IM Reasoning

Conversations to inspire critical thinking in clinical medicine and education

Welcome to IM Reasoning with your hosts Dr. Art Nahill and Dr. Nic Szecket, two general internists with a passion for teaching clinical reasoning.

Join us for case discussions, conversations and interviews that explore issues important to medical students, trainees and practitioners of clinical medicine, with a special focus on clinical reasoning, the once-mysterious process behind the remarkable abilities of the master clinician.

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63 comments

  1. Thanks so much for replying, Art,

    I have been avidly plugging your podcasts, including on a very active doctors-only Facebook Group for Australian and NZ GPs called “GPs Down Under” which has over 3200 members. You now have lots of new fans!

    I will certainly continue to recommend them to those sitting GP Fellowship exams as a fantastic way of getting to better understand clinical reasoning concepts.

    I really like the mix of topics and formats in your podcast episodes. Stump the Chumps and Cognitive Autopsy are my favourites and I would love to see more of both formats. I particularly liked the episodes on Feedback, Compassion and the Second Victim also.

    Keep up the wonderful work!

    Genevieve

    PS: Thanks for asking about my writing. Over the years I’ve dabbled in a variety of genres: playwriting, short film, musical theatre (co-wrote “GP the musical”), columnist (for the medical newspaper, Australian Doctor and others), and a novel. Nowadays my writing is mostly work-related, but I occasionally post on my rather neglected blog, https://genevieveyates.com/

  2. Dear Art and Nic,

    I rarely write fan mail, but had to share my delight at having recently discovered your podcast. I have binge listened my way through most of the episodes and thoroughly enjoyed them all. You have found the sweet spot – demonstrating a near perfect balance between the informative and authoritative , and the entertaining and self-deprecating.

    I am am Australian GP, medical educator and writer. My deep interest in teaching clinical reasoning stems largely from my role as a Royal Australian College of General Practitioners (RACGP) examiner and Censor. One of the three RACGP Fellowship exams for GPs in Australia is called the Key Feature Problems (KFP) exam. The KFP is a short answer written exam designed specifically to test clinical reasoning. It has the highest failure rates of any of the GP Fellowship exams (usually 40-50%) and many candidates find it the hardest of the three Fellowship exams to get through.

    As a Censor, one of my jobs is to give feedback to failed candidates. While exam technique and knowledge gaps are undoubtedly factors for many, time and time again I see doctors with good clinical knowledge but poor clinical reasoning (memorisers, not thinkers). They tend to find it difficult to assess patients in the context of the scenario given and to identify the key features/critical steps.

    Given the sheer number of doctors who fail the KFP (several hundred every six month exam cycle) and the mere handful of us who are giving feedback, extended one-on-one remediation is impossible. From here on in I intend to recommend your podcast as a KFP study plan essential – both for those intending to sit the exam for the first time, and for those who plan to re-sit.

    I will also recommend it more broadly as it is relevant to all of us!

    Thank you again for such a wonderful resource.

    warm regards
    Genevieve

    1. Nicolas Szecket says:

      Hi Genevieve, thanks so much for you lovely feedback. It sounds as though your role as an examiner for the College is a very challenging one. It’s difficult enough to give meaningful, transformative feedback to ONE individual you have worked with, let alone to many you probably don’t know who have failed an exam! I don’t envy you at all.
      Nic and I are glad you find the podcasts useful, and if they can be useful to struggling junior doctors, so much the better!
      By the way, what kind of writing do you do?

      Art

  3. Kate Rassie (nee Duggan) says:

    Hi Art and Nick

    I’m a General Medical Registrar at North Shore Hospital, a recent convert to IM Reasoning. Just thought I’d let you know that I am thoroughly enamoured with your podcast series.

    I’ve spent an entire week of to-from-hospital commuting bingeing on serial episodes, and am now totally hooked (sometimes doing gratuitous laps around the block to finish an episode!). The diagnostic reasoning stuff is brilliant: I don’t think metacognitive strategies, or the art of self-reflection; are nearly well-enough emphasised in undergraduate (or indeed post-graduate clinical) medical education. [Nor, of course, are the medical humanities, or empathy and compassion, or self-care and collegiality, or communication skills]. I’ve had an entire week delightedly analysing the cognitive idiosyncracies of our PAWR-reasoning… amazing what a sleep-deprived, flat-white-buzzing brain will do to save cognitive energy!

    Thank you whole-heartedly for a medical podcast which acknowledges the physician as a Person as opposed to a diagnostic machine.

    Some fantastic recent articles you may enjoy:

    http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
    (Atul Gawande on the epidemic of overdiagnosis, and the where-to-from-here)

    https://www.theguardian.com/books/2016/apr/22/literature-about-medicine-may-be-all-that-can-save-us
    (on medicine in literature, writing being my other main passion: and featuring many of the most inspiring contemporary medical minds)

    http://www.nejm.org/doi/full/10.1056/NEJMp1603934
    (a rather-lovely personal piece from the NEJM).

    These aren’t necessarily podcast-fodder, but just lovely mindfood for physicians everywhere, and pieces I thought you might enjoy.

    Keep up the good work, you eloquent souls: I’m a huge fan.

    Kate.

