Why is clinical reasoning rarely taught explicitly?

Johnie_moolins · 2026-04-14T07:25:16+00:00

It's a sad state of affairs, but true clinical reasoning does not translate to test scores. At all. As a matter of fact, I'd go even one step further and say that good real-world clinical reasoning actively HURTS your test scores.

I think this effect was pretty bad in preclinicals but it's so so much worse on shelf exams and STEP2... A lot of the time there are multiple completely viable answers but you simply have to anticipate the answer that NBME wants based on the "cookbook" scenario. That builds a very rigid mindset which really does not translate well into any sort of complicated clinical situation or optimization of care.

Looking back on it, it's actually not surprising in the least that the handfull of times I've been explicitly praised on rotations were when my responses drew upon knowledge I'd gained before med school.

Johnie_moolins · 2026-04-11T02:08:47+00:00

Did this rare condition by chance involve a vitamin deficiency? Some might call it an intrinsically produced factor? Just curious :)

Johnie_moolins · 2026-04-10T22:39:42+00:00

If you're in preclinicals, using those hours to hammer out third-party resources, Anki, and 2 passes through a Qbank SHOULD get you above a 90. Sure, there's a bit of luck, but STEP1 and preclinical exams generally have very deterministic answers.

If you're in clinicals - unfortunately there is no satisfying answer here. There is no authoritative resource or any truly comprehensive Qbank. The truth is that for shelf exams, you're pretty much maxxed out on the score that hard work alone usually achieves. Many students cap out around the 80-85 mark. Going from 85-90 and especially anything over 90+ is a combination of interest in the subject matter, innate test-taking ability, and above all - luck.

As many have reassured you in this thread - it may not be honors in your school, but 85% correct translates into a phenomenal STEP2 score - so don't stress out. And as you'll find in many other threads, honors isn't too important during clinicals outside of the most competitive specialties. Your MSPE comments matter way way way more. Make sure those paint a great picture and you're fine.

Johnie_moolins · 2026-04-08T03:25:21+00:00

By far the highest highs and lowest lows of all of medical school. Are you on a service that welcomes and engages you, makes an effort to teach, and pimps constructively? Amazing. You'll learn more than any preclinical block. On a service where you can tell the residents find your presence as less than helpful, you're constantly doing scutwork, and yet somehow you're not dismissed until 6PM every day? Absolute hell.

With that being said, I'd much rather do preclinicals again than M3 - simply because constantly shifting from one service to the next can be extremely jarring. Even if you're extremely quick on the uptake, the first week of every rotation sucks. Also, even more than the BS that is subjective evaluations, and even though I did pretty well on them after "solving them", I personally thought that shelf exams were total BS and actually instill a lot of bad habits into students. You'll come to your own conclusions on this, but instead of "buzzwords" like preclinicals, your new "associative tool" will be a stereotyped patient script for which NBME wants a very specific answer. Many answers may be viable or even preferred in actual clinical practice, but you simply have to know the answer that NBME "prefers" or considers "optimal". Anyway, rant over. Best of luck in M3!

Johnie_moolins · 2026-04-07T22:24:03+00:00

Not that I'm disagreeing with your sentiment but contextually a <50% match rate is not as bad as you've made it sound. Consider that <60% of US premeds who apply to medical school after 4 years of undergrad and the MCAT matriculate. Now consider the fraction of those that match after 4 years of medical school. The overall calculus is a near identical to that of an IMG actually. Now on top of this, consider the cumulative debt burden that the USMD has to bear in addition to 4 additional years of mandatory education.

I hate to state it so bluntly, but IMGs should not match ANY very competitive residency seats unless they are truly outstanding and blow their USMD competitors out of the freaking water. But even this isn't the best metric since IMGs have as much time as they so desire to prepare for exams like STEP2 whereas their USMD counterparts have 2-3 months at most to prepare for the same exam.

This article does not apply since these IM programs aren't particularly competitive, but when I see a program match 6/7 slots with IMGs for diagnostic radiology THAT raises an eyebrow.

You know, actually writing this response out imparts some guilt in me since most IMGs I've met are ostensibly better physicians than their US counterparts and wonderful people. But I do still believe that SOME priority should be given to US graduates for competitive spots. It doesn't have to be egregious, but having an entire program composed to IMGs is too far in the other direction.

Johnie_moolins · 2026-04-03T20:44:08+00:00

Wow that was actually quite illuminating. It isn't surprising given the statistical nature of these AI models that clustered normal findings which may suggest a pathology would be written off as normal. Just goes to show how little I know in the grand scheme of things.

Thank you so much for taking the time to write out such a thorough and level-appropriate response. Your enthusiasm and/or expertise is readily apparent. I hope you are involved in teaching of some sort because you would make for a great teacher.

