Using Shadowing to Learn Clinical Decision‑Making: A Case‑Based Approach

Only 27% of premeds use shadowing to actively practice diagnostic reasoning; most simply “watch and nod” without ever testing their own thinking.

That gap is exactly where you gain or lose real clinical intuition before you ever touch a prescription pad.

Shadowing can be passive background noise or it can be your first lab in clinical decision‑making. The setting and the name tag might be the same. What changes is how you structure what you are seeing into cases, choices, and consequences.

Let me break this down very specifically.

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Why Clinical Decision‑Making Is the Real Target of Shadowing

Most students say they shadow “to see what doctors do” or “to get hours for my application.” That is a low bar.

Clinical decision‑making is the core skill you are trying to glimpse:

• How a clinician frames a problem
• How they handle uncertainty and incomplete data
• How they trade off risks, benefits, and patient preferences
• How they choose the next best action, not just the final diagnosis

You cannot write orders as a premed. You cannot give medical advice. But you can build the cognitive scaffolding that clinicians use, if you treat each patient encounter as a case.

A useful mindset shift:

• Passive shadowing question: “What is going on with this patient?”
• Decision‑making question: “Given what we know right now, what would I do next, and why?”

This article focuses on a case‑based approach: using real patients you see while shadowing as live “exam questions” and then deconstructing how the attending answers those questions in real time.

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Setting Up Shadowing to Maximize Decision‑Making Exposure

Not all shadowing is equal. Two afternoons watching routine follow‑up visits in a cosmetic dermatology clinic will teach you something about communication and efficiency, but very little about tough clinical decisions.

1. Choosing the Right Environments

If your aim is clinical reasoning, prioritize settings where:

• New problems are common
• Workups and differentials are frequent
• Risk–benefit decisions are visible

High‑yield environments for decision‑making:

• Emergency Department (ED)

  • High volume of undifferentiated complaints (“chest pain”, “weak and dizzy”, “abdominal pain”)
  • Constant decisions: treat vs discharge, lab vs imaging, admit vs outpatient
  • Good for learning risk stratification and “worst‑first” thinking

• General Internal Medicine / Hospitalist Service

  • Daily reassessment: is the patient improving, stable, declining?
  • Management decisions: escalate care, change antibiotics, consult specialists
  • Great to see longitudinal thinking over a few days of shadowing

• Primary Care / Family Medicine

  • Balancing evidence‑based guidelines with patient preferences and real‑world barriers
  • Chronic disease management: blood pressure goals, diabetes regimens, screening decisions
  • Excellent for learning shared decision‑making

• Subspecialties where diagnostic puzzles are common

  • Rheumatology (vague systemic symptoms, long problem lists)
  • Neurology (localization, pattern recognition)
  • Infectious Disease (source control, antibiotic choice, epidemiology thinking)

Even in specialties that seem “procedural” (orthopedics, surgery, GI), target days or times involving consults, pre‑op decision visits, or post‑op complications, where more reasoning is on display.

When you request shadowing, be explicit:

“I am especially interested in how physicians make decisions under uncertainty. Are there particular clinics, days, or services where I might see more initial evaluations or complex cases?”

That signals seriousness and often gets you placed in higher‑yield contexts.

2. Align Expectations With the Physician

Before or at the start of your first day, ask for 5 minutes to clarify your goals:

• “I am trying to learn how clinicians reason through cases, not just the final answers. Is it alright if I occasionally pause after visits to walk through what you were thinking at key decision points?”

• “If there are moments where you are deciding among several options—tests, treatments, admission vs discharge—could you maybe ‘think out loud’ briefly so I can follow the reasoning?”

A surprising number of physicians will respond well to this. Medical students rarely ask that clearly; premeds almost never do. You stand out.

You are not asking them to teach you continuously. You are asking for short windows of explicit reasoning that you then develop on your own after hours.

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A Case‑Based Framework You Can Use in Any Encounter

To turn shadowing into a decision‑making lab, you need a mental template. Something you can quickly apply in a 10‑minute visit without getting lost.

