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Ovitsh RK, Gupta S, Kusnoor A, Jackson JM, Roussel D, Mooney CJ, Pinto-Powell R, Appel JL, Mhaskar R, Gold J. Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition. MEDICAL EDUCATION ONLINE 2024; 29:2307715. [PMID: 38320116 PMCID: PMC10848998 DOI: 10.1080/10872981.2024.2307715] [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: 08/24/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.
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Affiliation(s)
- Robin K. Ovitsh
- Department of Pediatrics, Downstate Health Sciences University College of Medicine, Brooklyn, NY, USA
| | - Shanu Gupta
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Anita Kusnoor
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer M. Jackson
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Danielle Roussel
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Christopher J. Mooney
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Roshini Pinto-Powell
- Department of Medicine and Medical Education, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Joel L. Appel
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa, FL, USA
| | - Jonathan Gold
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI, USA
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Benayon M, Latchupatula L, Mansoor M, Kocaqi E, Azim A, Sibbald M. Mock Wards: Incorporating a Theoretical Framework to Create a Blended Virtual and In-Person Clinical Reasoning Education Platform. Cureus 2024; 16:e64954. [PMID: 39040615 PMCID: PMC11260654 DOI: 10.7759/cureus.64954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 07/24/2024] Open
Abstract
Introduction The coronavirus 2019 pandemic highlighted virtual learning (VL) as a promising tool for medical education, yet its effectiveness in teaching clinical reasoning (CR) remains underexplored. Past studies have suggested VL can effectively prepare students for clinical settings. Informed by the Milestones of Observable Behaviours for CR (MOBCR) and whole-case theoretical frameworks, the Mock Wards (MW) program was created using a novel blended in-person learning (IPL) and VL platform. MW consisted of case-based small-group formats for medical students interested in learning approaches and differentials to commonly encountered presenting symptoms and diagnoses in internal medicine. This study sought to use MW's blended design to qualitatively analyze CR development and compare its utility between VL and IPL. Methods Qualitative analysis was conducted using in-depth semi-structured interviews with first-year pre-clerkship medical students (n = 8) who completed the MW program and participated in the study. The interview guide was informed by the MOBCR framework. Interview transcripts were analyzed using a directed qualitative content analysis approach. Translational coding and HyperRESEARCHTM (Researchware, Inc., Randolph, MA) software-generated mind maps guided the theme development. Results Three overarching themes were constructed: (1) tailoring pedagogical frameworks to learning modalities, (2) learning through interactivity, and (3) balancing accessibility with learner engagement. Participants emphasized that teaching CR skills is modality-specific and not fully interchangeable, with IPL being superior in facilitating social cohesion, non-verbal communication, and feedback. In contrast, VL required structured approaches and relied more on verbal communication and pre-made digital materials. IPL also enhanced interactivity, peer relationships, and spontaneous communication, whereas VL faced challenges such as social awkwardness and technological constraints hindering effective collaboration. VL provided superior accessibility to facilitate distributed learning and management of concurrent academic obligations. Conclusion The MW-blended platform highlights the importance of focusing on modality-tailored pedagogies, emphasizing group interactability, and balancing VL accessibility against decreased engagement within the IPL environment when teaching CR skills. Blended education models may benefit from a scaffolding approach, using IPL as a prerequisite to VL to improve CR development and alignment within a learner's zone of proximal development.
