A new methodology for teaching clinical reasoning skills: problem solving clinical seminars

Developing Clinical Reasoning in a Physician Assistant Curriculum: The University of Sheffield approach

ABSTRACT

Clinical reasoning remains a key area for development amongst clinical students across the world. Physician assistant (PA) roles (physician associate in the United Kingdom) are rapidly expanding, and there is a need to ensure that this core skill is reflected in course curricula. This article presents how the University of Sheffield has integrated clinical reasoning into the curriculum for its PA course. This includes recognizing the need to consider different approaches to reasoning and how they are taught, the assessment of reasoning across Miller's pyramid, and other considerations that contribute to embedding reasoning within the course. We discuss the implications of our approach and comment on issues that we may need to consider in the future.

The Challenging Case Conference: A Gamified Approach to Clinical Reasoning in the Video Conference Era

The development of clinical reasoning abilities is a core competency of emergency medicine (EM) resident education and has historically been accomplished through case conferences and clinical learning. The advent of the SARS-CoV-2 pandemic has fundamentally changed these traditional learning opportunities by causing a nationwide reliance on virtual education environments and reducing the clinical diversity of cases encountered by EM trainees.

We propose an innovative case conference that combines low-fidelity simulation with elements of gamification to foster the development of clinical reasoning skills and increase engagement among trainees during a virtual conference. After a team of residents submits a real clinical case that challenged their clinical reasoning abilities, a different team of residents “plays” through a gamified, simulated version of the case live on a video conference call. The case concludes with a facilitated debriefing led by a simulation-trained faculty, where both the resident teams and live virtual audience discuss the challenges of the case. Participants described how the Challenging Case Conference improved their perceptions of their clinical reasoning skills. Audience members reported increased engagement compared to traditional conferences. Participants also reported an unexpected, destigmatizing effect on the discussion of medical errors produced by this exercise. Residency programs could consider implementing a similar case conference as a component of their conference curriculum.

Effect of learning contracts in clinical pediatric nursing education on students' outcomes: A research article

BACKGROUND

According to previous research, learning contracts positively influence learners' self-directed learning ability, learning satisfaction, and academic performance. However, there are insufficient researches on the application of learning contracts to clinical training in pediatric nursing. This study sought basic data for developing an effective teaching and learning strategy for clinical education in pediatric nursing.

OBJECTIVE

This study aimed to validate the effect of learning contracts on students' problem-solving skills, self-directed learning capability, and communication self-efficacy.

DESIGN

Nonequivalent control group posttest design.

PARTICIPANTS AND SETTINGS

The participants comprised a total of 50 junior nursing students, 25 in each group at a college in Daejeon City, South Korea.

METHOD

This study compared the above-mentioned outcomes between control (before clinical pediatric nursing education) and experimental groups (after received such education and applied learning contracts).

RESULTS

The experimental group demonstrated higher problem-solving skills, self-directed learning capability, and communication self-efficacy scores than did the control group.

CONCLUSION

Learning contracts should be applied in practical courses as a teaching and learning method to improve relevant nursing skills, such as problem-solving skills, self-directed learning capabilities, and communication self-efficacy.

Design and delivery of a new clinical reasoning course

BACKGROUND AND PURPOSE

Teaching students therapeutic knowledge is not the same as teaching them how to reason through clinical problems. It was determined a new approach was necessary to close the gap between classroom learning and clinical application.

EDUCATIONAL ACTIVITY AND SETTING

A stand-alone clinical reasoning course was developed to enhance students' ability to think about and solve clinical problems. This course involved a variety of active-learning strategies based upon literature regarding clinical reasoning.

FINDINGS

The objective of this study was to determine if a clinical reasoning course influenced student perceptions on evolution of their thinking and learning strategies and ways to improve. Thematic analysis of midpoint student reflections (n = 133) revealed eight different themes of how students perceived evolution of their thinking. Top themes were approaching a problem (n = 76), evaluating information (n = 62), and efficiency (n = 44). Thematic analysis of final student reflections (n = 138) included two categories: thinking and improvement. Reflections related to evolvement of thinking revealed five themes, the top three of which were approaching a problem (n = 89), holistic (n = 55), and efficiency (n = 46). Reflections of improvement revealed four themes, the top two of which were continue applying (n = 74) and communication (n = 23).

DISCUSSION

The themes indicate that students began to understand clinical reasoning as a set of skills necessary to become an effective practitioner.

CONCLUSIONS

A novel course designed to develop clinical reasoning skills can help students evolve their perception of thinking and learning strategies and engage them in a process for the application of knowledge to patient care.

Role of academic self-efficacy in the relationship between self-directed learning readiness and problem-solving ability among nursing students

Objective

Problem-solving should be a fundamental component of nursing education because it is a core ability for professional nurses. For more effective learning, nursing students must understand the relationship between self-directed learning readiness and problem-solving ability. The aim of this study was to investigate the relationships among self-directed learning readiness, problem-solving ability, and academic self-efficacy among undergraduate nursing students.

