From the Masters: Seven lessons from a master clinician – Dr Jess Young’s clinical method

A proverb widely attributed to Socrates is: ‘I cannot teach anybody anything, I can only make them think’. Training medical students to think for themselves is challenging, especially in today’s evidence-based medicine paradigm. More and more, trial results are determined from select patient populations, leading to an algorithmic process that fits the patient into a care plan, rather than developing a care plan for the patient.

Dr Jess R Young (Figure 1), a master clinician with 40-plus years of experience in vascular medicine at Cleveland Clinic, understood the value of putting the patient in the middle of the equation. If the tough cases were not already on Dr Young’s desk, colleagues and partners turned to him for help, as conversations resulted in instructional moments and diagnostic practicums. I was fortunate to have been one of Dr Young’s many students and, later, colleagues. From my recollection, Dr Young utilized seven invaluable steps in his clinical process, all of which have made me a better physician (Figure 2).

Figure 1.

Jess R Young, MD, MSVM. Founding President of the Society for Vascular Medicine.

Figure 2.

Dr Young’s clinical method.

Step 1: Think proactively

Routines are helpful and necessary in patient care. However, routines can become mechanical, even mindless, as we focus on completing a task rather than engaging in a process of discovery. ‘Thinking proactively’ is about establishing an active process of engaging the mind prior to the patient encounter. It also has a hint of emotional engagement, such as: I want to care for this patient well. Establishing that fundamental before starting with the patient sets the tone for everything to follow.

In this era, there is a constant bombardment of messages and information that forces a ‘multitasking’ mindset. Dr Young attended to ‘interruptions’ in between patient encounters, not during them. His mental preparation of thinking proactively was an intentional attempt to de-clutter his mind prior to taking on a new assignment. Busyness carries the danger of being too dependent on others for information. When that happens, assumptions and conclusions are made on a limited and potentially inaccurate foundation. Physicians must be willing and determined to approach each patient with independent and proactive thinking.

Step 2: Perform your own physical examination

Medical care is a team effort, with multiple members and numerous roles. This is particularly true in a teaching hospital where teams are large. It is not uncommon for basic, patient care services to be provided by the least trained and more complex services by the most trained. The whole team though is held together by an accountability system, with the ultimate responsibility bestowed on the attending physician. Physician educators understand these roles and allow those under them to mature and progress according to their talents and knowledge, which can take years.

The least trained member of the team often performs the initial patient interview and examination. Then, the senior resident reviews that work before presenting it to the attending physician for approval. Dr Young was the recipient of many summaries. He listened intently and always asked questions. In fact, Young seemed to have the innate ability to ask the one question that exposed a pertinent fact that no one thought to ask. Dr Young would then enter the patient’s room with his trainees and obtain a medical history and perform his own physical examination. According to him, it is not possible to ensure a correct diagnosis without first collecting the ‘raw data’. In an effort to make those around him better, he would compare auscultation findings and grade pulses. Dr Young demonstrated excellence, even in his proper use of a reflex hammer. He demanded attention to detail from his understudies, and he was never in a hurry. For him, time with a patient was not an issue.

Step 3: Develop a differential diagnosis

There is almost always another disease that presents with the same signs and symptoms as your initial, presumed diagnosis. The importance of stopping to consider other diagnostic possibilities at this stage cannot be understated. Developing the differential diagnosis expands the medical history and leads to a more focused physical examination as one looks intently for diagnostic clues. The practice of adopting this mental STOP sign opens the mind and minimizes the reflex to start with the most common disease entity and pursue it in isolation.

Dr Young memorized and regularly refined lists of diseases that presented with similar signs and symptoms. Those lists were a part of patient rounds; in fact, his trainees were expected to know and recite them upon request. This step of developing a differential diagnosis requires continuous learning and is a crucial step for current and future patient care.

Step 4: Order tests strategically

The purpose of medical tests, like imaging and lab work, is two-fold: to screen for disease or to confirm a diagnosis. Ideally, a test used to confirm a diagnosis would also eliminate another diagnosis from the differential diagnostic list. This approach keeps the role of testing in the proper perspective, with the doctor making a diagnosis and then using a test as a tool for confirmation. In today’s medical care environment, there are so many tests ordered based on the patient’s chief complaint. The patient may not even be interviewed or examined until after the tests are run. This practice bypasses the mental process of test selection. Moreover, interpreting test results outside of the clinical context can be misleading.