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Affiliation(s)
- Myles Benayon
- Internal Medicine, McMaster University, Hamilton, CAN
| | | | | | - Etri Kocaqi
- Internal Medicine, McMaster University, Hamilton, CAN
| | - Arden Azim
- Internal Medicine, McMaster University, Hamilton, CAN
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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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Wagner FL, Sudacka M, Kononowicz AA, Elvén M, Durning SJ, Hege I, Huwendiek S. Current status and ongoing needs for the teaching and assessment of clinical reasoning - an international mixed-methods study from the students` and teachers` perspective. BMC MEDICAL EDUCATION 2024; 24:622. [PMID: 38840110 PMCID: PMC11151606 DOI: 10.1186/s12909-024-05518-8] [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: 01/16/2024] [Accepted: 05/06/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Clinical reasoning (CR) is a crucial ability that can prevent errors in patient care. Despite its important role, CR is often not taught explicitly and, even when it is taught, typically not all aspects of this ability are addressed in health professions education. Recent research has shown the need for explicit teaching of CR for both students and teachers. To further develop the teaching and learning of CR we need to improve the understanding of students' and teachers' needs regarding content as well as teaching and assessment methods for a student and trainer CR curriculum. METHODS Parallel mixed-methods design that used web-surveys and semi-structured interviews to gather data from both students (nsurvey = 100; ninterviews = 13) and teachers (nsurvey = 112; ninterviews = 28). The interviews and surveys contained similar questions to allow for triangulation of the results. This study was conducted as part of the EU-funded project DID-ACT ( https://did-act.eu ). RESULTS Both the surveys and interview data emphasized the need for content in a clinical reasoning (CR) curriculum such as "gathering, interpreting and synthesizing patient information", "generating differential diagnoses", "developing a diagnostic and a treatment plan" and "collaborative and interprofessional aspects of CR". There was high agreement that case-based learning and simulations are most useful for teaching CR. Clinical and oral examinations were favored for the assessment of CR. The preferred format for a train-the-trainer (TTT)-course was blended learning. There was also some agreement between the survey and interview participants regarding contents of a TTT-course (e.g. teaching and assessment methods for CR). The interviewees placed special importance on interprofessional aspects also for the TTT-course. CONCLUSIONS We found some consensus on needed content, teaching and assessment methods for a student and TTT-course in CR. Future research could investigate the effects of CR curricula on desired outcomes, such as patient care.
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Affiliation(s)
- F L Wagner
- Institute for Medical Education, Department for Assessment and Evaluation, University of Bern, Bern, Switzerland.
| | - M Sudacka
- Center of Innovative Medical Education, Department of Medical Education, Jagiellonian University, Kraków, Poland
| | - A A Kononowicz
- Faculty of Medicine, Department of Bioinformatics and Telemedicine, Jagiellonian University, Kraków, Poland
| | - M 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
| | - S J Durning
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - I Hege
- Institute of Medical Education, University Hospital, LMU Munich, Munich, Germany
| | - S Huwendiek
- Institute for Medical Education, Department for Assessment and Evaluation, University of Bern, Bern, Switzerland
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Si J. Exploring the responses of preclinical medical students and professors to flipped learning for the development of clinical reasoning. KOREAN JOURNAL OF MEDICAL EDUCATION 2024; 36:213-221. [PMID: 38835313 DOI: 10.3946/kjme.2024.297] [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: 12/04/2023] [Accepted: 03/15/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE This study developed and implemented case-based flipped learning using illness script worksheets and investigated the responses of preclinical students and professors to the intervention in terms of its effectiveness, design, and implementation. METHODS The study was conducted at a medical school in Korea, where the "clinical reasoning method" course, originally a lecture-oriented course, was redesigned into a flipped learning. In total, 42 second-year medical students and 15 professors participated in this course. After the class, online surveys were conducted, and a focus group interview was held with seven students to explore the students' experiences in more detail. RESULTS In total, 37 students and seven professors participated in the survey. The mean score for all items is 3.12/4 for the student survey and 3.43/4 for the professor survey. The focus group interview results were categorized as the beneficial aspects and challenges for the development of clinical reasoning. CONCLUSION The findings indicated that their responses to the intervention were generally positive, and it is thought to be an effective instructional method for fostering clinical reasoning skills in preclinical medical students.
