A BEME realist synthesis review of the effectiveness of teaching strategies used in the clinical setting on the development of clinical skills among health professionals: BEME Guide No. 61

Promoting clinical reasoning in undergraduate Family Medicine curricula through concept mapping: a qualitative approach

Clinical reasoning is a crucial skill for physicians, enabling them to bridge theoretical knowledge with practical application. The gap between basic sciences and clinical practice persists as a challenge, with traditional teaching methods yet to effectively bridge it. Concept maps (CMs), visual tools for organizing and connecting knowledge, hold promise for enhancing clinical reasoning in the undergraduate medical curriculum. However, further research is required to ascertain if CMs facilitate clinical reasoning development in medical students transitioning from basic sciences to clinical practice. This study aims to delineate how CMs can facilitate clinical reasoning in patients with multimorbidity within undergraduate Family Medicine curricula, as perceived by students and tutors, and to understand the implementation process and resources required. This exploratory qualitative study formed a part of an action research project. While introducing an educational intervention to 5th-year medical students, we conducted a qualitative evaluation. Subsequently, semi-structured group interviews were conducted with students, and a focus group was conducted with tutors. Three main educational impacts were identified: integration of clinical information, support for patient management and care plan, and collaborative learning. Key aspects for successful CM implementation included clear instructions for map construction, using user-friendly software, allocating sufficient time for the task, encouraging group discussion of CMs, and incorporating tutor feedback. CMs are pedagogical tools that facilitate clinical information integration and support management and treatment plans, helping students better understand multimorbidity patients and promoting some components of clinical reasoning in undergraduate medical education.

Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials

INTRODUCTION

Clinical reasoning is crucial in medical practice, yet its teaching faces challenges due to varied clinical experiences, limited time, and absence from competency frameworks. Despite efforts, effective teaching methodologies remain elusive. Strategies like the One Minute Preceptor (OMP) and SNAPPS are proposed as solutions, particularly in workplace settings. SNAPPS, introduced in 2003, offers a structured approach but lacks comprehensive evidence of its effectiveness. Methodological shortcomings hinder discerning its specific effects. Therefore, a systematic review is proposed to evaluate SNAPPS' impact on clinical reasoning teaching.

CONTENT

We searched PubMed, EMBASE, and CINAHL for randomized controlled trials (RCTs) comparing SNAPPS against other methods. Data selection and extraction were performed in duplicate. Bias and certainty of evidence were evaluated using Cochrane RoB-2 and GRADE approach.

SUMMARY

We identified five RCTs performed on medical students and residents. Two compared SNAPPS with an active control such as One Minute Preceptor or training with feedback. None reported the effects of SNAPPS in workplace settings (Kirkpatrick Level 3) or patients (Kirkpatrick Level 4). Low to moderate certainty of evidence suggests that SNAPPS increases the total presentation length by increasing discussion length. Low to moderate certainty of evidence may increase the number of differential diagnoses and the expression of uncertainties. Low certainty of evidence suggests that SNAPPS may increase the odds of trainees initiating a management plan and seeking clarification.

OUTLOOK

Evidence from this systematic review suggests that SNAPPS has some advantages in terms of clinical reasoning, self-directed learning outcomes, and cost-effectiveness. Furthermore, it appears more beneficial when used by residents than medical students. However, future research should explore outcomes outside SNAPPS-related outcomes, such as workplace or patient-related outcomes.

The effectiveness of concept mapping as a tool for developing critical thinking in undergraduate medical education - a BEME systematic review: BEME Guide No. 81

BACKGROUND

Concept maps (CMs) visually represent hierarchical connections among related ideas. They foster logical organization and clarify idea relationships, potentially aiding medical students in critical thinking (to think clearly and rationally about what to do or what to believe). However, there are inconsistent claims about the use of CMs in undergraduate medical education. Our three research questions are 1) What studies have been published on concept mapping in undergraduate medical education; 2) What was the impact of CMs on students' critical thinking; 3) How and why have these interventions had an educational impact?

METHODS

Eight databases were systematically searched (plus a manual and an additional search were conducted). After eliminating duplicate entries, titles and abstracts and full-texts were independently screened by two authors. Data extraction and quality assessment of the studies were independently performed by two authors. Qualitative and quantitative data were integrated using mixed-methods. The results were reported using the STructured apprOach to the Reporting In healthcare education of Evidence Synthesis statement and BEME guidance.

RESULTS

Thirty-nine studies were included from 26 journals (19 quantitative, 8 qualitative and 12 mixed-methods studies). CMs were considered as a tool to promote critical thinking, both in the perception of students and tutors, as well as in assessing students' knowledge and/or skills. In addition to their role as facilitators of knowledge integration and critical thinking, CMs were considered both a teaching and a learning methods.

