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Si J. Fostering clinical reasoning ability in preclinical students through an illness script worksheet approach in flipped learning: a quasi-experimental study. BMC MEDICAL EDUCATION 2024; 24:658. [PMID: 38872172 DOI: 10.1186/s12909-024-05614-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 05/29/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The consensus that clinical reasoning should be explicitly addressed throughout medical training is increasing; however, studies on specific teaching methods, particularly, for preclinical students, are lacking. This study investigated the effects of an illness script worksheet approach in flipped learning on the development of clinical reasoning abilities in preclinical students. It also explored whether the impact of this intervention differed depending on clinical reasoning ability after dividing the students into high and low groups based on their pre-diagnostic thinking inventory (DTI) scores. METHODS This study used a one-group pre-post test design and convenience sampling. Forty-two second-year medical students were invited to participate in this study. The course, "clinical reasoning method," was redesigned as an illness script worksheet approach in flipped learning. The course was an eight-week long program. The students met once or twice per week with a different professor each time and engaged with 15 clinical cases in small groups in one classroom. Each time, one professor facilitated seven groups in a single classroom. The effectiveness of the intervention was measured using DTI before and after the intervention. A learning experience survey was conducted with post-DTI assessment. RESULTS Thirty-six students participated in the survey and their data were analyzed. The mean pre-DTI score was 170.4, and the mean post-DTI score was 185.2, indicating an 8.68% increase (p < .001). Significant differences were also found in both high and low groups between the pre- and post-DTI assessments. However, the low group improved much more than the high group and exhibited a significant increase in one of the DTI subscales as well. The overall average score on the learning experience survey was 3.11 out of 4. CONCLUSION The findings indicated that the intervention was an effective instructional method for the development of clinical reasoning in preclinical students and was more beneficial for students with a low level of clinical reasoning ability. This study demonstrated that the intervention can be a feasible and scalable method to effectively and efficiently train clinical reasoning in preclinical students in a classroom.
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Affiliation(s)
- Jihyun Si
- Department of Medical Education, Dong-A University College of Medicine, 32 Daesingongwon-ro, Seo-gu, Busan, 49201, Korea.
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2
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Choi JJ, Gribben J, Lin M, Abramson EL, Aizer J. Using an experiential learning model to teach clinical reasoning theory and cognitive bias: an evaluation of a first-year medical student curriculum. MEDICAL EDUCATION ONLINE 2023; 28:2153782. [PMID: 36454201 PMCID: PMC9718553 DOI: 10.1080/10872981.2022.2153782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Most medical students entering clerkships have limited understanding of clinical reasoning concepts. The value of teaching theories of clinical reasoning and cognitive biases to first-year medical students is unknown. This study aimed to evaluate the value of explicitly teaching clinical reasoning theory and cognitive bias to first-year medical students. METHODS Using Kolb's experiential learning model, we introduced dual process theory, script theory, and cognitive biases in teaching clinical reasoning to first-year medical students at an academic medical center in New York City between January and June 2020. Due to the COVID-19 pandemic, instruction was transitioned to a distance learning format in March 2020. The curriculum included a series of written clinical reasoning examinations with facilitated small group discussions. Written self-assessments prompted each student to reflect on the experience, draw conclusions about their clinical reasoning, and plan for future encounters involving clinical reasoning. We evaluated the value of the curriculum using mixed-methods to analyze faculty assessments, student self-assessment questionnaires, and an end-of-curriculum anonymous questionnaire eliciting student feedback. RESULTS Among 318 total examinations of 106 students, 254 (80%) had a complete problem representation, while 199 (63%) of problem representations were considered concise. The most common cognitive biases described by students in their clinical reasoning were anchoring bias, availability bias, and premature closure. Four major themes emerged as valuable outcomes of the CREs as identified by students: (1) synthesis of medical knowledge; (2) enhanced ability to generate differential diagnoses; (3) development of self-efficacy related to clinical reasoning; (4) raised awareness of personal cognitive biases. CONCLUSIONS We found that explicitly teaching clinical reasoning theory and cognitive biases using an experiential learning model provides first-year medical students with valuable opportunities for developing knowledge, skills, and self-efficacy related to clinical reasoning.