Use a simple, repeatable frame:

1. Case Framing – What problem is the clinician trying to solve?
2. Key Data Selection – What data did they focus on, and what did they ignore?
3. Differential Thinking – What were the plausible options?
4. Decision Point(s) – Where were actual choices made, and what was chosen?
5. Rationale and Tradeoffs – Why that choice, with which risks accepted or avoided?
6. Follow‑up Plan – How will they know if the decision was right or needs revision?

Now let us walk through how you apply this live.

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Live Example: Chest Pain in the Emergency Department

You are shadowing on a busy evening ED shift. A 54‑year‑old male presents with “chest pain.”

Step 1: Frame Your Own Case Before Hearing the Attending

As soon as you hear “chest pain,” silently state to yourself:

• Core clinical question right now:
  “Is this chest pain likely to be life‑threatening, and what immediate actions are necessary?”

Before the physician goes in, you create a skeleton:

• Immediate life‑threatening possibilities you remember:
  • Acute coronary syndrome (ACS)
  • Pulmonary embolism
  • Aortic dissection
  • Tension pneumothorax
  • Esophageal rupture (Boerhaave)

You will not know all of these at premed level, but you can at least think: “heart, lungs, big vessels, holes/ruptures.” The point is to train your brain to ask, “What could kill this person soon?” before thinking about benign causes.

Step 2: Watch the Opening Minutes Like a Hawk

The first 2–3 minutes of the encounter are prime decision‑making territory.

Notice:

• What are the first 3 questions the attending asks?

  • Onset and character of pain?
  • Exertional vs at rest?
  • Associated dyspnea, diaphoresis, radiation?

• What immediate actions are ordered before the story is even complete?

  • EKG, vitals, IV access, aspirin?
  • Oxygen? Cardiac monitor?

Ask yourself silently: “What would I order right now if I had to pick 2 things?” Then compare.

Step 3: Build a Micro Differential in Real Time

After a few minutes of history and some physical exam, pause mentally and write (if appropriate) or mentally note:

• My top 3 possibilities right now:

• One thing I would be very worried about missing:

  • e.g., “Aortic dissection if pain is abrupt, tearing, radiating to back, with blood pressure differences.”

You are not aiming for accuracy at this stage. You are training the habit of committing to an internal hypothesis before you see what the expert does.

Step 4: Identify the Decision Points

Decision points are usually around:

• Tests ordered (EKG, troponins, D‑dimer, CT angiography)
• Disposition (discharge vs observation vs admission)
• Treatment intensity (aspirin only vs full ACS protocol vs no cardiac workup)

For each key order or decision, quietly ask yourself:

• What decision are they making here?
• What are the options they are implicitly choosing among?

Examples:

• Ordering a D‑dimer? That is a decision to consider PE vs other causes.
• Choosing serial troponins and observation rather than discharge? That is a decision that short‑term cardiac risk is not negligible.

If you get a brief moment afterward, you can ask one focused question:

“When you decided to admit for observation rather than discharge, what specific features of his story or EKG made you lean that way?”

Notice the structure:

• You named the decision (admit vs discharge).
• You asked about features—data that tipped the scale.

You are not asking for a lecture; you are asking them to label the weights on their mental balance.

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Turning Each Patient Into a “Case” You Can Study Later

When the shift is over, most students remember 2–3 dramatic cases vaguely and forget the details. That is wasted material.

You want to convert real encounters into study‑ready cases.

1. Create a 6‑Line Case Summary Template

After each day, choose 2–3 patients and write them into a very short, structured format:

1. ID: Age, sex, key defining features
2. Chief Concern: Why they sought care, in 1 sentence
3. Key Data: History and exam details that actually changed decisions
4. Clinical Question: The main decision the clinician faced
5. What Was Done: Tests, treatments, disposition
6. Rationale (as you understood it): Why that path seemed chosen

For the chest pain case:

1. 54‑year‑old man, smoker, hx hypertension, ED visit
2. Substernal chest pressure for 2 hours, started at rest, radiates to left arm
3. Diaphoretic, mildly hypotensive, EKG with ST depressions in lateral leads
4. Is this unstable angina/NSTEMI requiring admission and ACS protocol, or could this be managed as low‑risk chest pain?
5. Aspirin, heparin drip, serial troponins, admission to telemetry
6. Likely high short‑term cardiac risk due to age, risk factors, EKG changes, ongoing pain

Next time you see any chest pain in shadowing, you compare it against this prior “case index.” Patterns start emerging: age groups, EKG findings, what gets admitted vs discharged.