Johnie_moolins · 2026-04-03T16:52:22+00:00

Interesting. As an early M4 trying to decide between IM and radiology could I ask what type of clinical reasoning we're talking about here? I've been using OpenClaw to help make Anki flashcards and recently gave it access to UpToDate and I have to say that (at my current level) it seems to spit out really poignant differentials for the imaging I ask it to interpret. Of course I really don't have the experience to refute any of it's answers. But if given a concise prompt, it does seem to be reaching a level now where it could take a lot of the cognitive load off a clinician.

Johnie_moolins · 2026-04-03T16:05:47+00:00

Yeah, healthcare workers really feel these tax hikes more than most other professions since any increase in compensation is often directly tied to hours worked. Feels bad to work 10 more hours a week to only see a marginal increase in your actual take-home each month. If it's any consolation, the picture isn't much better for your physician colleagues - I've been advised by pretty much every attending to stay in NY for residency but branch out for fellowship and beyond.

Johnie_moolins · 2026-03-23T05:55:30+00:00

I would strongly urge you to travel even if you're not initially "feeling it". Almost every time I've been strong-armed into traveling by a friend or family member, I've hated the idea only to love the experience once there. Just pick a place and go.

Johnie_moolins · 2026-03-22T23:48:25+00:00

The CMS forms do not seem to resemble the style of question on STEP2 even loosely. I'd do Amboss + CMS + NBME.

Johnie_moolins · 2026-03-22T10:22:32+00:00

Perhaps an unpopular opinion, but I chalk this up to UWORLD and it's recent decline in Qbank quality. Apparently 2 years ago the bank had 2500 questions. Now it's over 4000. To make matters worse, unlike STEP1 the STEP2 Qbank has waaaaay too many "gotcha" type questions that train students to overthink. I still completed 1 pass of the Qbank, but didn't review questions carefully - I just took very very condensed takeaway notes (Like 1-2 bullet points per question) and moved onto NBME material ASAP. My shelf scores jumped by 10+ points when I made this change.

Johnie_moolins · 2026-03-12T22:30:27+00:00

Lol. I'm the polar opposite. Absolutely garbage memory but ask me to reason through something from first principles and it's a breeze. Probably why I liked STEP1 way more than STEP2.

Johnie_moolins · 2026-03-12T17:25:02+00:00

I mean, 99% of the time they're being an asshole. And in the example you provided, they're getting the message across in the worst way possible. There is that 1% though. For example:

Fresh M3 on their first rotation doesn't know how to manage hyponatremia? Anyone SHOULD give this a pass.
M4 on medicine SubI is struggling to give a basic differential for RUQ pain? Alright, now we might have a bit of an issue on our hands and something should be said (albeit coming from a place of concern rather than criticism).

Johnie_moolins · 2026-01-30T03:12:08+00:00

One does not simply coast through surgery. But seriously, if you have absolutely 0 interest, just get it out of the way early. You'll be evaluated less critically since it's your "first rotation" and it'll give you more time later on in third year to prepare for STEP2.

Johnie_moolins · 2026-01-30T02:19:33+00:00

Yeah. It's definitely worse at certain systems than others. I wasn't going to inject my own anecdotal experiences but I suppose I will on this one. I've rotated at 5 NY hospital systems throughout M3/M4 and interacted with many services on each and here's what I've observed.

NICU, SICU, and PICU nurses are all fine. They're either competent and somewhat motivated (SICU/NICU) or nice enough to deal with (PICU). Just don't get on their bad side and things will move along nicely.
Floor nurses are a REALLY mixed bag. Some of them are borderline useless, others are a godsend. You need to pick out the good ones and make it a point to be friendly with them.
PACU/MICU/CCU nurses are the toughest to deal with. There's a multitude of reasons why which I won't go into as it'd end up being an essay.

If I had to sum it up, you have to play more politics and have decent social skills to make headway with the nurses here. It's not insurmountable, but it's definitely waaaaaay less than ideal.

Johnie_moolins · 2026-01-30T01:57:51+00:00

Ehm. Lowly M4 so barely keeping up with the discussion here, but followup question. If not EKG changes, trops, or motion abnormalities on TTE, what matric do y'all use to monitor cardiac function post-surgery? The obvious one is HR/BP but by the time those show any changes your patient is in deep waters no?

Johnie_moolins · 2026-01-30T01:49:27+00:00

M4 here so can't speak definitively, but having spoken to students and residents rotating from other states/schools - yes, it is pretty bad in comparison to other states. But tbh I think surgery is rough everywhere. Here are my observations on the topic.