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Affiliation(s)
- Justin J. Choi
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jeanie Gribben
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Myriam Lin
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Erika L. Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Juliet Aizer
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
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3
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Duong QH, Pham TN, Reynolds L, Yeap Y, Walker S, Lyons K. A scoping review of therapeutic reasoning process research. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2023; 28:1289-1310. [PMID: 37043070 PMCID: PMC10624714 DOI: 10.1007/s10459-022-10187-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/09/2022] [Indexed: 06/19/2023]
Abstract
Therapeutic reasoning is when the purpose, task, or goal for engaging in reasoning is to determine the patient's management plan. As the field's understanding of the process of therapeutic reasoning is less well understood, we focused on studies that collected data on the process of therapeutic reasoning. To synthesize previous studies of therapeutic reasoning characteristics, methodological approaches, theoretical underpinnings, and results. We conducted a scoping review with systematic searching for English language articles with no date limits. Databases included MEDLINE, CINAHL Plus, Scopus, Embase, Proquest Dissertations and Theses Global, and ERIC. Search terms captured therapeutic reasoning in health professions education research. Initial search yielded 5450 articles. The title and abstract screening yielded 180 articles. After full-text review, 87 studies were included in this review. Articles were excluded if they were outside health professions education, did not collect data on the process of therapeutic reasoning, were not empirical studies, or not focused on therapeutic reasoning. We analyzed the included articles according to scoping questions using qualitative content analysis. 87 articles dated from 1987 to 2019 were included. Several study designs were employed including think-aloud protocol, interview and written documentation. More than half of the articles analyzed the data using qualitative coding. Authors often utilized several middle-range theories to explain therapeutic reasoning processes. The hypothetico-deductive model was most frequently mentioned. The included articles rarely built off the results from previous studies. Six key result categories were found: identifying themes, characterizing and testing previous local theory, exploring factors, developing new local theory, testing tools, and testing hypothesis. Despite the cast body of therapeutic reasoning research, individual study results remain isolated from previous studies. Our future recommendations include synthesizing pre-existing models, developing novel methodologies, and investigating other aspects of therapeutic reasoning.
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Affiliation(s)
- Quang Hung Duong
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - To Nhu Pham
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Lorenna Reynolds
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Yan Yeap
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Steven Walker
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Kayley Lyons
- Centre for Digital Transformation of Health, University of Melbourne, 700 Swanston St, Carlton, 3053, Australia.
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Elvén M, Welin E, Wiegleb Edström D, Petreski T, Szopa M, Durning SJ, Edelbring S. Clinical Reasoning Curricula in Health Professions Education: A Scoping Review. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231209093. [PMID: 37900617 PMCID: PMC10605682 DOI: 10.1177/23821205231209093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/09/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVES This scoping review aimed to explore and synthesize current literature to advance the understanding of how to design clinical reasoning (CR) curricula for students in health professions education. METHODS Arksey and O'Malley's 6-stage framework was applied. Peer-reviewed articles were searched in PubMed, Web of Science, CINAHL, and manual searches, resulting in the identification of 2932 studies. RESULTS Twenty-six articles were included on CR in medical, nursing, physical therapy, occupational therapy, midwifery, dentistry, and speech language therapy education. The results describe: features of CR curriculum design; CR theories, models, and frameworks that inform curricula; and teaching content, methods, and assessments that inform CR curricula. CONCLUSIONS Several CR theories, teaching, and assessment methods are integrated into CR curricula, reflecting the multidimensionality of CR among professions. Specific CR elements are addressed in several curricula; however, no all-encompassing CR curriculum design has been identified. These findings offer useful insights for educators into how CR can be taught and assessed, but they also suggest the need for further guidance on educational strategies and assessments while learners progress through an educational program.