    1. Nicolas Szecket says:

      Kate, thank you for your encouragement. Art and I really enjoy making these podcasts. Its certainly the best part of my day, on those too-few-days that we get to work on this… It makes us so happy that you enjoy the episodes.
      Thanks as well for the links. I will have a read right now! We are always looking for ideas for more episodes. Good stories lend themselves very well to an audio podcast. I am not sure what kind of writing you do…but I had a thought that you could write a piece that we could read for the listeners (or you could even come over to read it yourself…)
      Cheers, Nic

    2. Nicolas Szecket says:

      Hi Kate. Art here. I too share a passion for writing, mostly poetry. I’d love to hear about your writing and how it informs what you do as a clinician!

  4. Richard MG says:

    I was sent this webpage by a colleague and thought you mind enjoy it- the infographic at the bottom is pretty neat: https://betterhumans.coach.me/cognitive-bias-cheat-sheet-55a472476b18#.g6p2qcd5x

    Also an episode of the statistical aspects relating to diagnosis e.g. understanding the utility of likelihood ratios etc. might be useful?

    Thanks for the great podcasts. PS I don’t use facebook hence the website posts!

  5. Richard MG says:

    I would like to commend you both a really enjoyable and educational series of podcasts. I have found them all so interesting. Don’t lose the momentum- keep it up!
    It’s made me a better doctor

  6. Dhamidhu Eratne says:

    Hi Art and Nic,
    I stumbled upon your podcast (saw it on Tony Fernando’s Facebook feed, of course!) and wanted to say that I’m thoroughly enjoying it. I was once a house officer at Auckland Hospital, who wrote poetry (and Art was kind and polite enough to read some of it). Your podcast brings back good memories of general medicine at ACH. I’m now about to finish training in neuropsychiatry in Australia, and have a keen interest in clinical reasoning, and in particular the use of technology to aid diagnosis, and guide treatment decisions. It’s great to see physicians from Auckland setting up such a great podcast – keep up the good work!

    1. Nicolas Szecket says:

      Thanks for your comment Dhamindhu. and for the vote of confidence. Hopefully you’ve had a chance to listen to episode 19 where we introduce the work of Larry Weed. Next up is an interview with the man himself and further discussion about the use of technology to aid diagnosis.

  7. Hi Art and Nic,

    Great podcast. Really improved my commute to work. We’ve posted links on our website and twitter feed.

    A little suggestion if I may? I’d love to hear you interview Dr Gordon Caldwell who shares a lot of interests with you. He’s done loads of work on reducing errors on ward rounds, using checklists, reducing distractions, making care more patient-centred. He’s published some fascinating stuff. He’s also done some great stuff on CPR. A couple of his lectures are on youtube.

    I’m reluctant to put his contact details on this open forum, but he’s very active on twitter @doctorcaldwell and would respond to a direct message.

    Thanks again,
    Alex

    1. Nicolas Szecket says:

      Thanks Alex for the suggestion and the endorsement. We will definitely look into it.

  8. Hi. Greetings for Newmarket, Ontario, just a few km’s north of Nick’s old stomping ground. I’m a UofT grad and an ex-Sinai guy, too, Nick. Just stumbled upon your podcasts. Excellent stuff. Brings me back to the days of morning reports downtown! So, while I started listening to your show because of the diagnostic error material (a la Mark Graber), I really like your Stump The Chump more than anything. I give you a lot of credit for going through the process on the web. I remember how anxiety-provoking it was to speak up at morning report as a trainee, as a chief resident, and then as a staff doc! I’ve already used some of what I’ve learned on your show to enhance my residents’ experience here at Southlake Regional Health Centre. Keep up the great work! Many thanks.

    1. Nicolas Szecket says:

      Thanks Barry. Its great to hear you enjoy the podcast and find it useful! We had heard from others as well that Stump the Chumps is the highlight. We’ll try to do it more frequently.

  9. Marie says:

    Hi guys thank you for such interesting podcasts! I am a junior emergency doctor and recommend them to other emergency doctors all the time.
    I was wondering if you read this article and if you had any opinions on it? It seems embracing uncertainty would help to decrease diagnostic error.. is this part of the problem?
    http://well.blogs.nytimes.com/2016/05/26/doctors-getting-pimped/
    Thanks again!

    1. Nicolas Szecket says:

      Hi Marie. As it happens I had read that article! It was a great depiction and analysis of this almost unconscious practice in med ed.
      I think you’re on to something with “embracing uncertainty” IN FRONT of the patient… This ties into the IOM’s recent position paper on diagnostic error, where there was a big emphasis on “patient engagement” as one of the important strategies to reduce diagnostic error. I personally “think out loud” with my team in front of the patient, as we deliberate on their differential diagnosis. This gives them a peek into our clinical reasoning. Occasionally, they pipe in with a comment like, “Nah, that doesn’t sound right…”. A powerful moment in the diagnostic process…

  10. Zac says:

    Really enjoyed your podcast on feedback. I’m a nurse in a surgical stepdown unit in Missouri, but my previous training was in photography where critiques and feedback were a constant. The info on feedback gave some much needed insight and I look forward to trying to use it with the students I precept.

    1. Nicolas Szecket says:

      great. Thanks for your comments Zac. Very happy you found it useful. I love this idea of “coaching”. i now pre-empt feedback/evaluations to my juniors telling them that I intend to be pedantic. My job is to watch them carefully, identifying anything that could make their performance better the next time…and tell them.

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