. I find that pgy2 year is really when it starts kicking in for a lot of residents these days. I'm slightly weirded out by it when I start talking to junior residents. am i just being harsher on the younger residents and was i probably pretty ****ty as an intern? damn.

'Twas ever thus. S**t flows downhill, rather steeply in a teaching hospital. And I suppose the adjustment in thinking will also depend on what rotations you've done, Surgery and Medicine being the critical ones.

 

[Ismet]

Thanks for the response. There were two instances. One was after I gave a short presentation on a topic and failed to have a more in depth analysis on the papers I presented. I was told that my analysis of the papers was superficial and that I needed to think about them instead of just repeating the authors' conclusions. The other was a patient on the wards who presented with new neurological symptoms. I mentioned in my plan that I wanted to get a CT or MRI, but I wasn't sure what might be causing the problems. I was then told by the attending that in medicine we need people who will think and then he turned to the resident for their opinion. I wasn't given any further feedback. I should have asked specifically, but I guess in the heat of the moment, I didn't know what to think and just kind of stood there.

Differential comes before plan. Don't suggest a plan to do something, especially not imaging, if you don't know what you might be looking for. If you're having trouble coming up with a differential, talk to your resident before rounds. It shows that you're interested and that you're thinking about things, and it will lessen the risk of this happening on rounds.

The critical thinking will come with time and as your knowledge grows. Don't be ashamed to look things up. It doesn't all have to come from your brain.

 

[Arcan57]

Being a physician is essentially being a knowledge worker (+/- the procedural skills). What your attendings are trying to convey to you is that a knowledge worker that consistently outsources their thinking doesn't add any value to the system. And in today's environment, if you don't add value to the system, then you get replaced by someone cheaper. The days of being able to consult out every problem to a separate specialist with the only side effect being that everyone in the system makes more money are waning, and may well be gone by the time you're an attending.

In regards to journal articles, if you don't want to put in the work of thinking something through you'll find people that are happy to do it for you. Those people typically have an agenda and that agenda may or may not coincide with the interests of the patient(s) you are treating. Many studies published have conclusions that are only loosely supported by their data. Sometimes it's relatively obvious like when a study's primary endpoint is negative but the authors data-dredge a subgroup analysis or a non-patient centered secondary outcome and trumpet their results as positive. Other times it's more subtle, such as a non-inferiority trial whose primary endpoint has nothing to do with patient-oriented outcomes or that was tested against placebo instead of standard therapy.

 

[michaelrack]

In regards to journal articles, if you don't want to put in the work of thinking something through you'll find people that are happy to do it for you. Those people typically have an agenda and that agenda may or may not coincide with the interests of the patient(s) you are treating. Many studies published have conclusions that are only loosely supported by their data. Sometimes it's relatively obvious like when a study's primary endpoint is negative but the authors data-dredge a subgroup analysis or a non-patient centered secondary outcome and trumpet their results as positive. Other times it's more subtle, such as a non-inferiority trial whose primary endpoint has nothing to do with patient-oriented outcomes or that was tested against placebo instead of standard therapy.

In real life non-academia, doctors Very rarely analyze journal articles themselves. Do you think a pcp is going to look at the data for a new antihypertensive? In real life, docs primarily rely on recommendations from our specialty societies and other sources