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Affiliation(s)
- Maria Elvén
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Elisabet Welin
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Desiree Wiegleb Edström
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Tadej Petreski
- Institute for Biomedical Sciences, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Magdalena Szopa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Steven J. Durning
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Samuel Edelbring
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Dyre L, Grierson L, Rasmussen KMB, Ringsted C, Tolsgaard MG. The concept of errors in medical education: a scoping review. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:761-792. [PMID: 35190892 DOI: 10.1007/s10459-022-10091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/05/2022] [Indexed: 06/14/2023]
Abstract
The purpose of this scoping review was to explore how errors are conceptualized in medical education contexts by examining different error perspectives and practices. This review used a scoping methodology with a systematic search strategy to identify relevant studies, written in English, and published before January 2021. Four medical education journals (Medical Education, Advances in Health Science Education, Medical Teacher, and Academic Medicine) and four clinical journals (Journal of the American Medical Association, Journal of General Internal Medicine, Annals of Surgery, and British Medical Journal) were purposively selected. Data extraction was charted according to a data collection form. Of 1505 screened studies, 79 studies were included. Three overarching perspectives were identified: 'understanding errors') (n = 31), 'avoiding errors' (n = 25), 'learning from errors' (n = 23). Studies that aimed at'understanding errors' used qualitative methods (19/31, 61.3%) and took place in the clinical setting (19/31, 61.3%), whereas studies that aimed at 'avoiding errors' and 'learning from errors' used quantitative methods ('avoiding errors': 20/25, 80%, and 'learning from errors': 16/23, 69.6%, p = 0.007) and took place in pre-clinical (14/25, 56%) and simulated settings (10/23, 43.5%), respectively (p < 0.001). The three perspectives differed significantly in terms of inclusion of educational theory: 'Understanding errors' studies 16.1% (5/31),'avoiding errors' studies 48% (12/25), and 'learning from errors' studies 73.9% (17/23), p < 0.001. Errors in medical education and clinical practice are defined differently, which makes comparisons difficult. A uniform understanding is not necessarily a goal but improving transparency and clarity of how errors are currently conceptualized may improve our understanding of when, why, and how to use and learn from errors in the future.
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Affiliation(s)
- Liv Dyre
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University, Rigshospitalet, Ryesgade 53B, DK-2100, Copenhagen, Denmark.
| | - Lawrence Grierson
- Department of Family Medicine, Health Sciences Education Program, McMaster University, Toronto, Canada
| | - Kasper Møller Boje Rasmussen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University, Rigshospitalet, Ryesgade 53B, DK-2100, Copenhagen, Denmark
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | | | - Martin G Tolsgaard
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University, Rigshospitalet, Ryesgade 53B, DK-2100, Copenhagen, Denmark
- Department of Obstetrics, Copenhagen University, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
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Schaye V, Miller L, Kudlowitz D, Chun J, Burk-Rafel J, Cocks P, Guzman B, Aphinyanaphongs Y, Marin M. Development of a Clinical Reasoning Documentation Assessment Tool for Resident and Fellow Admission Notes: a Shared Mental Model for Feedback. J Gen Intern Med 2022; 37:507-512. [PMID: 33945113 PMCID: PMC8858363 DOI: 10.1007/s11606-021-06805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability. OBJECTIVE Our goal was to develop a valid and reliable assessment tool for clinical reasoning documentation building off the IDEA assessment tool. DESIGN, PARTICIPANTS, AND MAIN MEASURES The Revised-IDEA assessment tool was developed by four clinician educators through iterative review of admission notes written by medicine residents and fellows and subsequently piloted with additional faculty to ensure response process validity. A random sample of 252 notes from July 2014 to June 2017 written by 30 trainees across several chief complaints was rated. Three raters rated 20% of the notes to demonstrate internal structure validity. A quality cut-off score was determined using Hofstee standard setting. KEY RESULTS The Revised-IDEA assessment tool includes the same four domains as the IDEA assessment tool with more detailed descriptive prompts, new Likert scale anchors, and a score range of 0-10. Intraclass correlation was high for the notes rated by three raters, 0.84 (95% CI 0.74-0.90). Scores ≥6 were determined to demonstrate high-quality clinical reasoning documentation. Only 53% of notes (134/252) were high-quality. CONCLUSIONS The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.
