Educational strategies for improving clinical reasoning

A Pilot Longitudinal Clinical Reasoning Curriculum for Pediatric Residents

Introduction

Clinical reasoning (CR) is required for physicians. Pediatric residents often gain CR skills through experiential learning. Currently, deliberate education on CR targeted toward pediatric residents is inconsistent. Our objective was to implement a pilot CR curriculum, including five hour-long sessions, and evaluate its impact on self-identified CR Milestones and comfort with CR skills.

Methods

We used Kern's six steps for curriculum development to develop our curriculum. Five morning report sessions included didactics and small-group activities. Pre/post surveys assessed resident self-identified level on ACGME Milestones related to CR skills (Patient Care 4 [PC4] and Medical Knowledge 2 [MK2]) and comfort with CR skills. The postsurvey assessed resident attitudes toward the sessions. Paired samples for Milestone and comfort-based questions were analyzed using Wilcoxon signed rank tests. Attitude questions were reported with descriptive statistics.

Results

Each of the five curricular sessions was attended by 40-50 pediatric residents. Seventy-one trainees (58% of residency) and 51 trainees (42% of residency) completed the pre- and postsurveys, respectively, with 20 paired samples. Self-assessment of PC4 (p = .006) and resident comfort with all measured CR skills increased significantly. Of trainees who attended at least one session (n = 44), most reported finding the sessions helpful (97%), relevant to their clinical work (97%), and impactful on their clinical practice (73%).

Discussion

Following exposure to this CR curriculum, pediatric residents reported increased self-identified competency levels on the evaluated Milestones and improved comfort with CR skills. Dedicated CR education may advance pediatric resident understanding of and comfort with CR.

The case for metacognitive reflection: a theory integrative review with implications for medical education

The concepts of metacognitive reflection, reflection, and metacognition are distinct but have undergone shifts in meaning as they migrated into medical education. Conceptual clarity is essential to the construction of the knowledge base of medical education and its educational interventions. We conducted a theoretical integrative review across diverse bodies of literature with the goal of understanding what metacognitive reflection is. We searched PubMed, Embase, CINAHL, PsychInfo, and Web of Science databases, including all peer-reviewed research articles and theoretical papers as well as book chapters that addressed the topic, with no limitations for date, language, or location. A total of 733 articles were identified and 87 were chosen after careful review and application of exclusion criteria. The work of conceptually and empirically delineating metacognitive reflection has begun. Contributions have been made to root metacognitive reflection in the concept of metacognition and moving beyond it to engage in cycles of reflection. Other work has underscored its affective component, transformational nature, and contextual factors. Despite this merging of threads to develop a richer conceptualization, a theory of how metacognitive reflection works is elusive. Debates address whether metacognition drives reflection or vice versa. It has also been suggested that learners evolve along on a continuum from thinking, to task-related reflection, to self-reflection, and finally to metacognitive reflection. Based on prior theory and research, as well as the findings of this review, we propose the following conceptualization: Metacognitive reflection involves heightened internal observation, awareness, monitoring, and regulation of our own knowledge, experiences, and emotions by questioning and examining cognition and emotional processes to continually refine and enhance our perspectives and decisions while thoughtfully accounting for context. We argue that metacognitive reflection brings a shift in perspective and can support valuable reconceptualization for lifelong learning.

CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts

Introduction

Clinical reasoning enables safe patient care and is an important competency in medical education but can be challenging to teach. Illness scripts facilitate clinical reasoning but have not been used to create pediatric curricula.

Methods

We created CRISP (Clinical Reasoning with Illness Scripts in Pediatrics), a curriculum comprising four 1-hour learning sessions that deliberately incorporated clinical reasoning concepts and illness scripts to organize how four common chief complaints were taught to family medicine residents on inpatient pediatric rotations. We performed a multisite curriculum evaluation project over 6 months with family medicine residents at four institutions to assess whether the use of clinical reasoning concepts to structure CRISP was feasible and acceptable for learners and instructors and whether the use of illness scripts increased knowledge of four common pediatric chief complaints.

Results

For all learning sessions, family medicine residents and pediatric hospitalists agreed that CRISP's format was preferable to traditional didactic lectures. Pre-/posttest scores showed statistically significant increases in family medicine resident knowledge (respiratory distress [n = 42]: pretest, 72%, posttest, 92%; abdominal pain [n = 44]: pretest, 82%, posttest, 96%; acute febrile limp [n = 44]: pretest, 68%, posttest, 81%; well-appearing febrile infant [n = 42]: pretest, 58%, posttest, 73%; ps < .05).

Discussion

By using clinical reasoning concepts and illness script comparison to structure a pediatric curriculum, CRISP represents a novel instructional approach that can be used by pediatric hospitalists to increase family medicine resident knowledge about diagnoses associated with common pediatric chief complaints.

Clinical reasoning training sessions for health educators-A scoping review

Objectives

Clinical reasoning (CR) is important in health professions, because it ensures patient safety and decreases morbidity. CR should be introduced early in medical school. Health educators play a major role in advocating for the use of CR among students; however, educators themselves can be a barrier to the incorporation of CR; consequently, CR training sessions for educators have been proposed as a potential solution. This scoping review was conducted to highlight studies on CR training among health educators.

Methods

A scoping review was performed to identify studies on CR training sessions for health educators. PubMed, SciVerse Scopus, Web of Science Core Collection, EBSCO Medline Complete and ERIC databases were searched with terms including clinical reasoning, diagnostic reasoning, teacher and trainer, to identify articles published between 1991 and 2021.

Results

The initial search yielded 6587 articles; after careful selection, n = 12 articles were included in this scoping review. Most CR training sessions were in the medical field, were conducted in North America, and involved clinical educators. The sessions focused on the fundamentals and steps of CR; biases and debiasing strategies; and learners' difficulties with various teaching formats, such as didactic presentations, facilitated small group sessions with case discussions, roleplay, and use of tools and a mobile application. Educators and students had positive perceptions regarding the conduct and effectiveness of the training sessions.

Conclusions

These training sessions were rated highly; however, longitudinal feedback regarding the application of learnt CR teaching strategies is necessary.

