ARTE Module TWO – Understanding the Process of Care

Students and faculty work together to create a safe environment for students to ask questions.
Better student questions lead to better student learning, and teacher learning, as well. Asking questions is an important part of learning medicine. Getting good questions answered by experienced physicians is a hallmark of excellent clinical training.
Asking good question that lead to good learning opportunities is a skill that can be learned, practiced and improved. Much like the skills we learn in asking questions of patients, asking good questions of teachers, consultants and team members are marks of a curious, courteous physician.
Asking effective questions about important issues requires a trusting relationship between learner and teacher. Make this relationship a goal of your clerkship, the sooner the better. Discuss directly with your preceptor how to make your questions fit best into the flow of their practice.
The suggestions summarized below come from experienced medical students and family medicine clerkship teachers.
The Challenges of Teaching and Learning the Process of Care
Students tell us they sometimes have difficulty in seeing and making sense of what they observe when working with their faculty preceptors. This is particularly true with the higher-level skills and knowledge of the experienced family physician. Students learn best when the teacher explains what is going on in his or her head. Probing student questions help highlight the areas where this extra articulation is needed.
Teachers often have difficulty explaining how or why they do what they do, especially when they do their best work. Research shows that even the doctors recognized by their colleagues, as having the best doctor-patient skills often cannot explain what it is that they do so well.
Sometimes these aspects of practice are called:

  • The Art of Medicine
  • Clinical decision-making
  • Bedside manner
  • Patient management
  • “Clinical Jazz”

The suggestions summarized below come from experienced medical students and family medicine clerkship teachers.
Tips for Students – Understanding Clinical Thinking

  1. Tell the teacher what you need to learn. Help the teacher understand the point you are starting from. Provide some context for your question. Experienced teachers know that different students have different needs, but the student can help identify the starting point.
  2. Ask the faculty physician to think out loud as you work together through a challenging case.
  3. Work out with each preceptor how he or she wants to deal with your questions about patient management. Some discussions can occur in front of the patient. Some work better outside the exam room, after you have finished you evaluation but before the attending goes in to see the patient. Other discussions need more time or reflection and work best during the “Question Time” you have set up with the preceptor.
  4. You must learn about the process of care, not just the content.
  5. Seek to understand the rationale for the decisions, not just the decision. Ask about the process when it is not clear to you. You are not responsible for reading the teacher’s mind.
  6. Be prepared to see a variety of approaches and rationales. Important decisions are rarely simple. Tough questions often have more than one answer. Good doctors do more than follow algorithms.
  7. Observe, ask and listen respectfully to the explanation. Ask more questions to help you square the picture with what you have learned and seen from other clinicians. Be prepared to follow up with reading and review of evidence. You will eventually need to make up you own mind.
  8. Use your question asking skills. Better questions get better answers.
  9. Remember that, although this may be the patient’s first visit with you, it may be part of a long-term relationship and process of care with the attending physician. The doctor and patient may share a history that is not apparent to you unless you ask about it.

Balance your focus between:

Not just the: But also the:
Facts Reasons the facts are important for this case
Problem Context of the whole patient
Decision Rationale for the decision
Managing patients Managing relationships
Biomedicine Biopsychosocial patient care

Student Exercises – Understanding Clinical Thinking

  1. List three reasons why a doctor might do a physical examination on a patient with chest pain without performing all of the steps you memorized for ICM cardiovascular examination? Frame a question to ask the doctor about the way he conducted the examination.
  2. Recall a patient you have seen recently that presented complex or challenging problems that involved the care of several physicians. Did all the physicians have the same initial diagnosis and treatment plan? Did they list the patient’s problems in the same order of priority? Which were closest to your own conclusions about the patient? Why the variation about one patient?
  3. With a patient you see in the office – or with a fellow student, resident or faculty physician – practice “thinking out loud” about your process of diagnosis and patient management. How might it change the interaction, the process and the resulting decisions?