Clinical Gist and Medical Education

Abstract

THERE IS LITTLE EVIDENCE THAT CONTINUING MEDIcal education improves practicing physicians’ clinical reasoning and the quality of care. The central roles of medical education include helping clinicians assimilate new knowledge and assessing clinicians’ performance. Although electronic sources can deliver information quickly, human cognitive processes do not allow clinicians to encode all the information into memory promptly and predictably at the point of care (including approximately 1500 articles indexed daily by the National Library of Medicine). When learning new information, humans rely on 2 types of memory: verbatim and gist. Verbatim representations capture the literal facts or “surface form” of information (eg, that a cardiac syndrome is called Takotsubo cardiomyopathy), whereas gist representations capture its meaning or interpretation (eg, that the syndrome may be elicited by stress in the absence of coronary artery disease). An illustration of the difference between verbatim and gist memory is found in a comparison of the oral presentation of a medical student with that of an experienced clinician. The student presents the patient’s symptoms as a list of unconnected facts (eg, fever, cirrhosis, positive blood cultures, ascites, pneumonia, peritonitis, and urinary tract infection). The clinician’s discussion is meaningfully connected: a patient is immunocompromised from cirrhosis, which leads to enterococcal bacteremia with seeding of various sites and a concern about endocarditis. Clinical reasoning (the process of medical decision making) is clearly superior if the gist of patient symptoms can be recognized. Experienced physicians tend to rely on such gist-based reasoning. Verbatim and gist mental representations are key elements of a framework of memory and cognition called fuzzytrace theory. This is termed a dual process theory because it describes how verbatim and gist representations of information are encoded into memory separately and how each forms the basis of clinical reasoning. This framework describes and predicts many clinical observations important to medical educators, such as lack of significant clinical influence from guidelines, calculators, and continuing medical education. Gist memory has implications for medical education with respect to (1) the goals of instruction, (2) assessment, and (3) the type of education provided at the point of care. One of the goals of instruction is to ensure that learners remember not only verbatim detail but that they also retain the core gist of information. Although it may be assumed that physicians who can recall vast stores of knowledge in precise detail have mastered learned material, this has been disproved by research showing that the accuracy of verbatim memories has no bearing on the accuracy of gist memories. Because diagnostic expertise is content-specific, most physicians have gaps in both types of memory and educational methods should provide support for both. Inculcating gist memories requires a different process of instruction compared with rote recall, emphasizing far transfer (the ability to solve new problems that are not superficially similar to old problems). Methods used in medical education to achieve far transfer include presenting diverse examples that differ superficially from one another during training to help learners extract the underlying commonalities across cases. For instance, an elderly woman develops chest pain during her husband’s funeral. The emergency medicine resident orders an electrocardiogram (ECG) that indicates ischemia and cardiac markers that reveal an elevated troponin T level. The patient undergoes emergency cardiac catheterization, which reveals normal coronary arteries and a reduced left ventricular ejection fraction. Apical-ballooning syndrome, which the resident learns is also known as brokenheart syndrome and Takotsubo cardiomyopathy, is diagnosed. Later, the same resident sees a woman with diabetes and a history of heart disease, chest pain, an abnormal ECG, and elevated troponin T, who has an abnormal coronary catheterization. The resident creates a gist memory of the key difference between Takotsubo cardiomyopathy and acute coronary syndrome, specifically, that the origin of Takotsubo cardiomyopathy is not coronary artery disease. Helping learners extract gist has the advantages that gist memories endure over time and are more robust to interference from distractions such as stress and emotion.