Teaching Independent Decision-Making Through a Computer-Based Drug Utilization Review Simulation

Background: Drug utilization review (DUR) skills are important for pharmacists across all settings. Computer-based DUR simulations to teach student pharmacists are currently scarce. This article describes a computer-based DUR simulation that required limited faculty and financial resources and was implemented in collaboration among 3 institutions. Objective: To describe the innovation of a computer-based DUR simulation and its impact on pharmacy students' knowledge and confidence of DUR skills. Methods: This pre-post educational study assessed a computer-based DUR simulation that replicated the DUR process in dispensing systems. First- and third-year pharmacy students at 3 institutions were guided through simulated patient cases with various medication-related problems. The self-paced activity provided students with immediate, formative feedback and rationale for each option after an attempt was made in lieu of faculty intervention. Students completed pre-and post-assessments to evaluate changes in knowledge and confidence. Knowledge was assessed by comparing results of multiple choice and matching questions on the pre- and post-assessments. Confidence was assessed by the change in self-reported confidence scale measurements. Results: Students at all institutions (N = 405) had nonsignificant changes in knowledge scores from the pre-assessment to the post-assessment, with the exception of 1 question. All confidence survey questions significantly improved from pre- to post-assessment. Conclusion: The DUR educational innovation had a nonsignificant overall impact on students' knowledge but significantly improved confidence in their abilities. Skills-based instruction provides additional practice to increase student confidence.

Design, Implementation, and Outcomes of an Interprofessional Mobile Web Application for Preceptors for Challenging Issues

OBJECTIVE

The purpose of this study was to develop and assess an easily accessible interprofessional mobile web application to assist preceptors with challenging teaching and learning situations.

METHODS

Phase 1 was a modified Delphi process of 48 advanced practice nursing, dentistry, medicine, and pharmacy preceptors to determine the content of the application. Phase 2 consisted of 12 preceptors from the 4 disciplines piloting a prototype to refine the tool using design-thinking principles. Feedback was analyzed using inductive coding and thematic analysis. Phase 3 evaluated the impact of the final tool on 80 preceptors' satisfaction, knowledge, self-efficacy, and perception of behavior change.

RESULTS

Consensus on 10 topics was reached in the following 3 themes: feedback and communication, clinical and professional development of learners, and precepting efficiency. Preceptors rated the tool as efficient and applicable. Features perceived as useful included concise and applicable content that was easy to navigate with practical video examples. Features to improve included academic jargon, length of content, and lack of connectivity with other preceptors. Knowledge and self-efficacy improved after the use of the refined tool. Change in perceptions of behavior after 1 month was mixed, with a significant change in accessing resources to address challenging situations and regularly reflecting on challenging situations and no significant change in awareness, frequency, or success in managing challenging situations.

CONCLUSION

An interprofessional mobile web application for challenging teaching and learning situations developed through a modified Delphi process was deemed efficient and relevant and demonstrated positive knowledge and self-efficacy change.

Pharmacy students' perceptions of clinical reasoning development through a foundational thinking application framework

BACKGROUND AND PURPOSE

Pharmacy students must learn to integrate the foundational and clinical sciences to make therapeutic decisions. There is a need for a developmental framework and scaffolding tools to bridge foundational knowledge with clinical reasoning among novice learners in pharmacy education. Our purpose is to describe the development and student perceptions of a framework designed to integrate foundational knowledge and clinical reasoning in second-year pharmacy students.

EDUCATIONAL ACTIVITY AND SETTING

Using script theory as a conceptual model, a Foundational Thinking Application Framework (FTAF) was designed around a four-credit Pharmacotherapy of Nervous Systems Disorders course at the beginning of the second year of the doctor of pharmacy curriculum. The framework was implemented as two structured learning guides known as a unit plan and a pharmacologically based therapeutic evaluation. A total of 71 students in the course were asked to complete a 15-question online survey assessing perceptions towards specific components of the FTAF.

FINDINGS

Of 39 survey respondents, 37 (95%) described the unit plan as a useful organizer for the course. Thirty-five (80%) students agreed or strongly agreed that the unit plan helped organize instructional material for a given topic. Students (n = 32, 82%) preferred the pharmacologically based therapeutic evaluation format, with text comments highlighting that it provided good practice for clinical experiences and helped to organize critical thinking.

SUMMARY

Our study found that students had positive perceptions of FTAF's implementation within a pharmacotherapy course. Pharmacy education can benefit by adapting script-based strategies that have been successful in other health professions.

Educating for adaptive expertise: case examples along the medical education continuum

Adaptive expertise represents the combination of both efficient problem-solving for clinical encounters with known solutions, as well as the ability to learn and innovate when faced with a novel challenge. Fostering adaptive expertise requires careful approaches to instructional design to emphasize deeper, more effortful learning. These teaching strategies are time-intensive, effortful, and challenging to implement in health professions education curricula. The authors are educators whose missions encompass the medical education continuum, from undergraduate through to organizational learning. Each has grappled with how to promote adaptive expertise development in their context. They describe themes drawn from educational experiences at these various learner levels to illustrate strategies that may be used to cultivate adaptive expertise.At Vanderbilt University School of Medicine, a restructuring of the medical school curriculum provided multiple opportunities to use specific curricular strategies to foster adaptive expertise development. The advantage for students in terms of future learning had to be rationalized against assessments that are more short-term in nature. In a consortium of emergency medicine residency programs, a diversity of instructional approaches was deployed to foster adaptive expertise within complex clinical learning environments. Here the value of adaptive expertise approaches must be balanced with the efficiency imperative in clinical care. At Mayo Clinic, an existing continuous professional development program was used to orient the entire organization towards an adaptive expertise mindset, with each individual making a contribution to the shift.The different contexts illustrate both the flexibility of the adaptive expertise conceptualization and the need to customize the educational approach to the developmental stage of the learner. In particular, an important benefit of teaching to adaptive expertise is the opportunity to influence individual professional identity formation to ensure that clinicians of the future value deeper, more effortful learning strategies throughout their careers.

Medical Dispute Cases Caused by Errors in Clinical Reasoning: An Investigation and Analysis

Studies that examine medical dispute cases (MDC) due to clinical reasoning (CR) are scarce in Taiwan. A retrospective analysis was undertaken to review MDC filed at four hospitals in Taiwan between 2011 and 2015. Cases were examined for the healthcare professionals involved, their relevance to CR errors, clinical specialties, and seniority. Seventy-eight MDC were identified and 57.7% of which were determined to be related to CR errors (n = 45). Among the 45 cases associated with CR errors, 82.2% (37) and 22.2% (10) were knowledge- and skill-related errors, respectively. The healthcare professionals with the most MDC were obstetrician-gynecologists (10/90, 11.1%), surgeons (8/90, 8.9%), and emergency physicians (7/90, 7.8%). The seniority of less than 5 years or lower had the highest number of attending physicians to be associated with MDC. In contrast, the highest seniority (>25 years) in the physician group and year 6 in the resident group are both shown with zero MDC. In our study, the larger hospitals had a significantly higher incidence of MDC compared to the smaller hospitals (Pearson Correlation Coefficient = 0.984, p = 0.016). An examination of MDC reveals the frequency and nature of medical errors in Taiwanese hospitals. Having identified that CR errors contributed a substantial fraction to the overall MDC, strategies to promote reasoning skills and hence reduce medico-legal issues help safeguard both patients and healthcare professionals.