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Affiliation(s)
- Jihyun Si
- Department of Medical Education, Dong-A University College of Medicine, Busan, Korea
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Albahari D. Learning Clinical Reasoning: The Experience of Postgraduate Psychiatry Trainee Doctors in Qatar. TEACHING AND LEARNING IN MEDICINE 2024; 36:323-336. [PMID: 37154482 DOI: 10.1080/10401334.2023.2209076] [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: 08/19/2022] [Accepted: 04/10/2023] [Indexed: 05/10/2023]
Abstract
Phenomenon: As a core competency in medical education, clinical reasoning is a pillar for reducing medical errors and promoting patient safety. Clinical reasoning is a complex phenomenon studied through the lens of multiple theories. Although cognitive psychology theories transformed our understanding of clinical reasoning, the theories fell short of explaining the variations in clinical reasoning influenced by contextual factors. Social cognitive theories propose a dynamic relationship between learners' cognitive process and their social and physical environments. This dynamic relationship highlights the essential role of formal and informal learning environments for learning clinical reasoning. Approach: My research aimed to explore the personal experience of learning clinical reasoning in a sample of postgraduate psychiatry trainee doctors using cognitive psychology and social cognitive theories. A stratified convenience sample of seven psychiatry trainee doctors working in the Mental Health Services in Qatar completed semi-structured interviews in 2020. I analyzed the data manually using theoretical thematic analysis. Findings: I identified three overarching themes with multiple subthemes. The first theme was the hierarchical cultural impact on perceived learning opportunities and learning behavior. The first theme had two subthemes that explored the relationship with team members and the expected hierarchy roles. The second theme was the impact of emotions on the learning and execution of clinical reasoning.The second theme had three subthemes that explored the personal approach to managing emotions related to perceived self-efficacy and professional image. The third theme was characteristics of learning environments and their role in learning clinical reasoning. The last theme included three subthemes that explored stressful, autonomous, and interactive environments. Insights: The results accentuate the complexity of clinical reasoning. Trainees' experience of learning clinical reasoning was influenced by factors not controlled for in the curricula. These factors constitute a hidden curriculum with a significant influence on learning. Our local postgraduate training programmes will benefit from addressing the points raised in this study for effective and culturally sensitive clinical reasoning learning.
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Affiliation(s)
- Dalia Albahari
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar
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Torre DM, Mamede S, Bernardes T, Castiglioni A, Hernandez C, Park YS. Promoting Longitudinal and Developmental Computer-Based Assessments of Clinical Reasoning: Validity Evidence for a Clinical Reasoning Mapping Exercise. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:628-634. [PMID: 38266196 DOI: 10.1097/acm.0000000000005632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
PURPOSE Clinical reasoning is vitally important for practitioners across the health professions. However, the assessment of clinical reasoning remains a significant challenge. Combined with other assessment methods, non-workplace-based assessment can increase opportunities to address multiple components of clinical reasoning, evaluate growth, and foster learning, but tools with validity evidence to assess clinical reasoning outside the workplace are scare. This study examined validity evidence for a novel clinical reasoning mapping exercise (CResME). METHOD Data include CResME performance scores from 120 third-year medical students at the University of Central Florida for 3 topics in May 2022. Each CResME was scored by 2 physician raters based on a scoring rubric that included a combined diagnosis and sequence score. Descriptive statistics were used to examine trends in scores. The authors gathered validity evidence for response process, internal structure, and relations to other variables. RESULTS The overall mean (SD) score across cases was 66 (29). Internal consistency reliability of cases (Cronbach α) ranged from 0.75 to 0.91. The Phi and G coefficients were 0.45 and 0.56, respectively. Students accounted for 10% of the total variance, indicating the ability to differentiate high and low clinical reasoning skills; the interaction between learner and case accounted for 8.1% of the variance, demonstrating case specificity. There was a moderate correlation between the overall CResME scores and the mean overall score of patient encounter notes from an objective structured clinical examination performed at the end of the third year (0.46; P = .001). Significant associations were also found between the CResME scores and subject exam scores. CONCLUSIONS The CResME can be used to facilitate the assessment of clinical reasoning, supporting the developmental progress of learners throughout the curriculum. Future research is needed to gather validity evidence for CResMEs with different learners across different settings and formats.
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Durning SJ, Jung E, Kim DH, Lee YM. Teaching clinical reasoning: principles from the literature to help improve instruction from the classroom to the bedside. KOREAN JOURNAL OF MEDICAL EDUCATION 2024; 36:145-155. [PMID: 38835308 DOI: 10.3946/kjme.2024.292] [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: 03/18/2024] [Accepted: 04/30/2024] [Indexed: 06/06/2024]
Abstract
Clinical reasoning has been characterized as being an essential aspect of being a physician. Despite this, clinical reasoning has a variety of definitions and medical error, which is often attributed to clinical reasoning, has been reported to be a leading cause of death in the United States and abroad. Further, instructors struggle with teaching this essential ability which often does not play a significant role in the curriculum. In this article, we begin with defining clinical reasoning and then discuss four principles from the literature as well as a variety of techniques for teaching these principles to help ground an instructors' understanding in clinical reasoning. We also tackle contemporary challenges in teaching clinical reasoning such as the integration of artificial intelligence and strategies to help with transitions in instruction (e.g., from the classroom to the clinic or from medical school to residency/registrar training) and suggest next steps for research and innovation in clinical reasoning.