CONCLUSIONS

CMs are teaching and learning tools which seem to help medical students develop critical thinking. This is due to the flexibility of the tool as a facilitator of knowledge integration, as a learning and teaching method. The wide range of contexts, purposes, and variations in how CMs and instruments to assess critical thinking are used increases our confidence that the positive effects are consistent.

A comprehensive approach to identify challenges for clinical reasoning development in undergraduate dental students and their potential solutions

INTRODUCTION

Clinical reasoning is a core competence in health professions that impacts the ability to solve patients' health problems. Due to its relevance, it is necessary to identify difficulties arising from different sources that affect clinical reasoning development in students. The aim of this study was to explore a comprehensive approach to identify challenges for clinical reasoning development in undergraduate dental students and their potential solutions.

METHODS

Mixed methods were used in four stages: (1) students and clinical teachers focus groups to identify challenges to clinical reasoning development; (2) literature review to explore potential solutions for these challenges; (3) Delphi technique for teacher consensus on pertinence and feasibility of solutions (1-5 scale); and (4) teachers' self-perception of their ability to implement the solutions.

RESULTS

Three categories and seven subcategories of challenges were identified: (I) educational context factors influencing the clinical reasoning process; (II) teacher's role in clinical reasoning development; and (III) student factors influencing the clinical reasoning process. From 134 publications identified, 53 were selected for review, resulting in 10 potential solutions. Through two Delphi rounds, teachers rated the potential solutions very highly in terms of relevance (4.50-4.85) and feasibility (3.50-4.29). Finally, a prioritisation ranking of these solutions was generated using their scores for relevance, feasibility, and teachers' self-perception of their ability to implement them.

CONCLUSIONS

The present comprehensive approach identified challenges for clinical reasoning development in dental students and their potential solutions, perceived as relevant and feasible by teachers, requiring further research and follow-up actions to address them.

Faculty perspectives on facilitating medical students' longitudinal learning: A mixed-methods study

INTRODUCTION

Medical students' longitudinal care of patients supports clinical learning and promotes patient-centredness. The literature presents little empirically derived guidance for faculty to facilitate students' longitudinal learning and care. Informed by the conceptual framework of relational learning, this study investigated faculty perspectives about longitudinal teaching, their strategies for facilitating students' longitudinal learning and perceived barriers and enablers.

METHODS

Using a convergent mixed-methods approach at a single academic medical centre, the authors conducted a survey and two focus groups in 2018-2019 with faculty members teaching in three longitudinal clinical courses. Quantitative analyses included descriptive statistics and chi-square tests. Qualitative content analysis described deductive categories and identified inductive themes.

RESULTS

Forty-three eligible faculty (69%) completed the survey. Ninety-one percent (n = 39) reported that teaching in a longitudinal model enhanced their experience as preceptors. Faculty described activities students performed to provide longitudinal care: spending time with patients independently (n = 38, 88%), making follow-up phone calls (n = 35; 81%) and participating in home- and community-based visits (n = 20, 47%), among others. Twelve faculty participated in two focus groups. Deductive analysis characterised strategies for facilitating students' longitudinal learning and barriers and enablers. Strategies included "encouraging students to follow patients," "faculty adaptability," "offering guidance and setting expectations," and "careful patient selection." Barriers included scheduling limitations, and enablers included student initiative. Inductive analysis identified two themes: faculty goals for students and faculty benefits from teaching. Goals included meaningful engagement with patients and their illness over time. Benefits from teaching included personal gratification, mentorship, and holistic student assessment.

DISCUSSION

Our survey and focus group findings demonstrated positive faculty attitudes and experiences, characterised faculty goals and approaches, and identified elements of the educational context that hindered or facilitated longitudinal teaching and learning. This study's faculty perspectives build upon prior investigations of students' and patients' perspectives, offer teaching strategies, and may guide faculty development.

Enhancing Clinical Teaching in Critical Thinking, High-Value Care, and Health Care Equity

INTRODUCTION

Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC), and health care equity (HCE).

METHODS

The Communities of Practice model and Theoretical Domains Framework informed IG development. Three multidepartmental working groups (WGs) (CT, HVC, HCE) developed three 2-hour sessions delivered over three months. Evaluation addressed faculty satisfaction, knowledge acquisition, and behavior change. Data collection included surveys and observations of teaching during patient care. Primary analyses compared counts of post-IG teaching behaviors per hour across intervention group (IG), comparison group (CG), and WG groups. Statistical analyses of counts were modeled with generalized linear models using the Poisson distribution.

RESULTS

Eighty-seven faculty members participated (IG n = 30, CG n = 28, WG n = 29). Sixty-eight (IG n = 28, CG n = 23, WG n = 17) were observed, with a median of 3 observation sessions and 5.2 hours each. Postintervention comparison of teaching (average counts/hour) showed statistically significant differences across groups: CT CG = 4.1, IG = 4.8, WG = 8.2; HVC CG = 0.6, IG = 0.9, WG = 1.6; and HCE CG = 0.2, IG = 0.4, WG = 1.4 ( P < .001).