Dr Young intentionally used proactive thinking, patient examination, and differential diagnoses to determine his testing selection. He believed in and regularly applied Bayes’ theorem: the predictability of a positive test increases as the prevalence of disease increases in the population. Young ordered tests in waves, not batches. He started with the most likely diagnosis first and then moved into more selective testing as results from the initial testing became available. Tests were interpreted in the clinical context of the patient, with the goal of avoiding a ‘red herring’ (something that misleads or distracts from the main issue). Young would ask us: ‘What are you going to do different if the test is positive or negative?’. His point was simple: if the test result, either positive or negative, did not alter the clinical course then why order the test in the first place. Putting the patient in the center of the investigation requires both knowledge of the clinical context and the ability to select an appropriate and strategic medical workup.

Step 5: Take time to reason

The coherence between the patient’s history, physical examination, and laboratory testing is the best guarantee of safe and effective patient care. It is critical to consider whether these pieces correlate; does the puzzle fit together? This step is often skipped due to time restrictions and unfamiliarity with the clinical context. A physician must consider and appropriately weigh many pieces of information. Being anchored to any one piece of data too strongly can lead to shortcutting the process. The tendency to lock-in on positive test results and minimize negative results limits the evaluation of alternative diagnoses. Attribution error occurs when symptoms are associated with the wrong cause; taking the time to stop and apply reason will reduce this risk.

Dr Young consumed every piece of information presented, but he did not base his conclusions on other people’s data. He took the time to assimilate other’s thoughts with his personal evaluation. He was thorough and detailed when he dictated his personal findings. His documentation contained the important patient variables necessary for interpreting the tests and treatment.

Step 6: Provide individual treatment

The treatment plan should follow the previous five steps and be tailored to the patient. Patients deserve care specific to their problem, which means all options should be initially considered. Then, following a net assessment of risks and benefits, the best approach is decided. Patients may have preconceived ideas regarding which treatment is best for them. However, since what they want and what they need may not be the same thing, it is the physician’s responsibility to know the disease and the patient in order to recommend the treatment most likely to succeed. The perspective that doing something is better than nothing should be avoided. Moreover, the economics of medical practice should not dictate care. Selection of therapy must minimize conflict of interest, economic bias, and any turf issues.

Dr Young was a vocal advocate of knowing what is in the treatment ‘box’, but being willing to think outside of that box. He frequently asked: ‘What are the medical, interventional, and surgical options for this patient?’. This forced us to consider all treatment options so that we truly could make the best decision. Young was free of economic bias and turf issues; he had no conflict of interest.

Step 7: Be willing to reassess

Reassessment is a form of continuing medical education that promotes self-evaluation and reflection. The maintenance of this responsibility seems to be slipping away as patient-centered care often involves longitudinal care by a service of rotating physicians. In this approach, physicians are more likely to be unfamiliar with the problem and specific details unique to the patient. Moreover, the risk of not having an emotional attachment can make personalized care more elusive. Reassessment involves a commitment to reading, thinking, contemplating, and advancing our own knowledge for the benefit of each patient.

When faced with less than optimal results after therapy, Dr Young would go back to the beginning. He would rethink the situation, obtain additional history, re-examine the patient, expand his differential diagnostic list, order other laboratory studies, and/or offer a different therapy. For him, starting over did not equal failure; it was simply a reminder of how difficult it is to get it right the first time. Dr Young honestly, openly, and unashamedly assessed himself. He frequently responded with, ‘I don’t know’, but then quickly returned to his methods to figure it out.

Medical professionals should be taught how to think well. Cogent medical thinking requires deliberate analysis that involves insightful questioning, perceptive listening, and keen observation. There are times when our uncertainties of ‘what to do’ can be paralyzing. His method brings the art of medicine into balance with the science of medicine. The variability of human biology is enough to humble even the most astute clinician. We cannot afford to lose these insightful lessons on patient care from such a master clinician; we need to adopt them as we teach the next generation of students, residents, and fellows how to think.