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Affiliation(s)
- Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, MD, USA
| | - Eulho Jung
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, MD, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Do-Hwan Kim
- Department of Medical Education, Hanyang University College of Medicine, Seoul, Korea
| | - Young-Mee Lee
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
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Williams L. Exploring medical student perceptions of barriers to clinical reasoning in high-fidelity simulation: a qualitative study. CLINICAL TEACHER 2024:e13773. [PMID: 38684241 DOI: 10.1111/tct.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
- Leah Williams
- School of Medicine, University of Sunderland, Sunderland, UK
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Kıyak YS, Budakoğlu Iİ, Coşkun Ö. Test-Only Learning via Virtual Patients to Improve Surgical Illness Scripts of Preclinical Medical Students as a Preparation for Clinical Clerkships: An Experimental Study. Surg Innov 2024:15533506241246333. [PMID: 38596895 DOI: 10.1177/15533506241246333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
OBJECTIVE The aim was to determine whether preclinical medical students can develop their illness scripts to a level comparable to that of clerkship students through test-only learning using repeated formative online testlets. METHODS In this experimental study, participants were 52 preclinical and 53 clinical medical students. The intervention group consisted of preclinical medical students, and the control group consisted of clinical medical students. The intervention group responded to online testlets containing feedback, an innovative formative assessment method called ContExtended Questions, on general surgery for 8 days by spending no more than 30 minutes each day. The control group completed the general surgery clerkship. The performances were assessed using 20 Key-Feature Question items. The intervention group was assessed twice: immediately after the intervention (the immediate test), and again 1 month later (the delayed test). The control group was assessed once, immediately after the clerkship. All performance tests were identical. RESULTS The preclinical students had a significantly higher mean score on the immediate test (83.1 ± 9.6) compared to the clinical students (75.4 ± 8.9), P < .001. The effect size (Cohen's d) was .83. However, the mean score in the delayed test (76.9 ± 13.6) was not significantly different from clinical students' mean score (75.4 ± 8.9), P > .05. CONCLUSIONS Test-only learning as a spaced repetition of online formative testlets is effective in preparing preclinical medical students to the clinical clerkship. Through using this approach in preclinical period, they can prepare themselves for the clinical environment to optimize the benefits derived from clerkships.
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Affiliation(s)
- Yavuz Selim Kıyak
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Işıl İrem Budakoğlu
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Özlem Coşkun
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Ankara, Turkey
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Alvarez A, Monteiro S, Chen R, Cohen K, Fofana M, Powell C, Tago A, Martin L. Re-THINK: Use of narratives to explore social justice in clinical practice and education. J Eval Clin Pract 2024; 30:349-354. [PMID: 38062679 DOI: 10.1111/jep.13946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 04/18/2024]
Affiliation(s)
- Al'ai Alvarez
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Sandra Monteiro
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ruth Chen
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karen Cohen
- LCSW-R, Licensed Clinical Social Worker in New York and Florida, New York, New York, USA
| | - Mariame Fofana
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Carmin Powell
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Achieng Tago
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Leslie Martin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Liu Z, Sun N, Chen C, Zhang G, Hu Y. Comparative study of clinical reasoning competence and self-directed learning competence in nurses across varied years of experience. J Clin Nurs 2024. [PMID: 38500234 DOI: 10.1111/jocn.17051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/06/2024] [Accepted: 01/22/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To compare and analyse the differences in the clinical reasoning competence of nurses with different working years and their relationship with self-directed learning competence. METHODS A cross-sectional survey design (online investigation) was used. A total of 376 nurses were recruited from four independent hospitals in China. Online questionnaires collected data on nurses' demographic characteristics and assessed their clinical reasoning and self-directed learning competence. Pearson correlation analysis, t-test, analysis of variance (ANOVA) and multivariate regression analysis were used. RESULTS Clinical reasoning competence scores of nurses with working years >10 years were higher than those of other nurses. Self-directed learning competence scores of nurses with working years of <1 year and (from ≥1 year to <3 years) were lower than those of nurses with working years of 6-10 years and >10 years. Self-directed learning competence scores of nurses with working years of 3-5 years were lower than those of nurses with working years of >10 years. There was a positive correlation between clinical reasoning competence, self-directed learning competence and each dimension among nurses of different working years. There are differences in the influence of different dimensions of self-directed learning competence on clinical reasoning competence among different working years. CONCLUSION There were differences in clinical reasoning and self-directed learning competence among nurses with different working years. Self-directed learning competence is a positive predictor of nurses' clinical reasoning competence, which applied to nurses with all working years; however, the specific effect of self-directed learning competence on clinical reasoning competence differed among nurses with different working years. IMPLICATION FOR NURSING MANAGERS Nursing managers should pay attention to the development characteristics of clinical reasoning competence and self-directed learning competence of nurses with different working years and determine effective intervention strategies according to specific influencing factors.