A picture with a caption: Using photovoice as cultural self-reflection in communication sciences and disorders

PURPOSE

Self-reflection is an essential component of developing cultural competence. However, there is a paucity of research on how to best accomplish cultural self-reflection in CSD courses. Therefore, the purpose of this research study is to examine the teaching and learning practice of using Photovoice as a means of cultural self-reflection in a foundational, multicultural course in CSD.

METHOD

This qualitative investigation employed a phenomenological approach with emphasis on the scholarship of teaching and learning. Data gathering involved completion of a Photovoice assignment and a prompted reflection of the assignment. The Photovoice assignment entailed the students reflecting and examining their culture. Then, the students submitted two photographs, one that represents a strength of a culture they identify with and one that represents a challenge of a culture they identify with. The students presented their cultural strength and challenges in small and large group discussions. The prompted reflection required the students to address questions in a written or video-recorded response. When the course was completed, the researcher commenced line-by-line focused coding to cluster frequently used terms and common experiences into specific themes.

RESULTS

The student participants shared photos of cultural strengths and challenges, discussed these photos in small and large groups, and completed a prompted reflection of the Photovoice assignment. While each student's project and reflection were unique, common themes prevailed. The themes of safety, privilege, and mental health emerged from the Photovoice projects and the themes of learning and formating arose from the reflections on use of the project toward cultural competence.

CONCLUSIONS

The results of this study suggests that Photovoice is a valuable tool for cultural self-reflection and learning in all courses in CSD programs. In this way cultural self-reflection and the progression toward cultural competence is an on-going process where students are better prepared to provide client-centered, culturally competent care for all people.

A clinical reasoning curriculum for medical students: an interim analysis

OBJECTIVES

Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis.

METHODS

In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies.

RESULTS

Students rated DR highly (range 4.13-4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis.

CONCLUSIONS

Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.

Development and evaluation of clinical reasoning using 'think aloud' approach in pharmacy undergraduates - A mixed-methods study

Introduction

Given the widespread use of clinical reasoning (CR) in the healthcare practice, it is essential to inculcate the CR practice in undergraduate pharmacy education which can not only facilitate their clinical education and clinical rotations but can also help them become better clinical pharmacists. There is very limited CR employed in the pharmacy curriculum and practice in the Middle East countries. This study aimed to develop and evaluate CR practice in pharmacy undergraduates in one college of pharmacy in Saudi Arabia.

Methods

We employed a mixed-methods methodology that included two phases. In Phase I, students were introduced to CR practice ('think aloud' method) and given geriatric clinical cases which they used in two sessions together with a tutor. This was followed by the writing of SOAP notes using the tutor feedback and completion of a survey that included a self-reflection about their experience of using the CR method. Phase II included face-to-face semi-structured interviews involving selected students that were recruited via convenience sampling to further explore the issues identified in Phase I of the study.

Results

Of the 155 students who completed the survey (response rate 94%), the majority of them agreed that CR using the 'think aloud' method was useful in gathering (92%) and interpreting (95%) relevant patient information, identifying medication-related problems (95%), exploring therapeutic options for the problem(s) (93%) and formulating a treatment plan for the patient (90%). Qualitative data analysis of the 12 interviews was consistent with these findings. Furthermore, it provided an insight into the challenges faced by the students in applying this CR method.

Conclusions

Students found the practice of CR using the 'think aloud' method helpful in working through given cases and taking clinical decisions. This method can be widely employed in pharmacy education and practice.

Qualitative development and content validation of the "SPART" model; a focused ethnography study of observable diagnostic and therapeutic activities in the emergency medical services care process

BACKGROUND

Clinical reasoning is a crucial task within the Emergency Medical Services (EMS) care process. Both contextual and cognitive factors make the task susceptible to errors. Understanding the EMS care process' structure could help identify and address issues that interfere with clinical reasoning. The EMS care process is complex and only basically described. In this research, we aimed to define the different phases of the process and develop an overarching model that can help detect and correct potential error sources, improve clinical reasoning and optimize patient care.

METHODS

We conducted a focused ethnography study utilizing non-participant video observations of real-life EMS deployments combined with thematic analysis of peer interviews. After an initial qualitative analysis of 7 video observations, we formulated a tentative conceptual model of the EMS care process. To test and refine this model, we carried out a qualitative, thematic analysis of 28 video-recorded cases. We validated the resulting model by evaluating its recognizability with a peer content analysis utilizing semi-structured interviews.

RESULTS

Based on real-life observations, we were able to define and validate a model covering the distinct phases of an EMS deployment. We have introduced the acronym "SPART" to describe ten different phases: Start, Situation, Prologue, Presentation, Anamnesis, Assessment, Reasoning, Resolution, Treatment, and Transfer.

CONCLUSIONS

The "SPART" model describes the EMS care process and helps to understand it. We expect it to facilitate identifying and addressing factors that influence both the care process and the clinical reasoning task embedded in this process.

Competence of medical and obstetric registrars in the management of systemic lupus erythematosus in pregnancy

Introduction

Systemic lupus erythematosus has a predilection for women of childbearing age. Globally a shortage of rheumatologists exists resulting in general physicians and obstetricians treating systemic lupus erythematosus in pregnancy.

Methods

We conducted a survey amongst medical and obstetric registrars in South Africa to assess their subjective and objective competence in managing pregnant women with systemic lupus erythematosus.

Results

The pass rate for the objective section was 70.8% with no statistically significant difference in the pass rate between medical and obstetric registrars. Participants felt unprepared to manage pregnant women with systemic lupus erythematosus, with a mean overall score of 3.4 out of 7 for the subjective section, based on four Likert scale type questions.

Conclusion

Trainees are not able to accurately assess their own levels of competence in order to identify their learning needs. Due to the shortage of rheumatologists and lack of obstetric physicians in South Africa, general physicians and obstetricians must be equipped to provide adequate care to pregnant women with systemic lupus erythematosus.

Developing a process to manage challenges encountered by experiential education administrators

INTRODUCTION

This study explored preceptor and student related issues reported in pharmacy experiential education settings and solutions that experiential education administrators (EEAs) applied to inform a process to manage these challenges.

METHODS

This mixed-methods study was conducted in two phases. In phase one, five EEAs from three schools of pharmacy collected quantitative and qualitative data over a two-year period on issues reported by students and preceptors and the solutions EEAs employed. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data, respectively. Interviews with six EEAs from four schools were completed in phase two. An additional school was added in phase two. Open coding, pattern coding, and summative analysis were completed on interview data.