2. Add a “What Would I Have Done?” Line

After the 6 lines, add:

7. My decision at the key choice point (before knowing outcome)

Force yourself to write it as if it were a USMLE‑style question:

“Given this presentation, I would [admit to telemetry on ACS protocol] rather than [discharge with outpatient stress test], because…”

You are building a habit of making defensible, explicit choices, even as a trainee observer.

3. Create Themed Mini‑Collections

Over time, group cases you encountered by theme:

• Shortness of breath
• Syncope
• Abdominal pain
• Medication decisions (starting/stopping/adjusting)
• Screening/preventive care decisions

Each theme becomes a mini casebook of 5–15 patients you saw, with key decisions.

When you eventually begin clinical rotations, this prior exposure will give your reasoning a “pre‑loaded” structure that most peers do not have.

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Shadowing in Clinic: Learning Longitudinal and Preventive Decisions

Emergency medicine is high drama. Outpatient clinics are where you see subtler, but equally important decisions.

Let us take a common internal medicine / primary care scenario.

Case: Primary Care Diabetes Visit

You are shadowing a general internist. A 62‑year‑old woman with type 2 diabetes comes for follow‑up. Her A1c has risen from 7.4% to 8.6% in 6 months.

Your decision‑making lens:

1. Clinical Question
   “How aggressively should we escalate therapy, given her current control, comorbidities, and preferences?”

2. Key Data to Watch For

   • Current medications (metformin dose, any GLP‑1, insulin, etc.)
   • Comorbidities (CKD, heart failure, ASCVD)
   • Lifestyle constraints (work schedule, financial concerns, injection aversion)
   • Any hypoglycemic episodes

3. Possible Options You List Mentally

   • Increase current medication dose
   • Add a second oral agent
   • Start GLP‑1 agonist or insulin
   • Emphasize lifestyle changes with minimal med change (low intensity)

4. Decision Points

   • Did they prioritize cardio‑renal protection (e.g., SGLT2 inhibitor) because of CKD or heart failure?
   • Did they deliberately avoid insulin due to hypoglycemia risks given her living situation?
   • Did they choose a medication based on cost or insurance coverage?

5. After the Visit, Ask a Focused Question

   • “There were several medication options. What made you choose [X] instead of [Y] for her specifically?”

You learn that clinical decisions are rarely about “What is the best drug?” They are about “What is the best choice for this person, given her kidney function, insurance, risk of hypoglycemia, and likelihood of adherence?”

That is decision‑making under constraints, not under ideal textbook conditions.

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Shadowing as Real‑World “Multiple‑Choice” Training

Standardized exams present you with clear choices labeled A, B, C, D. Real clinical encounters present messy narratives, then force a decision that has no answer key.

You can simulate multiple‑choice structure for yourself during shadowing.

1. Pre‑Commitment Exercise During a Visit

Choose a moment in a visit when the clinician steps out to review labs, order imaging, or document.

Quickly list 3 plausible next steps:

• A: Order X and discharge with instructions
• B: Order Y and observe or admit
• C: No further tests, treat symptomatically

Then label:

• Which seems most aggressive?
• Which seems most conservative?
• Which would you choose, and why?

When the physician returns and acts, you compare. If appropriate, ask:

“I had thought of options A and B, and I would have leaned toward B because ___. You chose A—could you help me see what I am overestimating or underestimating in terms of risk/benefit?”

That is a very different question than “Why did you do that?” You show you tried to reason first, then you calibrate.

2. Track Your “Prediction Error”

Over weeks of shadowing, note when your expected decision differs from what clinicians choose.

Patterns you might discover:

• You systematically over‑admit or over‑test in your thinking (safety bias).
• You underestimate how much patient preference shifts a decision.
• You ignore specific red flags that experts never ignore.

Each discrepancy is a data point in calibrating your future clinical judgment.

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Learning How Doctors Think Under Uncertainty and Time Pressure

Decision‑making is not only about medical facts. It is also about how clinicians manage uncertainty, incomplete data, and workflow limitations.