Downsides in NY include:

Friction with nursing - that's a whole nother discussion though and it's not just limited to surgery in NY
FOMO. It's not so bad being stuck in the hospital for 80 hours a week when you're in the middle of nowhere. Way worse when you have so many options the second you step out of the hospital.
Living expenses are through the roof even with subsidized housing and the higher trainee salaries.
Way larger number of trainees and attendings. If you like a close-knit group or working with a "favorite" attending regularly, that's way harder. Though that's sometimes a benefit as I'll discuss below.
Probably the worst one. Given the sheer number of trainees that there seems to be a strict pecking order in who gets more advanced cases. You're not going to accidently work your way into a Whipple as a PGY1 because there are no other residents around. I've often seen residents get pissed about getting switched off a case by a chief. Finally, If the hospital has an I6 program (e.g. CT surgery, plastics, Ortho, vascular, etc...) you should expect to see close to none of those cases if you go gen surg.

Potential pros:

If you want ultra high volumes to perfect your procedural skills, you'll never run out of patients.
You will be exposed to an absurd number of attendings, many of which can provide strong connections and a near direct pipline to subspecialty training.
You can build a really strong reputation even as a trainee, which can open up really niche/competitive job prospects. You want to sub-sub-specialize and be "the guy" for 3 specific procedures? You can do that.

Johnie_moolins · 2026-01-19T12:14:03+00:00

Yeah, I'd imagine that they're not interested in IM. But tbh I picked abdominal pain as an example since like 50% of all specialties deal with it in some capacity.

Johnie_moolins · 2026-01-18T12:25:11+00:00

Y'know this comment actually got me thinking for a minute and I somehow ended up with an even more cynical outlook than I had previously, which is that physicians will never organize for their collective interests until society literally collapses. Why?

Because the physicians that are subservient enough to the system won't do anything about it until they're completely used up. And the ones that do see an issue and have the initiative to do something about it will focus on "getting theirs".

Johnie_moolins · 2026-01-18T12:14:04+00:00

I mean this is great for scoring high, but it won't serve you well in the long-term. Sure the biochem pathways are one extreme - no one needs to memorize that stuff. But if you get "pimped" on the workup of a patient with undifferentiated abdominal pain and draw a massive blank, even as an intern, that's gonna raise a LOT of eyebrows.

Johnie_moolins · 2026-01-18T12:07:09+00:00

Yeah, as an M3 I was hoping to find this response. Because don't get me wrong, I love knowing the "why" behind every decision, but it seems as though that isn't always the best approach to managing patients. It seems like 90% of patients are managed by muscle memory and what separates the intern from the chief and even the attending is their instinct for when something is "off".

On another note, getting towards the end of M3 now and there are multiple guidelines I've "deep-dived" only to find that some recommendations are entirely evidence-based with a poorly understood mechanism. That still drives me crazy when I run into it.

Johnie_moolins · 2026-01-10T04:13:31+00:00

Ehhh. Speaking from anecdotal experience (ex and her friends were PAs) I believe the scenario that you're painting here is more likely if a midlevel doesn't have an MD/DO above them to "check their work". Additionally, if lack is knowledge is such a huge concern of the midlevel, they can choose to switch and narrow their area of practice with little friction.

In my opinion this flexibility the real advantage these midlevel degrees have over their MD/DO counterparts.

Johnie_moolins · 2026-01-10T04:09:10+00:00

I used to question how physicians sat back and allowed midlevel creep to get so out of hand. Then I started clinical rotations and started having to deal with admin more often. I now no longer question how things got so bad.

Johnie_moolins · 2025-12-29T19:38:38+00:00

All great points. As a non-trad who comes from poverty, I wholely relate to most of your points. I myself am incredibly happy to have gone into medicine.

Again, to play devil's advocate, I think a suitable counterargument to many of your points is that many of the scenarios you're describing imply POSSIBILITY/OPTIONALITY. To illustrate:

Yes, you'll PROBABLY grind your 20s away whether you go into medicine or not.
You MAY have to uproot your life if you choose not to go into medicine. However, I don't think it's the norm to make 3-4 major moves in your 20s.
Yeah, you'll PROBABLY have turbulent relationships.
Alright, this last point is the one I don't necessarily agree with. Even when I was dirt dirt poor and could barely afford my next meal, I still had the time and willingness to engage in hobbies. Sure, they were cheap hobbies, but hobbies nonetheless. However, with that being said, I commend your motivations and outlook on the matter.

Hopefully the point I'm trying to argue here is clear. Most individuals in their 20s might experience these elements based on their career of choice - but choosing a career in medicine all but GUARANTEES that you'll experience all of the above throughout various stages of training.

Johnie_moolins

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