RESULTS

Preceptors and students reported 156 and 65 issues, respectively. The most common issues reported were student reliability/responsibility (22, 14%) and preceptor communication (13, 20%). The most frequently applied solutions were coach preceptor (51, 24%) and meet with student (20, 24%). Interviews revealed more information about the strategies EEAs used. Approaches included reactive responses such as talking to and coaching preceptors or students. Preventative strategies were desired, such as tracking data and training.

CONCLUSIONS

Results informed two approaches that EEAs can employ to resolve student and preceptor issues. In the proactive process, issues are tracked to inform student and preceptor development. The reactive approach involves meeting with the preceptor or student, gathering information from both parties, coaching the preceptor or student, and involving other administrators as needed for serious concerns.

Clinician Response to Child Abuse Presentations in the Vietnamese Hospital Emergency Setting

Ongoing fiscal stability has enabled the National Assembly in Vietnam to turn its attention to improving the health and well-being of women and children. Training pediatric health care professionals in the recognition and response to child abuse presentations in the emergency setting has the potential to improve outcomes for the disproportionate number of vulnerable children presenting to the emergency setting with nonaccidental injuries. This study explored the training needs and expectations of the staff preparing to undertake such a clinical training program. This qualitative study is based on semistructured interviews with 16 clinicians from the emergency setting of a leading pediatric hospital in Vietnam. Interview questions focused on current practice in recognizing and responding to child abuse and neglect presentations, the level of training and experience of participants, and subjective reports of confidence in recognizing abuse. Interviews were conducted in English and Vietnamese, with check-translation of transcripts performed by an independent translator. A culture of collegiality and innovative workplace practices was revealed. Analysis revealed two overarching themes that were related to the need for evidence, forensic analysis, respecting families, and consultation. Despite participant confidence in recognizing and reporting child abuse and neglect presentations, knowledge deficits were found. This article presents a critical analysis of the context within which the first evidence-based clinical training program of its kind in Vietnam was developed and implemented in a pediatric children's hospital. Clinicians felt a strong moral obligation to protect children from further harm, however encountered a number of barriers inhibiting this process. Findings significantly shaped the Safe Children Vietnam training program and will also contribute to the development of protocols and improvement of community support services at the study site.

Assessing clinical reasoning in undergraduate medical students during history taking with an empirically derived scale for clinical reasoning indicators

BACKGROUND

The clinical reasoning process, which requires biomedical knowledge, knowledge about problem-solving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians' daily practice but difficult to assess. The aim of this study was to empirically develop a Clinical Reasoning Indicators-History Taking-Scale (CRI-HT-S) and to assess the clinical reasoning ability of advanced medical students during a simulation involving history taking.

METHODS

The Clinical Reasoning Indictors-History Taking-Scale (CRI-HT-S) including a 5-point Likert scale for assessment was designed from clinical reasoning indicators identified in a qualitative study in 2017. To assess indicators of clinical reasoning ability, 65 advanced medical students (semester 10, n = 25 versus final year, n = 40) from three medical schools participated in a 360-degree competence assessment in the role of beginning residents during a simulated first workday in hospital. This assessment included a consultation hour with five simulated patients which was videotaped. Videos of 325 patient consultations were assessed using the CRI-HT-S. A factor analysis was conducted and the students' results were compared according to their advancement in undergraduate medical training.

RESULTS

The clinical reasoning indicators of the CRI-HT-S loaded on three factors relevant for clinical reasoning: 1) focusing questions, 2) creating context, and 3) securing information. Students reached significantly different scores (p < .001) for the three factors (factor 1: 4.07 ± .47, factor 2: 3.72 ± .43, factor 3: 2.79 ± .83). Students in semester 10 reached significantly lower scores for factor 3 than students in their final year (p < .05).

CONCLUSIONS

The newly developed CRI-HT-S worked well for quantitative assessment of clinical reasoning indicators during history taking. Its three-factored structure helped to explore different aspects of clinical reasoning. Whether the CRI-HT-S has the potential to be used as a scale in objective structured clinical examinations (OCSEs) or in workplace-based assessments of clinical reasoning has to be investigated in further studies with larger student cohorts.

Clinical reasoning: exploring its characteristics and enhancing its learning

Clinical reasoning is an extensive and intricate field, dealing with the process of thinking and decision making in practice. Its study can be quite challenging because it is context and task dependent. Educational frameworks such as the conscious competence model and the dual process reasoning model have been developed to help its understanding. To enhance the learning of clinical reasoning, there are significant areas that can be targeted through learning processes. These include knowledge adequacy; ability to gather appropriate patient data; use of proper reasoning strategies to address specific clinical questions; and the ability to reflect and evaluate on decisions taken, together with the role of the wider practice community and the activity of professional socialisation. This article explores the characteristics of clinical reasoning and delves deeper into the various strategies that prove useful for learning.

Assessing validity evidence for a serious game dedicated to patient clinical deterioration and communication

Background

A serious game (SG) is a useful tool for nurse training. The objectives of this study were to assess validity evidence of a new SG designed to improve nurses’ ability to detect patient clinical deterioration.

Methods

The SG (LabForGames Warning) was developed through interaction between clinical and pedagogical experts and one developer. For the game study, consenting nurses were divided into three groups: nursing students (pre-graduate) (group S), recently graduated nurses (graduated < 2 years before the study) (group R) and expert nurses (graduated > 4 years before the study and working in an ICU) (group E). Each volunteer played three cases of the game (haemorrhage, brain trauma and obstructed intestinal tract). The validity evidence was assessed following Messick’s framework: content, response process (questionnaire, observational analysis), internal structure, relations to other variables (by scoring each case and measuring playing time) and consequences (a posteriori analysis).

Results

The content validity was supported by the game design produced by clinical, pedagogical and interprofessional experts in accordance with the French nurse training curriculum, literature review and pilot testing. Seventy-one nurses participated in the study: S (n = 25), R (n = 25) and E (n = 21). The content validity in all three cases was highly valued by group E. The response process evidence was supported by good security control. There was no significant difference in the three groups’ high rating of the game’s realism, satisfaction and educational value. All participants stated that their knowledge of the different steps of the clinical reasoning process had improved. Regarding the internal structure, the factor analysis showed a common source of variance between the steps of the clinical reasoning process and communication or the situational awareness errors made predominantly by students. No statistical difference was observed between groups regarding scores and playing time. A posteriori analysis of the results of final examinations assessing study-related topics found no significant difference between group S participants and students who did not participate in the study.