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Affiliation(s)
- Zhenya Liu
- Cerebrovascular Department of Henan Provincial People's Hospital, Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Na Sun
- Cerebrovascular Department of Henan Provincial People's Hospital, Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Cancan Chen
- Henan Provincial People's Hospital, Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Guifang Zhang
- Cerebrovascular Department of Henan Provincial People's Hospital, Henan Provincial Key Medicine Laboratory of Nursing, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Yanli Hu
- School of Nursing, Guangzhou Medical University, Guangzhou, China
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Hornos E, Pleguezuelos E, Bala L, Collares CF, Freeman A, van der Vleuten C, Murphy KG, Sam AH. Reliability, validity and acceptability of an online clinical reasoning simulator for medical students: An international pilot. MEDICAL TEACHER 2024:1-8. [PMID: 38489473 DOI: 10.1080/0142159x.2024.2308082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/17/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Clinical reasoning skills are essential for decision-making. Current assessment methods are limited when testing clinical reasoning and management of uncertainty. This study evaluates the reliability, validity and acceptability of Practicum Script, an online simulation-based programme, for developing medical students' clinical reasoning skills using real-life cases. METHODS In 2020, we conducted an international, multicentre pilot study using 20 clinical cases with 2457 final-year medical students from 21 schools worldwide. Psychometric analysis was performed (n = 1502 students completing at least 80% of cases). Classical estimates of reliability for three test domains (hypothesis generation, hypothesis argumentation and knowledge application) were calculated using Cronbach's alpha and McDonald's omega coefficients. Validity evidence was obtained by confirmatory factor analysis (CFA) and measurement alignment (MA). Items from the knowledge application domain were analysed using cognitive diagnostic modelling (CDM). Acceptability was evaluated by an anonymous student survey. RESULTS Reliability estimates were high with narrow confidence intervals. CFA revealed acceptable goodness-of-fit indices for the proposed three-factor model. CDM analysis demonstrated good absolute test fit and high classification accuracy estimates. Student survey responses showed high levels of acceptability. CONCLUSION Our findings suggest that Practicum Script is a useful resource for strengthening students' clinical reasoning skills and ability to manage uncertainty.