Methods

From November to December 2016, research was conducted among 500 nursing undergraduate students in Tianjin, China, using a self-directed learning readiness scale, an academic self-efficacy scale, a questionnaire related to problem-solving, and self-designed demographics. The response rate was 85.8%.

Results

For Chinese nursing students, self-directed learning readiness and academic self-efficacy reached a medium-to-high level, while problem-solving abilities were at a low level. There were significant positive correlations among the students’ self-directed learning readiness, academic self-efficacy, and problem-solving ability. Furthermore, academic self-efficacy demonstrated a mediating effect on the relationship between the students’ self-directed learning readiness and problem-solving ability.

Conclusions

To enhance students’ problem-solving ability, nursing educators should pay more attention to the positive impact of self-directed learning readiness and self-efficacy in nursing students’ education.

Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors

BACKGROUND

Recent reports, including the Institute of Medicine's Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools.

OBJECTIVE

To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning.

DESIGN

Cross-sectional multicenter study.

PARTICIPANTS

US institutional members of the Clerkship Directors in Internal Medicine (CDIM).

MAIN MEASURES

Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school's clinical reasoning curriculum.

KEY RESULTS

The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers.

CONCLUSIONS

Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.

Effectiveness of modified seminars as a teaching-learning method in pharmacology

Context:

Student-led seminars (SLS) are adopted as a teaching-learning (T-L) method in pharmacology. Previous studies assessing the feedback on T-L methods in pharmacology points out that the traditional seminars consistently received poor feedbacks as they were not favorite among the students.

Aims:

This study aimed to obtain feedback on traditional SLS, introduce modified SLS and compare the modified seminars with the traditional ones.

Settings and Design:

This was a prospective interventional study done for 2 months in medical undergraduates of fifth semester attending Pharmacology seminars at a Government Medical College in South India.

Subjects and Methods:

Structured questionnaire was used to elicit feedback from participants. The responses were coded on 5-point Likert scale. Modifications in seminar sessions such as role plays, quiz, tests, group discussion, and patient-oriented problem-solving exercises were introduced along with SLS.

Statistical Analysis Used:

The data were analyzed using SPSS version 16. The descriptive data were expressed using frequencies and percentages. Wilcoxon signed rank test, and Friedman tests were used to compare traditional with modified seminars.

Results:

The participants identified interaction as the most important component of a seminar. Majority opined that the teacher should summarize at the end of SLS. Student feedback shows that modified seminars created more interest, enthusiasm, and inspiration to learn the topic when compared to traditional SLS. They also increased peer coordination and group dynamics. Students opined that communication skills and teacher-student interactions were not improved with modified seminars.

Conclusions:

Interventions in the form of modified SLS may be adopted to break the monotony of traditional seminars through active participation, peer interaction, and teamwork.

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.

Integrated Cases Section: a course designed to promote clinical reasoning in year 2 medical students

BACKGROUND

Medical students often have difficulty applying basic science knowledge within clinical contexts as they transition into clerkships.

DESCRIPTION

To enhance clinical reasoning skills in 2nd-year medical students, we developed a 7-week transition course called the Integrated Cases Section. Curricular instruction incorporated analytic and nonanalytic clinical reasoning models. Practice with variable case scenarios enhanced students' application of basic science knowledge to clinical problem solving.

EVALUATION

We evaluated curricular design and objectives by measuring student perceptions during the course and following completion of 2 clerkship rotations. To obtain measurement of students' clinical reasoning ability we administered a script concordance test immediately before and after the course.

CONCLUSIONS

Students reported increased confidence in their diagnostic reasoning ability during the course and after completion of 2 clerkships. Students' clinical reasoning showed a significant gain after the Integrated Cases Section on a script concordance test. Student support has solidified Integrated Cases Section in the curriculum.

Diagnostic ability in relation to clinical seminars and extended-matching questions examinations

CONTEXT

At the Katholieke Universiteit Leuven, Belgium, final year medical students participate in 70 problem-solving clinical seminars over a period of 2 months, concentrating on clinical reasoning for formulating differential diagnoses. The clinical seminars end in an examination consisting of 200 extended-matching questions (EMQs).

OBJECTIVES

This study asks whether problem-solving clinical seminars improve clinical reasoning and whether the EMQ examination measures clinical decision making. In order to detect an increase in diagnostic ability, the Diagnostic Thinking Inventory (DTI) was applied. The research hypotheses were: (i) DTI scores will be higher after the seminars than before, and (ii) the correlations between DTI scores and EMQ examination scores will be significant.

METHODS

In the academic year 2003-04, 3 series of problem-solving clinical seminars were held. At the beginning and end of each series the students filled in the DTI. This questionnaire measures 2 aspects of diagnostic thinking: the degree of flexibility in thinking, and how knowledge is structured in the memory.

RESULTS

For all data together, the DTI scores after the clinical seminars were significantly higher than before. Pearson correlations between DTI scores and EMQ examination scores were low but significant, with the exception of post-test Structure (not significant).

CONCLUSIONS

Two months of intensive problem-solving clinical training was accompanied by an improvement in diagnostic thinking, as measured by DTI scores. Correlation between DTI scores and examination scores indicates that the EMQs measure an aspect of student achievement that is related to clinical reasoning.