February 12, 2014

The Perils of Clinical Pearls

by Kimberley Harris, PharmD, BCPS, PGY2 Critical Care Pharmacy Practice Resident, University of Maryland

Picture this situation: you’re standing on rounds listening to the attending physician relate anecdotes about patients similar to the one being discussed and something catches your attention.  So you quickly write down this pearl of wisdom hoping you’ll remember it in the future.  I’ve kept a running list of these teaching points for nearly four years and have accrued an 80-page word document filled with “interesting thoughts to remember for later.”  But what have I collected exactly?  Could some of those teaching points contradict each other?  How will I retrieve a point written years ago and reliably use it in a clinical situation if I cannot remember its source or attest to its validity?

Clinical Pearls: Defined

The term “clinical pearl” is commonly used in medicine, but what are you truly getting when a someone uses the term?  Clinical pearls have been described as brief statements that are transmitted in a “catchy delivery style”, “generalizable to many patients”, “easy to remember”, and pithy “expert opinion.”1,2  A clinical pearl is usually expressed by someone who is respected for having great knowledge about a topic through years of experience.2  Clinical pearls summarize key concepts and learners scramble to capture them.  However, from a teaching and learning perspective, these pearls lack certain important qualities.

The Dark Side of the Pearl

If clinical pearls are based on anecdotes and derived from personal experience, many (perhaps most) aren’t backed up by evidence.  And learning how to use evidence to make decisions is critically important in healthcare today.1  Learners who rely on (and teachers who overuse) clinical pearls may hamper the development of critical thinking skills because they foster surface learning (which focuses on memory and recall).  Moreover, clinical pearls are hard to organize in a systematic way and do not require the learner to compare this new knowledge to prior knowledge.1,3  For example, the acronym “MONA BASS” is commonly taught as a way to remember the medications that should be used to manage patients who present with acute coronary syndromes.  While this pearl may facilitate the learner’s ability to recall the recommended medications, it does not indicate which statin or dose would most benefit the patient, which medications reduce mortality, and which medications merely relieve symptoms.  A learner might forget that the “A” in BASS stands for “ACE inhibitor” (not “aspirin”) and that the second “S” stands for “salicylate”, a reminder to use aspirin … not any salicylate … and in some cases another antiplatelet agent would be a better choice.  So while MONA BASS is a helpful mnemonic, it only provides superficial clues about what the right course of action is and can easily be misinterpreted.

While a pearl can be useful in situations when data is lacking, they ideally should be paired with evidence in order to promote deep learning.  This type of learning focuses on problem solving, comparison of new knowledge with previous knowledge, and a search for truthfulness in the information that is presented.3   The following are a few strategies that teachers can employ to promote analytical thinking and avoid using the pearl as a sole teaching strategy. 

Facilitating Critical Thinking with Pearls

The One Minute Preceptor: This model was developed to efficiently and effectively teach in an experiential environment.  It uses a strategy which combines the Socratic method of questioning with constructive feedback and one minute of didactic instruction.  During these brief encounters, the preceptor discusses the general principles (or perhaps deliver a clinical pearl).4  By “gaining a commitment” from the learner and “probing for supporting evidence” via directed questioning, this facilitates the development of critical thinking skills.4  Using this Socratic-style of questioning, the teacher guides the students’ thought process to lead them through the clinical assessment.  Moreover, students do the majority of the talking.3  Once the students have realized the “big picture”, the clinical pearl is then used to summarize the key point(s).  The clinical pearl is now linked to a thought process related to a specific situation that the learner has experienced rather than rote memorization of a fact.

Link Pearls to Evidence: Evidence Based Medicine (EBM) is perhaps the antithesis of a clinical pearl.  It relies on available scientific evidence to make decisions for an individual patient.2  Critical thinking skills are necessary when applying EBM because the clinician must determine the quality of evidence and decide if the findings apply to the patient based on the population enrolled in the study.  However, EBM is not always useful, especially when the available evidence can’t be applied to the specific clinical situation at hand.  Ideally, EBM should integrate research findings with clinical experience to arrive at a decision that applies to the patient’s unique characteristics and situation.5  Since pearls are based on experience, they can be useful because they summarize the collective wisdom and expert opinion.1 This is particularly important when EBM does not exist for a specific situation.  However, analytical skills are necessary to realize when an expert opinion is appropriate.  Pearls can be used as a way to introduce the learner to the application of EBM.1  Back to our example, after introducing the “MONA BASS” pearl, a teacher could link the acronym to the guideline recommendations.   To then facilitate deep learning, students can use this foundation to critically examine the literature that supports the guideline recommendations.  This will help develop a connection between the surface message of the pearl and the deeper meaning behind it.

See the Pearl in a New Light

Clinic pearls alone do not provide the decision-making skills necessary to take prior knowledge and apply it to new situations.  Now, four years into my career, I can take my 80-pages of teaching points and erase half of them — not because I have memorized those facts/statistics/pearls, but because I now have the deep learning and critical thinking skills that give meaning to them.

1. Lorin ML, Palazzi DL, Turner TL, Ward MA. What is a clinical pearl and what is its role in medical education? Medical Teacher 2008;30:870-4.
2. Mangrulkar RS, Saint S, Chu S, Tierner LM. What is the role of the clinical “pearl”? Am J Med 2002;113:617-24.
3. Harasym PH, Tsai T, Hemmati P. Current trends in developing medical students’ critical thinking abilities.  Kaohsiung J Med Sci 2008;24:341-55. 
4. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419-424.
5. Straus SE, Richardson WS, Glasziou P, Haynes BH. Evidence-based medicine: how to practice and teach EBM, 3rd ed. Elsevier Churchill Livingstone. p. 1. 

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