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.
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.
References:
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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