DISCUSSION

A faculty development intervention focused on teaching in the context of providing clinical care resulted in more frequent teaching of CT, HVC, and HCE in the intervention group compared with controls. WG faculty demonstrated highest teaching counts and provide benchmarks to assess future interventions. With the creation of durable teaching materials and a cadre of trained faculty, this project sets a foundation for infusing substantive content into clinical teaching.

Learning Analytics Applied to Clinical Diagnostic Reasoning Using a Natural Language Processing-Based Virtual Patient Simulator: Case Study

BACKGROUND

Virtual patient simulators (VPSs) log all users' actions, thereby enabling the creation of a multidimensional representation of students' medical knowledge. This representation can be used to create metrics providing teachers with valuable learning information.

OBJECTIVE

The aim of this study is to describe the metrics we developed to analyze the clinical diagnostic reasoning of medical students, provide examples of their application, and preliminarily validate these metrics on a class of undergraduate medical students. The metrics are computed from the data obtained through a novel VPS embedding natural language processing techniques.

METHODS

A total of 2 clinical case simulations (tests) were created to test our metrics. During each simulation, the students' step-by-step actions were logged into the program database for offline analysis. The students' performance was divided into seven dimensions: the identification of relevant information in the given clinical scenario, history taking, physical examination, medical test ordering, diagnostic hypothesis setting, binary analysis fulfillment, and final diagnosis setting. Sensitivity (percentage of relevant information found) and precision (percentage of correct actions performed) metrics were computed for each issue and combined into a harmonic mean (F₁), thereby obtaining a single score evaluating the students' performance. The 7 metrics were further grouped to reflect the students' capability to collect and to analyze information to obtain an overall performance score. A methodological score was computed based on the discordance between the diagnostic pathway followed by students and the reference one previously defined by the teacher. In total, 25 students attending the fifth year of the School of Medicine at Humanitas University underwent test 1, which simulated a patient with dyspnea. Test 2 dealt with abdominal pain and was attended by 36 students on a different day. For validation, we assessed the Spearman rank correlation between the performance on these scores and the score obtained by each student in the hematology curricular examination.

RESULTS

The mean overall scores were consistent between test 1 (mean 0.59, SD 0.05) and test 2 (mean 0.54, SD 0.12). For each student, the overall performance was achieved through a different contribution in collecting and analyzing information. Methodological scores highlighted discordances between the reference diagnostic pattern previously set by the teacher and the one pursued by the student. No significant correlation was found between the VPS scores and hematology examination scores.

CONCLUSIONS

Different components of the students' diagnostic process may be disentangled and quantified by appropriate metrics applied to students' actions recorded while addressing a virtual case. Such an approach may help teachers provide students with individualized feedback aimed at filling competence drawbacks and methodological inconsistencies. There was no correlation between the hematology curricular examination score and any of the proposed scores as these scores address different aspects of students' medical knowledge.

Enhancing the one-minute preceptor method for clinical teaching with a DEFT approach

Few validated methods that are grounded in educational theory exist to effectively teach medical knowledge, clinical skills, and diagnostic reasoning to learners at different stages of medical training. The goal of this Perspective was to address potential gaps in clinical education pedagogy by modeling new concepts for teaching in the field of infectious diseases. Our approach involved synthesizing the relevant literature, identifying proven approaches, and enhancing an existing educational microskills model — the one-minute preceptor. Our strategy was to emphasize the essential core elements of the one-minute preceptor using a descriptive acronym — DEFT (Diagnosis, Evidence, Feedback, Teaching), meaning skillful — as a potentially helpful reminder to improve the quality of interactions between learners and preceptors. The need for learners to discuss risk factors, mechanisms of disease, and potential complications, and for preceptors to model analytical and diagnostic skills, was further illustrated using a practical example of a teacher-learner interaction about a child with a respiratory infection. The one-minute preceptor/DEFT approach is experiential, adaptable, case-driven, and skills-focused, and also applicable to clinical training in other specialties.

Using the Five-Microskills Method in Veterinary Medicine Clinical Teaching

Effective clinical teaching is essential for the development of veterinary learners. Teaching clinical reasoning is a challenge for veterinary instructors as many lack adequate training in clinical teaching. In this paper, we propose the use of the five-microskills (FMS; also known as the one-minute preceptor) model of clinical teaching as a tool that can be used not only in teaching during clinical encounters but also during traditional teaching sessions (e.g., practicals). The FMS model assists the instructor in estimating the level of knowledge and development of the learner and allows for providing feedback. The FMS model is applicable in the busy clinical or teaching schedule of the instructor and requires training only of the instructor, not the learner. We provide two examples of the use of the FMS model, one of a clinical encounter and the other a biochemistry practical. From the examples, readers should be able to extract the basis of the model and start using it in their day-to-day practice. For proper use of the model, 1-4 h of training is usually recommended.