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Affiliation(s)
- Eduardo Hornos
- Practicum Foundation, Institute of Applied Research in Health Sciences Education, Madrid, Spain
| | - Eduardo Pleguezuelos
- Practicum Foundation, Institute of Applied Research in Health Sciences Education, Madrid, Spain
| | - Laksha Bala
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Carlos Fernando Collares
- European Board of Medical Assessors, Maastricht, the Netherlands
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Campus Gualtar, Braga, Portugal
| | - Adrian Freeman
- European Board of Medical Assessors, Maastricht, the Netherlands
- College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Cees van der Vleuten
- European Board of Medical Assessors, Maastricht, the Netherlands
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
| | - Kevin G Murphy
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Amir H Sam
- Imperial College School of Medicine, Imperial College London, London, UK
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Si J. Validating the Korean shorter Diagnostic Thinking Inventory in medical education: a pilot study. KOREAN JOURNAL OF MEDICAL EDUCATION 2024; 36:17-26. [PMID: 38462239 PMCID: PMC10925811 DOI: 10.3946/kjme.2024.281] [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: 11/10/2023] [Revised: 01/11/2024] [Accepted: 01/31/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE Developing clinical reasoning across the medical curriculum requires valid, reliable, and feasible assessment tools. However, few validated tools are available for the convenient and efficient quantification of clinical reasoning. Thus, this study aimed to create a shorter version of the Diagnostic Thinking Inventory (DTI) and validate it in the Korean medical education context (DTI-SK). METHODS The DTI-SK was constructed using content validity and a translation and back-translation process. It comprises two subcategories and 14 items. Its validity and reliability were explored using exploratory and confirmatory factor analyses, mean comparisons of four medical student groups (med 1 to med 4), and internal consistency using Cronbach's α. Two hundred medical students were invited to participate through email, and the survey was administered for 2 weeks. RESULTS Data from 136 students were analyzed. Exploratory factor analysis revealed two factors with eigenvalues greater than 1.0 and they together explained 54.65% of the variance. Confirmatory factor analysis demonstrated that the model had acceptable level of fit and convergent validity. Discriminant validity was confirmed using heterotrait-monotrait criterion. Group comparisons demonstrated that the med 4 students showed significantly higher scores than the med 1 and 2 students. The inventory exhibited strong internal consistency for all items (Cronbach's α=0.906). CONCLUSION The findings indicated that the DTI-SK is a reliable and valid tool for measuring medical students' clinical reasoning in the context of Korean medical education.
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Affiliation(s)
- Jihyun Si
- Department of Medical Education, Dong-A University College of Medicine, Busan, Korea
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Gonullu I, Bayazit A, Erden S. Exploring medical students' perceptions of individual and group-based clinical reasoning with virtual patients: a qualitative study. BMC MEDICAL EDUCATION 2024; 24:189. [PMID: 38403641 PMCID: PMC10895817 DOI: 10.1186/s12909-024-05121-x] [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: 09/25/2023] [Accepted: 01/31/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Virtual Patients are computer-based simulations used to teach and evaluate patient interviews, medical diagnoses, and treatment of medical conditions. It helps develop clinical reasoning skills, especially in undergraduate medical education. This study aimed to and investigate the medical students' perceptions of individual and group-based clinical reasoning and decision-making processes by using Virtual Patients. METHODS The study group comprised 24 third-year medical students. Body Interact® software was utilized as a VP tool. The students' readiness and the courses' learning goals were considered when choosing the scenarios. Semi-structured interview forms were employed for data collection. MAXQDA 2020 qualitative analysis software was used to analyze the data. The students' written answers were analyzed using content analysis. RESULTS The participants perceived individual applications as beneficial when making clinical decisions with Virtual Patients, but they suggested that group-based applications used with the same cases immediately following individual applications were a more appropriate decision-making method. The results indicated that students learn to make decisions through trial and error, based on software scoring priorities, or using clinical reasoning protocols. CONCLUSION In group-based reasoning, the discussion-conciliation technique is utilized. The students stated that the individual decision-making was advantageous because it provided students with the freedom to make choices and the opportunity for self-evaluation. On the other hand, they stated that the group based decision-making process activated their prior knowledge, assisted in understanding misconceptions, and promoted information retention. Medical educators need to determine the most appropriate method when using Virtual Patients, which can be structured as individual and/or group applications depending on the competency sought.
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Affiliation(s)
- Ipek Gonullu
- Faculty of Medicine, Department of Medical Education and Informatics, Ankara University, Cebeci, Ankara, Turkey.
| | - Alper Bayazit
- Faculty of Medicine, Department of Medical Education and Informatics, Ankara University, Cebeci, Ankara, Turkey
| | - Sengul Erden
- Faculty of Medicine, Department of Medical Education and Informatics, Ankara University, Cebeci, Ankara, Turkey
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Mohd Tambeh SN, Yaman MN. Clinical reasoning training sessions for health educators-A scoping review. J Taibah Univ Med Sci 2023; 18:1480-1492. [PMID: 37434867 PMCID: PMC10331482 DOI: 10.1016/j.jtumed.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/02/2023] [Accepted: 06/02/2023] [Indexed: 07/13/2023] Open
Abstract
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.