1. Notice How They Verbalize (or Do Not Verbalize) Uncertainty

Listen for phrases like:

• “I think this is most likely… but we need to rule out…”
• “Given your history, I am not comfortable sending you home without…”
• “We cannot be 100% certain today, but here is the plan to watch for warning signs…”

Ask yourself:

• When do they explicitly share uncertainty with patients?
• When do they “hold” uncertainty internally but project calm?
• How do they document reasoning in the chart to justify their choices?

This is the difference between good test‑takers and safe clinicians: comfort with being less than certain, while still acting decisively.

2. Watch Tradeoffs Between Thoroughness and Reality

In a busy ED or clinic, you will see tension:

• Only 10 minutes per patient.
• Hallway stretchers, limited imaging slots.
• Long waiting room times.

See how decisions flex:

• A test that would be ideal in theory is deferred because of low yield and resource strain.
• A borderline case is admitted because the patient has poor outpatient follow‑up.
• Two similar cases get different workups because of age or comorbidities.

Try capturing in your notes:

“Given ideal resources, I suspect they might have done X, but due to [time, beds, insurance, patient factors], they did Y.”

This trains you to see the context around decisions, not just the medical algorithm.

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Adapting This Approach for Different Training Levels

Your strategy will shift slightly as you move from premed to early medical student.

For Premeds

Constraints:

• You usually cannot examine patients independently.
• You will have less foundational knowledge.

Strategies:

• Focus heavily on case framing and identifying decisions, even if you do not know all the disease names.
• Ask more process‑oriented questions: “What were you trying to rule out with that test?” instead of “What disease is that?”
• Spend more time after hours filling gaps with basic reading (UpToDate public patient pages, trusted textbooks, or review notes).

Aim: Build a habit of thinking “What is the main question here?” and “What are the options?”, even at a conceptual level.

For Early Medical Students

You have more tools:

• Basic science and introductory pathology
• Ability to do supervised focused exams
• Early exposure to problem lists and assessment/plan

Strategies:

• Before each day, name 2–3 chief complaints you hope to see (e.g., abdominal pain, syncope, headache). After the day, write 1–2 structured cases for each if possible.
• During a lull, ask the resident or attending to let you quickly present a case back to them in “SOAP” format, emphasizing your assessment and plan options.
• After you present, ask: “If this were an OSCE or Step question, what answer choices would you expect them to give, and which would be trap answers?”

You are now aligning real cases with exam‑style reasoning, which makes both stronger.

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Common Mistakes Students Make in Shadowing (And How to Correct Them)

Three errors show up repeatedly.

1. Treating Shadowing as Silent Observation Only

Students assume they must never interrupt, never ask questions, and never reveal ignorance. That yields politeness but very little learning.

Better:

• Ask permission at the start of the day to jot notes and to ask 1–2 questions between patients.
• Respect workflow. If the clinician looks rushed, save your question. If they are charting quietly, a concise question is usually welcome.

2. Focusing on Diagnoses, Not Decisions

Students want to know: “What did the patient have?” Clinicians care more about: “What did I need to do with this patient today?”

Re‑orient your internal questions:

• Instead of: “Was it pneumonia or bronchitis?”
• Ask: “Why antibiotics vs no antibiotics? Why outpatient vs admission? Why this imaging vs none?”

The name of the disease is often only one input into a decision, not the decision itself.

3. Failing to Write Anything Down

You will forget the details rapidly. The cases will blur.

Minimal fix:

• Carry a small pocket notebook or secured digital note app (no identifiers).
• After each striking case, step aside for 60 seconds and write 3–5 bullets: age, key complaint, most important decision, what was done.
• Flesh it into your 6‑line template that evening.

Those notes become gold later—far beyond personal statement material.

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Bringing It All Together

If you use shadowing as a case‑based decision‑making lab, you will walk into clinical rotations and residency interviews already thinking like a junior clinician, not a passive observer.

Three key takeaways:

1. Structure every patient you see into a case with a core clinical question and at least one clear decision point.
2. Pre‑commit to what you would do before seeing what the clinician chooses, then compare and calibrate.
3. Build a written case library from your shadowing—short, structured summaries focused on decisions, not just diagnoses.

That is how shadowing stops being about “hours” and starts being about building the habits of mind that real clinical decision‑making demands.