Show Your Working (Metacognition)
Definition
Explaining how clinical information leads to decisions – focusing not on the diagnosis but justifying the management steps taken (especially in cases of diagnostic or decision uncertainty).
How to Apply
This is also probably one of my favourite frameworks and one that I perceive to be of the utmost importance clinically. Remember back to A level Maths where you get 4 marks for showing your working and only 1 mark for the final answer. The same applies to medicine – management process > diagnosis!
We often have a tendency in medicine to emphasis diagnosis above all else – diagnosis before examining the patient, diagnosis before pre-test probability, diagnosis before considering frailty & multi-morbidity, diagnosis before even completing tests (starting to sound like a poem…)
Even the medical drama – House shows us that the clinical reasoning & management process is more important than the diagnosis. How many times have you done a scan and been surprised at the unexpected results or thought I’m glad I did that? Or felt a surge of compassion after a holistic discussion with the patient’s family for a Best Supportive Care (BSC) approach?
Focusing on the management steps will not only provide optimal care for patients but also develop us as clinicians when we are forced to stop & consider all of our actions. Furthermore, M&Ms, complaints and coroner’s referrals do not scrutinize the diagnosis but the individual MANAGEMENT STEPS!
The Acute Mind 