DEVELOPMENT OF MEDICAL EXPERTISE AND CLINICAL DECISION MAKING -

A COGNITIVE APPROACH

Prof. (Dr.) V. K. Chauhan, MD (Hom)

Ex-Principal / Professor
Dr B R Sur Homoeopathic Medical College, Hospital & Research Centre,
Nanak Pura, Moti Bagh, New Delhi

Dr. Meeta Gupta, MD (Hom)

Chief Medical Officer (NFSG)
Dr B R Sur Homoeopathic Medical College, Hospital & Research Centre,
Nanak Pura, Moti Bagh, New Delhi

Abstract
The primary aim of medical education is to prepare a medical graduate to develop knowledge,
aptitude and skills to be competent, confident and proficient so as to serve society as health
professional, medical educator, researcher and policy maker. However, there is lack of universal
appreciation and application of the dynamics of the levels of cognition by all players in the
medical profession. In the wake of information explosion and unprecedented developments in
the medical field, it is essential to define minimum essential knowledge and skills for the
development of medical expertise and clinical decision making. Taxonomy of Educational
Objectives, often called Bloom's Taxonomy, is one of the systems utilized in the composition and
assessment of educational learning.

Key Words: Bloom’s Taxonomy, Homeopathy

Clinical management of a case is of paramount importance for every practicing physician. A

precise therapeutic formulation, in most cases, lead to effective treatment. Case management
must therefore always be logical based on the dynamic internal and external environment of a
human body. Investigations and treatment must be reasonable on the basis of the clinical
assessment and standard treatment protocols.

Case management is a cognitive process that involves the physician in analytical reasoning of the
patient’s condition. To an experienced physician, the processes involved are mostly
subconscious. Most physicians would ascribe that capacity to knowledge and experience gained
over years of clinical practice.

The cognitive process of clinical case management is complex and there is no conventional
approach to describe this complexity. However it can be comprehended in the light of
“Taxonomy of Educational Objectives”, proposed in 1956 by Benjamin Bloom, an educational
psychologist at the University of Chicago. Bloom's Taxonomy is described in three interrelating
dynamic domains:
1. Cognitive domain (intellectual capability, i.e., knowledge, or ‘think')
2. Affective domain (feelings, emotions and behaviour, i.e., attitude, or 'feel')
 3. Psychomotor domain (manual and physical skills, i.e., skills, or 'do')

The cognitive domain is categorized into sequential progression of six dynamic levels, i.e.
remembering, understanding, applying, analysing, evaluating, creating. An important principle is
that a physician must develop proficiency in skills related to each level before progressing to the
next. There is progressively increasing difficulty in various level of learning development in each
domain.

Utilization of Cognitive Levels in Clinical Decision Making

A seven year old boy presented with cough, loss of appetite and
tiredness. There was history of fever along with pain and swelling
Case Summary of joints three weeks back. On inspection he had fever, pallor, pedal
(indicative only) oedema. On palpation he had enlarged axillary nodes, rapid pulse,
palpable precordial thrill, and enlarged tender liver. No stethoscope
was available to auscultate the chest. He was diagnosed as a case of
cardiac failure due to valvular damage from rheumatic fever.
In order to make such specific assessment, all levels of cognition
are involved, from case history, physical examination, differential
diagnosis, investigations, treatment and prognosis.
Cognitive Level Application
1 Remembering  Recall of basic facts of anatomy, physiology, pathology.
(knowledge, recall,  Identification and recognition of symptoms and signs.
identify, recognize)
2 Understanding Ascribing symptoms and signs to appropriate organ systems:
(comprehension,  Cough, tiredness, oedema, thrill to cardiovascular system.
translate,  Weakness, tiredness, pallor, rapid pulse to haematologic system.
extrapolate)
3 Applying Relate or associate symptoms and signs to specific pathological
(relate, transfer, conditions:
associate)  Enlarged tender liver suggests hepatitis or congestive cardiac
failure.
 Rapid pulse suggests hyperdynamic circulation.
4 Analysing Discriminating or distinguishing specific from non-specific
(discriminate, symptoms and signs:
distinguish)  Fever, anorexia, tachycardia are non-specific.
 Precordial thrill is specific for organic valvular cardiac lesion.
5 Evaluating Compiling features together into a pattern for specific condition:
(constitute, combine,  Cough, pedal oedema, tachycardia, enlarged tender liver suggest
formulate, specify) congestive cardiac failure.
 Palpable thrill indicates failure from organic valvular cardiac
lesion.
 Age of onset suggests acquired lesion.
 History of fever with pain and swelling of joints suggests
rheumatic fever.
6 Creating  Correlation of provisional diagnosis with all signs and
(validate, argue, symptoms.
reconsider, appraise)  Missing features of diagnosed condition.
 Re-evaluating features not explained by diagnosis.
 Differential diagnosis / other causes.
 Interventions required and justification.
 Expected therapeutic response.

Utilization of Cognitive Levels in Homoeopathic Undergraduate and Postgraduate Medical

Institutions

Cognitive Level Application

1 Remembering Beginner (first year student) has no concept of what is organized
(knowledge and knowledge of medical subjects, and how to co-relate each other.
development of Student must be able to recall facts or explain prototypes of
elaborate causal disease processes.
networks) Knowledge should be very basic, measured and synchronized one.
Aim is to generate a long term interest in the subject.
2 Understanding Middle level academic needs are for students of second and third
(comprehension years.
and compilation of Learners have developed a concept of pre-clinical and can now co-
abridged networks) relate with clinical subjects.
They should be provoked to introspect anatomical, physiological,
pathological and epidemiological dimensions of the disease, and
correlate them clinically.
3 Applying Academic level of fourth year demands clinically oriented study.
(Emergence of At this stage they have good background of pre-clinical and
Disease Imprints) clinical subjects.
Disease imprints develop based on repeated encounters with
patients.
4 Analysing Academic level of internship period demands advanced applied
& and and research oriented study, along with professional development
5 Evaluating of young graduate.
(Synthesising and In involves integration of philosophical concepts based on
storing case Organon, Miasmatic interpretation; Natural History of Disease in
management as terms of Primary, Secondary and Tertiary Stages and their
memory imprints) treatment planning with use of Miasmatic, Constitutional, Psycho-
pathological and Patho-Physiological basis.
Such encounters with individual patients become “imprints” in the
memory of interns, the recollection of which often activates the
recall of relevant knowledge. As such new patients are recognized
as similar to patient x, and treated as how patient x was treated.
6 Creating Each physician has his own clinical reasoning for case
(Life-long management so that methods are varied.
Thinking) The best level for this stage is PG curriculum. One should study all
 ways of learning, understand their individual principles and
guiding features, observe merits and demerits, and deduce a logical
explanation of each.
After studying all ways, let each one adopt his own method and
pursues it through professional life.

Conclusion
Although clinical decision making is the prerogative of the physician at the best side and is very
frequently instinctual as the patient walks into the consulting room, the classification of cognitive
domain must be systematically applied to one’s own learning or analysis of case management
process, irrespective of the level of skill, knowledge and efficiency so that physicians, teachers
and students appreciate cognitive levels of different clinical activities.

Reference:
http://www.bloomstaxonomy.org/

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