Having worked part time in Medical Education for the last couple of years, I have become more and more convinced of the need for clinicians to understand not just what we think but why we think what we do. Too often we concentrate on whether what we think is correct rather than asking ourselves how we got to that answer and this is particularly true when making diagnostic decisions. Having stumbled across this article by Robert Lloyd…
…and from there been led to this article…
Clinical reasoning of junior doctors in emergency medicine: a grounded theory study: E Adams, C Goyder, C Heneghan, L Brand, R Ajjawi Emerg Med J emermed-2015-205650 Published Online First: 23 June 2016doi:10.1136/emermed-2015-205650
…I decided I needed a way to help clinicians reflect upon their diagnostic thinking and so the Random Patient Generator was born. It allows you to create a random patient using various demographics, medical issues and vital signs and then use this patient in a three step process to improve your Diagnostic Thinking.
Step One: Spend some time generating differential diagnoses for your patient, considering investigations you would choose and a management plan to follow before moving on to the next step.
Step Two: Now, rather than being too concerned about what you are thinking spend time reflecting upon why you are thinking that. What cues have you picked up on? What assumptions are you making? Which pieces of information are you favouring or ignoring? What previous experiences, good or bad, are influencing you?
Step Three: Finally, change one or more of the patient’s variables and see what it does to your thoughts about them. Does it change the diagnosis? Has it changed your threshold for an investigation? Has it made no difference at all? Doing this should help us reflect upon how we think, perhaps identifying our biases or flaws in our thought processes.
I firmly believe that having a better understanding of how we think, will help make us better clinicians and improve care for our patients. Spend some time getting to know your own ways of thinking and teach those around you to do the same, it’s not just good practice it’s good fun too!
Sadly, there isn’t any real evidence that understanding our biases makes us any less likely to be subject to them. However, the point of this activity is to open our eyes to the fact that we are biased and that not everyone thinks or sees things as we do. Once we realise that, it helps us understand why we need to be more humble in our work. We need the support and opinions of other staff, of guidelines and checklists to keep our patients safe. We should never treat challenges or assistance to our thinking as a bad thing, instead we should embrace it as an opportunity to get to the right answer, the one that will give the best outcome for our patients.
If you would like to make your own copy of the Random Patient Generator you can find the relevant files in my shared Medical Education Resources Dropbox by clicking the link below.
The original RPG is designed to be printed off on coloured card and then put in a standard 12mm binding comb. Coloured card isn’t necessary but it gives a nice effect in use. Prior to binding but after cutting the binding holes (find someone in your medical education centre to show you how!) you will need to cut across the pages of patient information to allow them to move separately… you should find that you can cut between every two holes. Once bound with the pages that do not require cutting, it is ready for use.
An alternative, much easier (and now my preferred) option is to have an unbound version like a deck of cards. Separate the cards in to piles of each type of variable, shuffle and stack them and then deal out one of each to create your initial patient. As you require changes, turn over a card from the relevant pile or for a completely new patient, turn over one of each. If you print each type of variable off on a different colour of card they are easier to sort! If you haven’t got access to coloured card, choose the Word file from the Dropbox and then colour in the text box on each page using the fill tool to create the same effect when printing. You can choose to print the cards off at any size choosing the ‘pages per sheet’ option and then cutting them appropriately or printing on to a specific page size. I have a set of A4 for large group teaching and a smaller set for individual use (using the 9 pages per sheet option on A4 from the pdf).