Conclusion

While it appears that this SG cannot be used for summative assessment (score validity undemonstrated), it is positively valued as an educational tool.

Trial registration

ClinicalTrials.gov ID: NCT03092440

Comparison of Assessment by a Virtual Patient and by Clinician-Educators of Medical Students' History-Taking Skills: Exploratory Descriptive Study

BACKGROUND

A virtual patient (VP) can be a useful tool to foster the development of medical history-taking skills without the inherent constraints of the bedside setting. Although VPs hold the promise of contributing to the development of students' skills, documenting and assessing skills acquired through a VP is a challenge.

OBJECTIVE

We propose a framework for the automated assessment of medical history taking within a VP software and then test this framework by comparing VP scores with the judgment of 10 clinician-educators (CEs).

METHODS

We built upon 4 domains of medical history taking to be assessed (breadth, depth, logical sequence, and interviewing technique), adapting these to be implemented into a specific VP environment. A total of 10 CEs watched the screen recordings of 3 students to assess their performance first globally and then for each of the 4 domains.

RESULTS

The scores provided by the VPs were slightly higher but comparable with those given by the CEs for global performance and for depth, logical sequence, and interviewing technique. For breadth, the VP scores were higher for 2 of the 3 students compared with the CE scores.

CONCLUSIONS

Findings suggest that the VP assessment gives results akin to those that would be generated by CEs. Developing a model for what constitutes good history-taking performance in specific contexts may provide insights into how CEs generally think about assessment.

Integrating Bayesian reasoning into medical education using smartphone apps

Background Diagnostic reasoning is an important topic in medical education, and diagnostic errors are increasingly recognized as large contributors to patient morbidity and mortality. One way to improve learner understanding of the diagnostic process is to teach the concepts of Bayesian reasoning and to make these concepts practical for clinical use. Many clinician educators do not fully understand Bayesian concepts and they lack the tools to incorporate Bayesian reasoning into clinical practice and teaching. Methods The authors developed an interactive workshop using visual models of probabilities and thresholds, clinical cases, and available smartphone apps to teach learners about Bayesian concepts. Results Evaluations from 3 years of workshops at a national internal medicine chief resident conference showed high satisfaction, with narrative comments suggesting learners found the visual and smartphone tools useful for applying the concepts with future learners. Conclusions Visual models, clinical cases, and smartphone apps were well received by chief residents as a way to learn and teach Bayesian reasoning. Further study will be needed to understand if these tools can improve diagnostic accuracy or patient outcomes.

Reasoning processes in clinical reasoning: from the perspective of cognitive psychology

Clinical reasoning is considered a crucial concept in reaching medical decisions. This paper reviews the reasoning processes involved in clinical reasoning from the perspective of cognitive psychology. To properly use clinical reasoning, one requires not only domain knowledge but also structural knowledge, such as critical thinking skills. In this paper, two types of reasoning process required for critical thinking are discussed: inductive and deductive. Inductive and deductive reasoning processes have different features and are generally appropriate for different types of tasks. Numerous studies have suggested that experts tend to use inductive reasoning while novices tend to use deductive reasoning. However, even experts sometimes use deductive reasoning when facing challenging and unfamiliar problems. In clinical reasoning, expert physicians generally use inductive reasoning with a holistic viewpoint based on a full understanding of content knowledge in most cases. Such a problem-solving process appears as a type of recognition-primed decision making only in experienced physicians' clinical reasoning. However, they also use deductive reasoning when distinct patterns of illness are not recognized. Therefore, medical schools should pursue problem-based learning by providing students with various opportunities to develop the critical thinking skills required for problem solving in a holistic manner.

The terminology of clinical reasoning in health professions education: Implications and considerations

Introduction: Clinical reasoning is considered to be at the core of health practice. Here, we report on the diversity and inferred meanings of the terms used to refer to clinical reasoning and consider implications for teaching and assessment. Methods: In the context of a Best Evidence Medical Education (BEME) review of 625 papers drawn from 18 health professions, we identified 110 terms for clinical reasoning. We focus on iterative categorization of these terms across three phases of coding and considerations for how terminology influences educational practices. Results: Following iterative coding with 5 team members, consensus was possible for 74, majority coding was possible for 16, and full team disagreement existed for 20 terms. Categories of terms included: purpose/goal of reasoning, outcome of reasoning, reasoning performance, reasoning processes, reasoning skills, and context of reasoning. Discussion: Findings suggest that terms used in reference to clinical reasoning are non-synonymous, not uniformly understood, and the level of agreement differed across terms. If the language we use to describe, to teach, or to assess clinical reasoning is not similarly understood across clinical teachers, program directors, and learners, this could lead to confusion regarding what the educational or assessment targets are for "clinical reasoning."

Can a reflective rubric be applied consistently with raters globally? A study across three countries

INTRODUCTION

Reflection is a powerful tool for assisting students to develop the skills to make better informed decisions. As a pharmacy competency standard, reliable and fair assessment strategies are required to measure reflective skills and support students in developing their reflective capacity. The aim of this research was to explore whether we can extend the applicability of a previously tested rubric to a range of educational settings, to account for diversity of pharmacy educators and curricula internationally.

METHODS

Four raters from three countries applied a reflective rubric to assess a sample (n = 43) of reflective accounts, representing 41% of a cohort of 105 second-year undergraduate pharmacy students. The interrater reliability (IRR) was measured utilizing the intra-class correlation coefficient (ICC), using a two-way random effects model with absolute agreement, to determine the level of agreement between the raters' absolute scores. Generalizability Theory analysis was used to estimate generalizability of raters and stages.

RESULTS

Results indicated agreement of raters for (i) each of the seven stages of reflection and (ii) overall score for the reflective account, with moderate to substantial agreement (ICC = 0.55-0.69, p < 0.001); and high agreement for all raters for the overall score (ICC = 0.96, p < 0.001), respectively. The G-Study estimated a relative error coefficient of 0.78.

CONCLUSION

This additional analysis further confirms the reliability and applicability of the rubric to a range of rater academic backgrounds.

Theories of truth and teaching clinical reasoning and problem solving

In this paper, we will first discuss two current meta-theories dealing with different, aspects of "truth". The first metatheory conceives of truth in terms of coherence (rationality, consistency): a body of knowledge is true when it contains no inconsistencies and has at least some credibility. The second metatheory conceives of truth as correspondence, i.e., empirical accuracy. The two metatheories supplement each other, but are also incommensurable, i.e., they cannot be expressed in each other's terms, for they employ completely different criteria to establish truth (Englebretsen in Bare facts and naked truths: a new correspondence theory of truth, Routledge, London, 2005). We will discuss both the role of both metatheories in medicine, in particular in medical education in a clinical context. In line with Hammond's view (Med Decis Mak 16(3):281-287, 1996a; Human judgment and social policy: irreducible uncertainty, inevitable error, unavoidable injustice, Oxford University Press, New York, 1996b), we will extend the two metatheories to two forms of competence: coherence competence and correspondence competence, and demonstrate that distinguishing these two forms of competence increases our insights as to the best way to teach undergraduate students clinical problem solving.