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Affiliation(s)
- Verity Schaye
- NYU Grossman School of Medicine, New York, NY, USA. .,NYC Health + Hospitals/Bellevue, New York, NY, USA.
| | - Louis Miller
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | | | - Jonathan Chun
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | - Marina Marin
- NYU Grossman School of Medicine, New York, NY, USA
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Connor DM, Narayana S, Dhaliwal G. A clinical reasoning curriculum for medical students: an interim analysis. Diagnosis (Berl) 2022; 9:265-273. [PMID: 34904425 DOI: 10.1515/dx-2021-0112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/22/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Denise M Connor
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Sirisha Narayana
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
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Sudacka M, Adler M, Durning SJ, Edelbring S, Frankowska A, Hartmann D, Hege I, Huwendiek S, Sobočan M, Thiessen N, Wagner FL, Kononowicz AA. Why is it so difficult to implement a longitudinal clinical reasoning curriculum? A multicenter interview study on the barriers perceived by European health professions educators. BMC MEDICAL EDUCATION 2021; 21:575. [PMID: 34772405 PMCID: PMC8588939 DOI: 10.1186/s12909-021-02960-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 09/27/2021] [Indexed: 05/28/2023]
Abstract
BACKGROUND Effective clinical reasoning is a core competency of health professionals that is necessary to assure patients' safety. Unfortunately, adoption of longitudinal clinical reasoning curricula is still infrequent. This study explores the barriers that hinder the explicit teaching of clinical reasoning from a new international perspective. METHODS The context of this study was a European project whose aim is to develop a longitudinal clinical reasoning curriculum. We collected data in semi-structured interviews with responders from several European countries who represent various health professions and have different backgrounds, roles and experience. We performed a qualitative content analysis of the gathered data and constructed a coding frame using a combined deductive/inductive approach. The identified themes were validated by parallel coding and in group discussions among project members. RESULTS A total of 29 respondents from five European countries participated in the interviews; the majority of them represent medicine and nursing sciences. We grouped the identified barriers into eight general themes: Time, Culture, Motivation, Clinical Reasoning as a Concept, Teaching, Assessment, Infrastructure and Others. Subthemes included issues with discussing errors and providing feedback, awareness of clinical reasoning teaching methods, and tensions between the groups of professionals involved. CONCLUSIONS This study provides an in-depth analysis of the barriers that hinder the teaching of explicit clinical reasoning. The opinions are presented from the perspective of several European higher education institutions. The identified barriers are complex and should be treated holistically due to the many interconnections between the identified barriers. Progress in implementation is hampered by the presence of reciprocal causal chains that aggravate this situation. Further research could investigate the perceptual differences between health professions regarding the barriers to clinical reasoning. The collected insights on the complexity and diversity of these barriers will help when rolling out a long-term agenda for overcoming the factors that inhibit the implementation of clinical reasoning curricula.
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Affiliation(s)
- Małgorzata Sudacka
- Department of Medical Education, Jagiellonian University Medical College, Krakow, Poland.
| | | | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Samuel Edelbring
- Learning and Professional Development Group, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Ada Frankowska
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Daniel Hartmann
- Medical Education Sciences, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Inga Hege
- Medical Education Sciences, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute for Medical Education, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Sören Huwendiek
- Institute for Medical Education, University of Bern, Bern, Switzerland
| | - Monika Sobočan
- Centre for Medical Education, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Division of Gynecology and Perinatology, University Medical Centre Maribor, Maribor, Slovenia
| | - Nils Thiessen
- EDU - a degree smarter, Digital Education Holdings Ltd., Kalkara, Malta
| | | | - Andrzej A Kononowicz
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
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Learning and teaching aren’t the same – the need for diagnosis curricula in graduate medical education. Diagnosis (Berl) 2020; 7:1-2. [DOI: 10.1515/dx-2019-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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