Clinical Gist and Medical Education: Title and subTitle BreakConnecting the Dots

There is little evidence that continuing medical education improves practicing physicians' clinical reasoning and the quality of care.¹ The central roles of medical education include helping clinicians assimilate new knowledge and assessing clinicians' performance. Although electronic sources can deliver information quickly, human cognitive processes do not allow clinicians to encode all the information into memory promptly and predictably at the point of care (including approximately 1500 articles indexed daily by the National Library of Medicine).² When learning new information, humans rely on 2 types of memory: verbatim and gist.^{2 - 3} Verbatim representations capture the literal facts or “surface form” of information (eg, that a cardiac syndrome is called Takotsubo cardiomyopathy), whereas gist representations capture its meaning or interpretation (eg, that the syndrome may be elicited by stress in the absence of coronary artery disease).

An illustration of the difference between verbatim and gist memory is found in a comparison of the oral presentation of a medical student with that of an experienced clinician. The student presents the patient's symptoms as a list of unconnected facts (eg, fever, cirrhosis, positive blood cultures, ascites, pneumonia, peritonitis, and urinary tract infection). The clinician's discussion is meaningfully connected: a patient is immunocompromised from cirrhosis, which leads to enterococcal bacteremia with seeding of various sites and a concern about endocarditis. Clinical reasoning (the process of medical decision making) is clearly superior if the gist of patient symptoms can be recognized. Experienced physicians tend to rely on such gist-based reasoning.⁴

Verbatim and gist mental representations are key elements of a framework of memory and cognition called fuzzy-trace theory.² This is termed a dual process theory⁵ because it describes how verbatim and gist representations of information are encoded into memory separately and how each forms the basis of clinical reasoning.² This framework describes and predicts many clinical observations important to medical educators, such as lack of significant clinical influence from guidelines, calculators, and continuing medical education.^{2 ,4}

Gist memory has implications for medical education with respect to (1) the goals of instruction, (2) assessment, and (3) the type of education provided at the point of care. One of the goals of instruction is to ensure that learners remember not only verbatim detail but that they also retain the core gist of information. Although it may be assumed that physicians who can recall vast stores of knowledge in precise detail have mastered learned material, this has been disproved by research showing that the accuracy of verbatim memories has no bearing on the accuracy of gist memories.² Because diagnostic expertise is content-specific, most physicians have gaps in both types of memory and educational methods should provide support for both. Inculcating gist memories requires a different process of instruction compared with rote recall, emphasizing far transfer (the ability to solve new problems that are not superficially similar to old problems).⁶ Methods used in medical education to achieve far transfer include presenting diverse examples that differ superficially from one another during training to help learners extract the underlying commonalities across cases.

For instance, an elderly woman develops chest pain during her husband's funeral. The emergency medicine resident orders an electrocardiogram (ECG) that indicates ischemia and cardiac markers that reveal an elevated troponin T level. The patient undergoes emergency cardiac catheterization, which reveals normal coronary arteries and a reduced left ventricular ejection fraction. Apical-ballooning syndrome, which the resident learns is also known as broken-heart syndrome and Takotsubo cardiomyopathy, is diagnosed. Later, the same resident sees a woman with diabetes and a history of heart disease, chest pain, an abnormal ECG, and elevated troponin T, who has an abnormal coronary catheterization. The resident creates a gist memory of the key difference between Takotsubo cardiomyopathy and acute coronary syndrome, specifically, that the origin of Takotsubo cardiomyopathy is not coronary artery disease.

Helping learners extract gist has the advantages that gist memories endure over time and are more robust to interference from distractions such as stress and emotion.² Ensuring that learners acquire the essential gist of information promotes longer-term goals of medical education, such as transfer to new cases that were not directly taught, retention of information over long periods, and resistance to distractions that are common in the context of actual practice.

The second implication of gist memory is related to assessment, because the ability to retrieve correct facts—verbatim memory—is not the same as understanding and integrating information to derive its gist. Both forms of memory for instructed information must be assessed. Reciting the newest protocols for diagnosing pulmonary embolism or sepsis is not sufficient in practice. Physicians must integrate patients' symptoms contextually in order to apply the appropriate protocol. For example, a 4-year-old child brought to an emergency department with fever, rhinitis, and sore throat, and who has family members with similar symptoms, probably has a viral syndrome and most likely does not require a workup for sepsis. A novice clinician may work up each symptom separately and order a rapid strep test, sinus and chest x-rays, and blood cultures, rather than treating the likely viral syndrome with fluids, acetaminophen, rest, and observation. Less experienced clinicians tend to treat pieces of information as isolated entities rather than spontaneously picking up the theme or gist that connects the pieces.⁷ Assessment of this ability requires testing methods that differ from assessing recall of isolated facts.

The third implication of gist memory is related to the type of education provided at the point of care, which must be designed differently for clinicians who lack verbatim memories (eg, cannot retrieve the name of a medication from memory) compared with those who lack essential gist (eg, do not understand why following the protocol for deep vein thrombosis prophylaxis, including anticoagulation therapy, is contraindicated in a patient admitted for gastrointestinal bleeding). Continuing medical education should differ with respect to gist vs verbatim memory support. During the course of professional development, there is a shift favoring greater reliance on gist.² However, a systematic review found that those in practice longer scored lower on measures such as medical knowledge and adherence to guidelines and concluded that “Physicians who have been in practice longer may be at risk for providing lower quality care. Therefore, this subgroup of physicians may need quality improvement interventions.”⁸

Without reminders, physicians will lose verbatim memories over time (eg, names of similar sounding medications).^{2 - 3} In addition, aging makes verbatim memories less accessible, and hence increases reliance on gist.⁹ A physician who cannot retrieve the names of the most common types of thyroid cancer, but knows the gist that they are curable, has preserved the essential elements of training. A verbatim reminder of the names—papillary and follicular—could be quickly provided by an Internet search. The upshot of this distinction between verbatim and gist memory failure is that verbatim memory failure can be remedied easily with cognitive assistance from online information tools and is fundamentally different from not understanding the clinical gist, which requires a more comprehensive intervention (eg, an online tutorial, structured review, or teaching exercise).¹⁰

The ability to “connect the dots” across pieces of information depends on understanding the gist that connects them, which can be explicitly taught and assessed. Methods to improve decision making at the point of care are essential if medical education is to make a difference in reducing the quality gaps of medical professionals over the course of a career.