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Affiliation(s)
- Siti N. Mohd Tambeh
- Department of Medical Education, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Physiology, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Mohamad N. Yaman
- Department of Medical Education, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Xu D, Feng S, Yang D, Ding S, Rosman JB, Kuang M, Xiao H. Reflecting on Students' Experiences of an Innovative Teaching Model During Aged Care Visit in Clinical Placements: A Qualitative Pilot Study. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2023; 14:1339-1346. [PMID: 38046262 PMCID: PMC10693279 DOI: 10.2147/amep.s436905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Abstract
Purpose Clinical placement teaching could be challenging due to time constraints, lack of effective teaching models and consensus approaches. Learner-centred approach facilitated deeper learning by demonstrating "seeing-patients-under-supervision" being ideal during Residential-Aged-Care-Facility (RACF)-visit in GP clinical placements. The study aimed to reflect on the students' experiences in aged-care visits by applying an innovative teaching model of "students-being-the-GP-clinician-in-charge-of-RACF-visit-ward-round-under-the-supervision-of-clinical-supervisor". Through students' reflections, this study identified 12 commonly managed RACF problems to be introduced into the curriculum to optimise clinical reasoning learning during RACF-visit. Methods This qualitative study used online surveys and interviews. All participating students reported all the encountered cases during the RACF visit through an online survey. The participating students acted as GP in charge of all clinical interactions with patients, caregivers, and nurses during RACF visits and final management plan discussions with GP supervisors to ensure clinical-service safety and teaching-and-learning quality. The interview questionnaires applied standard-and-open-ended-questions to examine the impact of this innovative teaching model on clinical-reasoning-learning, clinical-competence-improvement, Objective Structured Clinical Exam (OSCE) preparation, limitations-from-students'-patients'-and-supervisors' perspectives, and intern readiness. Results An online survey summarising students' encountered cases was returned by 30 students. The 12 most commonly-managed problems were tabulated. Falls, urinary tract infections, and behavioural and psychological symptoms of dementia were the three most commonly-managed problems. All thirty students' reflections indicated the positive impact of the innovative-teaching-models on "Improving-Clinical-Reasoning-Learning", "Enhancing-Clinical-Competency", "Enriching-Salient-Learning-Points", "Facilitating-Feedback-Discussion-with-Supervisor", "Strengthening-OSCE-exam-preparation", "Understanding-the-Limitation-from-students'-patients'-and-supervisors'-perspectives", "Enabling-intern-readiness". Twelve students' individual reflections were demonstrated. Conclusion This qualitative pilot study demonstrated through students' reflection that "Student-doctor-in-charge-of-nursing-home-round" is an innovative teaching model for clinical reasoning learning. This model extended the concepts of "cognitive-apprenticeship" in the context of modern medical education. Students' reflections and summary of commonly managed problems indicated the need for further study to verify the feasibility of implementing this teaching model in the formal curriculum and creating a RACF-visit-specific curriculum for students.
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Affiliation(s)
- Dan Xu
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Shaoting Feng
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Daya Yang
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Shuqin Ding
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Johan B Rosman
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Ming Kuang
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Haipeng Xiao
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
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Isbej L, Fuentes-Cimma J, Véliz Paiva C, Valladares-Pérez S, Riquelme A. A comprehensive approach to identify challenges for clinical reasoning development in undergraduate dental students and their potential solutions. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2023; 27:859-868. [PMID: 36458893 DOI: 10.1111/eje.12876] [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: 05/23/2022] [Revised: 10/05/2022] [Accepted: 10/30/2022] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Lorena Isbej
- Faculty of Medicine, School of Dentistry, Pontificia Universidad Católica de Chile, Santiago, Chile
- Pharmacology and Toxicology Programme, Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
| | - Javiera Fuentes-Cimma
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
- Department of Health Sciences, Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Véliz Paiva
- Faculty of Medicine, School of Dentistry, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Arnoldo Riquelme
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Centre of Medical Education and Health Sciences, Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