Pharmacy Students' Utilization of an Online Tool for Immediate Formative Feedback on Reflective Writing Tasks

Objective. To assess pharmacy students' perceptions of the benefits and utility of a novel online reflective-writing tool. Methods. After completing a required Academic Writing Analytics (AWA) workshop, Master of Pharmacy students submitted a reflective writing assignment in the AWA web application. A six-item survey was administered to students prior to and immediately after using AWA. Results. Sixty students volunteered to participate in the study; however, only 39 students provided a pseudonym that allowed their pretest and posttest to be matched. A comparison of students' responses on the pretest with those on the posttest, which was administered four weeks after the workshop, suggest a noticeable increase in agreement with AWA's benefits as an effective, online tool for improving their reflective learning skills. Conclusion. This novel online tool has the potential to assist pharmacy students with self-critiquing and improving their reflective writing assignments prior to submission. Furthermore, as the elements of reflection are transferable, this tool has the potential to be used in other educational contexts.

A conceptual framework for orthotic and prosthetic education

BACKGROUND

Variables that influence orthotic and prosthetic patient outcomes beyond direct care are poorly conceptualized for orthotic and prosthetic students. Restructuring educational curricula around important clinical reasoning variables (i.e. factors that may influence outcomes) could improve teaching, learning, and clinical practice.

OBJECTIVES

To propose an orthotic and prosthetic education framework to enhance the development of orthotic and prosthetic students' clinical reasoning skills.

STUDY DESIGN

Scoping review.

METHODS

We conducted a scoping review, identified variables of orthotic and prosthetic usability, and performed a qualitative thematic analysis through the lens of orthotic and prosthetic clinical educators to develop a conceptual framework for orthotic and prosthetic education.

RESULTS

Sorting of variables identified from the literature resulted in three thematic areas: (1) the state of functioning, disability, and health (International Classification of Functioning, Disability and Health); (2) orthotic and prosthetic technical properties, procedures, and appropriateness; and (3) professional service as part of orthotic and prosthetic interventions. The proposed orthotic and prosthetic education framework includes these three areas situated within the context of patient-centered care.

CONCLUSIONS

A conceptual framework was developed from variables identified in peer-reviewed literature. This orthotic and prosthetic education framework provides a structure to explore orthotic and prosthetic clinical reasoning and advance our teaching and assessment of students' clinical reasoning skills.

CLINICAL RELEVANCE

The proposed orthotic and prosthetic (O&P) education framework is intended to promote conversation about variables (e.g. health condition, procedures, services, and O&P principles) that influence O&P clinical practice outcomes and further advance our teaching and assessment of students' clinical reasoning skills.

Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance

PURPOSE

An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore the existing menu of CR assessments.

METHOD

Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were sorted by assessment methods and reviewed by pairs of authors. Extracted data were used to construct descriptive appendixes, summarizing each method, including common stimuli, response formats, scoring, typical uses, validity considerations, feasibility issues, advantages, and disadvantages.

RESULTS

A total of 377 articles were included in the final synthesis. The articles broadly fell into three categories: non-workplace-based assessments (e.g., multiple-choice questions, extended matching questions, key feature examinations, script concordance tests); assessments in simulated clinical environments (objective structured clinical examinations and technology-enhanced simulation); and workplace-based assessments (e.g., direct observations, global assessments, oral case presentations, written notes). Validity considerations, feasibility issues, advantages, and disadvantages differed by method.

CONCLUSIONS

There are numerous assessment methods that align with different components of the complex construct of CR. Ensuring competency requires the development of programs of assessment that address all components of CR. Such programs are ideally constructed of complementary assessment methods to account for each method's validity and feasibility issues, advantages, and disadvantages.

Manual analysis of recorded bat echolocation calls: summary, synthesis, and proposal for increased standardization in training practices

Automated recording units are frequently used for passive acoustic monitoring of taxa, including bats. Detection and species-level identification of bat echolocation calls using manual techniques is a common practice, often supplementing automated analysis by software. However, few standardized protocols exist for manual analysis, which is challenging for novices and impedes comparisons among research groups. In this two-part review, I first summarize and synthesize current approaches to manual call analysis. Three observations about the processes used to conduct manual call identification emerge: (1) there are significant knowledge gaps and few comparisons of interoperator variability; (2) they are individual- and location-specific, with no standardized underlying framework; and (3) they are often not well-described in the peer-reviewed literature. In response to these observations, I then conduct a comparative analysis of the fields of clinical reasoning (the study of medical decision-making) and the identification of bat echolocation calls. Clinical reasoning is a mature area of research and findings from this field may inform practices and instructional strategies for manually identifying echolocation calls. I demonstrate similarities between clinical reasoning and call identification processes and then make recommendations on how to apply findings from the clinical reasoning literature to call identification practices and training.

Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search

BACKGROUND

Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training.

METHODS

A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations.

RESULTS

The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students.

DISCUSSION

Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities.

CONCLUSION

Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

How Exemplary Inpatient Teaching Physicians Foster Clinical Reasoning

BACKGROUND

Clinical reasoning is a crucial component of training in health professions. These cognitive skills are necessary to provide quality care and avoid diagnostic error. Much previous literature has focused on teaching clinical reasoning in nonclinical environments and does not include learner reflections. The authors sought to explore, through multiple perspectives including learners, techniques used by exemplary inpatient clinician-educators for explicitly cultivating clinical reasoning.

METHODS

The authors conducted (2014-2015) a multisite, exploratory qualitative study examining how excellent clinician-educators foster clinical reasoning during general medicine rounds. This was accomplished through interviews of educators, focus group discussions with learners, and direct observations of clinical teaching. The authors reviewed field notes and transcripts using techniques of thematic analysis.

RESULTS

Twelve clinician-educators, 57 current learners, and 26 former learners participated in observations and interviews. The techniques and behaviors of educators were categorized into 4 themes, including 1) emphasizing organization and prioritization, 2) accessing prior knowledge, 3) thinking aloud, and 4) analyzing the literature.

CONCLUSIONS

The findings of this comprehensive study both confirm strategies found in previous literature and provide novel approaches. This is the first study to incorporate the perspectives of learners. Educators' techniques and behaviors, identified through direct observation and supported by reflections from the entire team, can inform best practices for the teaching of clinical reasoning.

