Diagnosing the learner is a process whereby teachers identify deficiencies in students' medical knowledge and skills. Diagnosing the learner naturally follows the previous component of this approach to teaching (ie, establishing a relationship with the learner) because learners will reveal themselves within comfortable relationships and teachers cannot discern a learner's limitations without asking questions. Diagnosing the learner is a crucial step. Just as physicians must diagnose diseases before treating patients, teachers must diagnose learners before improving learners' clinical development and diagnostic reasoning abilities.
Models for diagnosing learners are either analytic (ie, they break up) or synthetic (ie, they put together). One example of an analytic model is termed Knowledge, Skills and Attitudes (KSA). The components of this model, while educationally important, generally do not present an integrated framework for diagnosing learners at progressive stages of growth. However, models described by Pangaro25
provide extremely useful developmental approaches for diagnosing learners when they are presenting cases, either in the clinic or at the bedside.
observed that medical students progress through 4 stages labeled Reporter, Interpreter, Manager and Educator (RIME). Reporters
take reliable histories, perform accurate physical examinations, and effectively communicate the findings to their preceptors. They are also dependable and have good interpersonal skills. Students should master this level by the 3rd or 4th year of medical school. Interpreters
understand the meaning of patients' problems and prioritize them into differential diagnoses. Students at this level show increased participation in patient care and further integration into the health care team. Managers
act on their diagnostic impressions by making executive decisions and tailoring plans to a patient's individual needs. Educators
gain a deeper knowledge of their disciplines from regular self-directed learning. Through reading, students at this level teach their colleagues and assimilate existing evidence to justify their management decisions. Notably, progression through these 4 stages assumes that students have demonstrated adequate competency in the preceding levels.
Bordage's model is used to assess learners' diagnostic thinking. Bordage et al28-30
showed that clinical reasoning is determined by the organization of knowledge in memory. On the basis of this understanding, Bordage26
articulated 4 types of discourse organization: reduced, dispersed, elaborated, and compiled. Diagnosing learners' reasoning abilities is accomplished by listening to them think through cases, asking probing questions, and using teaching frameworks (described in the “Use Teaching Frameworks” section) that require commitment to a diagnosis.
According to Bordage's model, learners with reduced
knowledge present the facts but provide minimal diagnostic impressions. They fail to link a patient's findings with their own knowledge because such knowledge is lacking. Dispersed
-type learners have abundant knowledge without awareness of context or capacity for application. They describe elaborate histories and physical examinations and give long lists of diagnoses but suggest no working diagnosis, thus missing the forest for the trees. Learners with elaborated
knowledge use terms that are more abstract than the patient's signs and symptoms. These terms are called semantic axes
Examples of semantic axes are acute
vs chronic, unilateral
, and localized
. Using semantic axes, clinicians with elaborated knowledge can weigh likely against unlikely diagnoses, yielding a diagnostic accuracy of about 80%.30
Learners with compiled
knowledge immediately recognize patterns and synthesize the clinical data into highly abstract and “compiled” terms (eg, acute coronary syndrome
). In fact, the diagnostic impression is often so abstract that it needs deciphering for novice physicians to understand its meaning.
Bordage's model describes a spectrum of diagnosticians ranging from weak (reduced and dispersed) to strong (elaborated and compiled), in which stronger diagnosticians are characterized by their abilities to use semantic axes.26
Fortunately, strategies exist for improving weak diagnosticians. Specifically, learners with reduced or dispersed structures have a tendency toward rote memorization, so they are advised to read about their patients and then reflect. For example, after reading about a patient with angina, the learner should ponder, “How would patients with angina present differently from patients with pulmonary embolism, pneumonia, or aortic dissection?” To resolve this problem, the learner would use semantic axes. Thus, he or she might reflect, “Chest pain from angina or pneumonia would develop more gradually, whereas chest pain from pulmonary embolism or aortic dissection would be acute.”