Cognitive aspects of clinical performance during patient workup: The role of medical expertise

This paper examines the role of medical expertise in clinical reasoning, using a complete workup of a patient with an endocrine disorder. Endocrinologists, housestaff, and final year medical students were asked to develop the case. This consisted of history-taking, interpreting physical examination results, request for tests and their interpretations, and providing therapeutic and patient management plans, and an explanation of the pathophysiology underlying the problem. The subjects were also asked to provide explanations supporting their decisions during the patient workup. A variety of techniques deriving from cognitive psychology were used to analyze the data. The main concern was how expertise affected the building of relationship between the components of the workup. Experts formed integrated knowledge-rich structures that were generated during the history-taking and used consistently throughout the workup. Housestaff formed more tentative and less integrated representations which were modified during the patient encounter. Students representations superficially resembled those of experts, but were knowledge-lean. The results are interpreted in terms of clinical performance of endocrinologists, housestaff, and students during the workup, and its relationship to the explanation task as an indicator of clinical competence of the patient problem provided by the subjects. It is proposed that the explanation given after the problem solving process could be used as an indicator of clinical competence.