Using Reflective Writing as a Predictor of Academic Success in Different Assessment Formats

Objectives. To investigate whether reflective-writing skills are associated with academic success. Methods. Two hundred sixty-four students enrolled in a pharmacy practice course completed reflective statements. Regression procedures were conducted to determine whether reflective-writing skills were associated with academic success in different assessment formats: written, oral, and video tasks. Results. Reflective-writing skills were found to be a predictor of academic performance in some formats of assessment: written examination; oral assessment task and overall score for the Unit of Study (UoS). Reflective writing skills were not found to predict academic success in the video assessment task. Conclusions. Possessing good reflective-writing skills was associated with improved academic performance. Further research is recommended investigating the impact of reflective skill development on academic performance measures in other health education.

A Retrospective Study on Students' and Teachers' Perceptions of the Reflective Ability Clinical Assessment

Objective. To evaluate student and teacher perceptions of the utility of the Reflective Ability Clinical Assessment (RACA) in an undergraduate pharmacy curriculum at an Australian university. Methods. A mixed-method study comprising the administration of a 7-item student survey on a 6-point Likert-type scale and a 45-minute focus group/phone interview with teachers. Results. Student (n=199) and teaching staff respondents (n=3) provided their perceptions of the implementation of the new educational tool. Student responses showed significant positive correlations between self-directed learning, counseling skills, relevance to future practice, and performance in an oral examination. Seven key themes emerged from the teacher interviews. Conclusion. The study revealed both students and teachers perceive the RACA as an effective educational tool that may enhance skill development for future clinical practice.

An Investigation into the Clinical Reasoning Development of Veterinary Students

Clinical reasoning is a fundamental skill for veterinary clinicians and a competency required of graduates by the Royal College of Veterinary Surgeons. However, it is unknown how veterinary students develop reasoning skills and where strengths and shortcomings of curricula lie. This research aimed to use the University of Nottingham School of Veterinary Medicine and Science (SVMS) as a case study to investigate the development of clinical reasoning among veterinary students. The analysis was framed in consideration of the taught, learned, and declared curricula. Sixteen staff and sixteen students from the SVMS participated separately in a total of four focus groups. In addition, five interviews were conducted with recent SVMS graduates. Audio transcriptions were used to conduct a thematic analysis. A content analysis was performed on all curriculum documentation. It was found that SVMS graduates feel they have a good level of reasoning ability, but they still experience a deficit in their reasoning capabilities when starting their first job. Overarching themes arising from the data suggest that a lack of responsibility for clinical decisions during the program and the embedded nature of the clinical reasoning skill within the curriculum could be restricting development. In addition, SVMS students would benefit from clinical reasoning training where factors influencing "real life" decisions (e.g., finances) are explored in more depth. Integrating these factors into the curriculum could lead to improved decision-making ability among SVMS graduates and better prepare students for the stressful transition to practice. These findings are likely to have implications for other veterinary curricula.

Raising awareness of cognitive biases during diagnostic reasoning

INTRODUCTION

Bias in diagnostic reasoning can potentially lead to severe consequences. We explored how to design an experiential learning workshop in a general practice clerkship to raise awareness on bias.

METHOD

A group of 12 students was split into two groups. Both groups 'diagnosed' two patients in two case studies. Only one group, without them knowing, were given a case including salient distracting features. The whole group discussed the influence of these distractors. In the second round all students had salient distracting features in their case descriptions but only one group had a debiasing tool, a checklist to reconsider their first diagnosis, which they discussed in the final large group discussion.

RESULTS

Students were misled by salient distracting features and thus experienced how one small difference in a case description may lead to a different diagnosis, due to bias. The debiasing tool was regarded with scepticism. Afterwards, students indicated that, thanks to experiencing bias themselves, they felt better equipped to recognize the risk of bias.

CONCLUSIONS

An experiential learning approach with case studies containing salient distracting features seems to be a viable method to learn about bias in a general practice clerkship.

Exploring a New Simulation Approach to Improve Clinical Reasoning Teaching and Assessment: Randomized Trial Protocol

BACKGROUND

Helping trainees develop appropriate clinical reasoning abilities is a challenging goal in an environment where clinical situations are marked by high levels of complexity and unpredictability. The benefit of simulation-based education to assess clinical reasoning skills has rarely been reported. More specifically, it is unclear if clinical reasoning is better acquired if the instructor's input occurs entirely after or is integrated during the scenario. Based on educational principles of the dual-process theory of clinical reasoning, a new simulation approach called simulation with iterative discussions (SID) is introduced. The instructor interrupts the flow of the scenario at three key moments of the reasoning process (data gathering, integration, and confirmation). After each stop, the scenario is continued where it was interrupted. Finally, a brief general debriefing ends the session. System-1 process of clinical reasoning is assessed by verbalization during management of the case, and System-2 during the iterative discussions without providing feedback.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of Simulation with Iterative Discussions versus the classical approach of simulation in developing reasoning skills of General Pediatrics and Neonatal-Perinatal Medicine residents.

METHODS

This will be a prospective exploratory, randomized study conducted at Sainte-Justine hospital in Montreal, Qc, between January and March 2016. All post-graduate year (PGY) 1 to 6 residents will be invited to complete one SID or classical simulation 30 minutes audio video-recorded complex high-fidelity simulations covering a similar neonatology topic. Pre- and post-simulation questionnaires will be completed and a semistructured interview will be conducted after each simulation. Data analyses will use SPSS and NVivo softwares.

RESULTS

This study is in its preliminary stages and the results are expected to be made available by April, 2016.

CONCLUSIONS

This will be the first study to explore a new simulation approach designed to enhance clinical reasoning. By assessing more closely reasoning processes throughout a simulation session, we believe that Simulation with Iterative Discussions will be an interesting and more effective approach for students. The findings of the study will benefit medical educators, education programs, and medical students.

How to improve the teaching of clinical reasoning: a narrative review and a proposal

CONTEXT

The development of clinical reasoning (CR) in students has traditionally been left to clinical rotations, which, however, often offer limited practice and suboptimal supervision. Medical schools begin to address these limitations by organising pre-clinical CR courses. The purpose of this paper is to review the variety of approaches employed in the teaching of CR and to present a proposal to improve these practices.

METHODS

We conducted a narrative review of the literature on teaching CR. To that end, we searched PubMed and Web of Science for papers published until June 2014. Additional publications were identified in the references cited in the initial papers. We used theoretical considerations to characterise approaches and noted empirical findings, when available.

RESULTS

Of the 48 reviewed papers, only 24 reported empirical findings. The approaches to teaching CR were shown to vary on two dimensions. The first pertains to the way the case information is presented. The case is either unfolded to students gradually - the 'serial-cue' approach - or is presented in a 'whole-case' format. The second dimension concerns the purpose of the exercise: is its aim to help students acquire or apply knowledge, or is its purpose to teach students a way of thinking? The most prevalent approach is the serial-cue approach, perhaps because it tries to directly simulate the diagnostic activities of doctors. Evidence supporting its effectiveness is, however, lacking. There is some empirical evidence that whole-case, knowledge-oriented approaches contribute to the improvement of students' CR. However, thinking process-oriented approaches were shown to be largely ineffective.

CONCLUSIONS

Based on research on how expertise develops in medicine, we argue that students in different phases of their training may benefit from different approaches to the teaching of CR.

Evidence in clinical reasoning: a computational linguistics analysis of 789,712 medical case summaries 1983-2012

Background

Better understanding of clinical reasoning could reduce diagnostic error linked to 8% of adverse medical events and 30% of malpractice cases. To a greater extent than the evidence-based movement, the clinical reasoning literature asserts the importance of practitioner intuition—unconscious elements of diagnostic reasoning. The study aimed to analyse the content of case report summaries in ways that explored the importance of an evidence concept, not only in relation to research literature but also intuition.

Methods

The study sample comprised all 789,712 abstracts in English for case reports contained in the database PUBMED for the period 1 January 1983 to 31 December 2012. It was hypothesised that, if evidence and intuition concepts were viewed by these clinical authors as essential to understanding their case reports, they would be more likely to be found in the abstracts. Computational linguistics software was used in 1) concept mapping of 21,631,481 instances of 201 concepts, and 2) specific concept analyses examining 200 paired co-occurrences for ‘evidence’ and research ‘literature’ concepts.

Results

‘Evidence’ is a fundamentally patient-centred, intuitive concept linked to less common concepts about underlying processes, suspected disease mechanisms and diagnostic hunches. In contrast, the use of research literature in clinical reasoning is linked to more common reasoning concepts about specific knowledge and descriptions or presenting features of cases. ‘Literature’ is by far the most dominant concept, increasing in relevance since 2003, with an overall relevance of 13% versus 5% for ‘evidence’ which has remained static.

Conclusions

The fact that the least present types of reasoning concepts relate to diagnostic hunches to do with underlying processes, such as what is suspected, raises questions about whether intuitive practitioner evidence-making, found in a constellation of dynamic, process concepts, has become less important. The study adds support to the existing corpus of research on clinical reasoning, by suggesting that intuition involves a complex constellation of concepts important to how the construct of evidence is understood. The list of concepts the study generated offers a basis for reflection on the nature of evidence in diagnostic reasoning and the importance of intuition to that reasoning.

Example-based learning: comparing the effects of additionally providing three different integrative learning activities on physiotherapy intervention knowledge

BACKGROUND

Example-based learning using worked examples can foster clinical reasoning. Worked examples are instructional tools that learners can use to study the steps needed to solve a problem. Studying worked examples paired with completion examples promotes acquisition of problem-solving skills more than studying worked examples alone. Completion examples are worked examples in which some of the solution steps remain unsolved for learners to complete. Providing learners engaged in example-based learning with self-explanation prompts has been shown to foster increased meaningful learning compared to providing no self-explanation prompts. Concept mapping and concept map study are other instructional activities known to promote meaningful learning. This study compares the effects of self-explaining, completing a concept map and studying a concept map on conceptual knowledge and problem-solving skills among novice learners engaged in example-based learning.

METHODS

Ninety-one physiotherapy students were randomized into three conditions. They performed a pre-test and a post-test to evaluate their gains in conceptual knowledge and problem-solving skills (transfer performance) in intervention selection. They studied three pairs of worked/completion examples in a digital learning environment. Worked examples consisted of a written reasoning process for selecting an optimal physiotherapy intervention for a patient. The completion examples were partially worked out, with the last few problem-solving steps left blank for students to complete. The students then had to engage in additional self-explanation, concept map completion or model concept map study in order to synthesize and deepen their knowledge of the key concepts and problem-solving steps.

RESULTS

Pre-test performance did not differ among conditions. Post-test conceptual knowledge was higher (P < .001) in the concept map study condition (68.8 ± 21.8%) compared to the concept map completion (52.8 ± 17.0%) and self-explanation (52.2 ± 21.7%) conditions. Post-test problem-solving performance was higher (P < .05) in the self-explanation (63.2 ± 16.0%) condition compared to the concept map study (53.3 ± 16.4%) and concept map completion (51.0 ± 13.6%) conditions. Students in the self-explanation condition also invested less mental effort in the post-test.

CONCLUSIONS

Studying model concept maps led to greater conceptual knowledge, whereas self-explanation led to higher transfer performance. Self-explanation and concept map study can be combined with worked example and completion example strategies to foster intervention selection.

Diagnostic errors in the pediatric and neonatal ICU: a systematic review

OBJECTIVE

Diagnostic errors lead to preventable hospital morbidity and mortality. ICU patients may be at particularly high risk for misdiagnosis. Little is known about misdiagnosis in pediatrics, including PICU and neonatal ICU. We sought to assess diagnostic errors in PICU and neonatal ICU settings by systematic review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, and Cochrane.

STUDY SELECTION

We identified observational studies reporting autopsy-confirmed diagnostic errors in PICU or neonatal ICU using standard Goldman criteria.

DATA EXTRACTION

We abstracted patient characteristics, diagnostic error description, rates and error classes using standard Goldman criteria for autopsy misdiagnoses and calculated descriptive statistics.

DATA SYNTHESIS

We screened 329 citations, examined 79 full-text articles, and included 13 studies (seven PICU; six neonatal ICU). The PICU studies examined a total of 1,063 deaths and 498 autopsies. Neonatal ICU studies examined a total of 2,124 neonatal deaths and 1,259 autopsies. Major diagnostic errors were found in 19.6% of autopsied PICU and neonatal ICU deaths (class I, 4.5%; class II, 15.1%). Class I (potentially lethal) misdiagnoses in the PICU (43% infections, 37% vascular) and neonatal ICU (62% infections, 21% congenital/metabolic) differed slightly. Although missed infections were most common in both settings, missed vascular events were more common in the PICU and missed congenital conditions in the neonatal ICU.

CONCLUSION

Diagnostic errors in PICU/neonatal ICU populations are most commonly due to infection. Further research is needed to better quantify pediatric intensive care-related misdiagnosis and to define potential strategies to reduce their frequency or mitigate misdiagnosis-related harm.