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Ishizuka K, Shikino K, Kasai H, Hoshina Y, Miura S, Tsukamoto T, Yamauchi K, Ito S, Ikusaka M. The influence of Gamification on medical students' diagnostic decision making and awareness of medical cost: a mixed-method study. BMC MEDICAL EDUCATION 2023; 23:813. [PMID: 37898743 PMCID: PMC10613361 DOI: 10.1186/s12909-023-04808-x] [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: 04/10/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND The gamification of learning increases student enjoyment, and motivation and engagement in learning tasks. This study investigated the effects of gamification using decision-making cards (DMCs) on diagnostic decision-making and cost using case scenarios. METHOD Thirty medical students in clinical clerkship participated and were randomly assigned to 14 small groups of 2-3 medical students each. Decision-making was gamified using DMCs with a clinical information heading and medical cost on the front, and clinical information details on the back. First, each team was provided with brief clinical information on case scenarios. Subsequently, DMCs depending on the case were distributed to each team, and team members chose cards one at a time until they reached a diagnosis of the case. The total medical cost was then scored based on the number and contents of cards drawn. Four case scenarios were conducted. The quantitative outcomes including confidence in effective clinical decision-making, motivation to learn diagnostic decision-making, and awareness of medical costs were measured before and after our gamification by self-evaluation using a 7-point Likert scale. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using DMCs. RESULT Confidence in effective clinical decision-making, motivation to learn diagnostic decision-making, and awareness of medical cost were significantly higher after the gamification. Furthermore, comparing the clinical case scenario tackled last with the one tackled first, the average medical cost of all cards drawn by students decreased significantly from 11,921 to 8,895 Japanese yen. In the content analysis, seven advantage categories of DMCs corresponding to clinical reasoning components were extracted (information gathering, hypothesis generation, problem representation, differential diagnosis, leading or working diagnosis, diagnostic justification, and management and treatment). CONCLUSION Teaching medical students clinical reasoning using DMCs can improve clinical decision-making confidence and learning motivation, and reduces medical cost in clinical case scenarios. In addition, it can help students to acquire practical knowledge, deepens their understanding of clinical reasoning, and identifies several important clinical reasoning skills including diagnostic decision-making and awareness of medical costs. Gamification using DMCs can be an effective teaching method for improving medical students' diagnostic decision-making and reducing costs.
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Affiliation(s)
- Kosuke Ishizuka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan.
- Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan.
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
- Department of Community-oriented Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
| | - Hajme Kasai
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoji Hoshina
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
| | - Saito Miura
- Department of Psychiatry, Chiba University Hospital, Chiba, Japan
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
- Department of Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuyo Yamauchi
- Department of Community-oriented Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
| | - Shoichi Ito
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
- Department of Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
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Régent A, Thampy H, Singh M. Assessing clinical reasoning in the OSCE: pilot-testing a novel oral debrief exercise. BMC MEDICAL EDUCATION 2023; 23:718. [PMID: 37789308 PMCID: PMC10548592 DOI: 10.1186/s12909-023-04668-5] [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: 01/31/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023]
Abstract
INTRODUCTION Clinical reasoning (CR) is a complex skill enabling transition from clinical novice to expert decision maker. The Objective Structured Clinical Examination (OSCE) is widely used to evaluate clinical competency, though there is limited literature exploring how this assessment is best used to assess CR skills. This proof-of-concept study explored the creation and pilot testing of a post-station CR assessment, named Oral Debrief (OD), in the context of undergraduate medical education. METHODS A modified-Delphi technique was used to create a standardised domain-based OD marking rubric encapsulating the key skills of CR that drew upon existing literature and our existing placement-based CR tool. 16 OSCE examiners were recruited to score three simulated OD recordings that were scripted to portray differing levels of competency. Adopting a think-aloud approach, examiners vocalised their thought processes while utilising the rubric to assess each video. Thereafter, semi-structured interviews explored examiners' views on the OD approach. Recordings were transcribed, anonymised and analysed deductively and inductively for recurring themes. Additionally, inter-rater agreement of examiners' scoring was determined using the Fleiss Kappa statistic both within group and in comparison to a reference examiner group. RESULTS The rubric achieved fair to good levels of inter-rater reliability metrics across its constituent domains and overall global judgement scales. Think-aloud scoring revealed that participating examiners considered several factors when scoring students' CR abilities. This included the adoption of a confident structured approach, discriminating between relevant and less-relevant information, and the ability to prioritise and justify decision making. Furthermore, students' CR skills were judged in light of potential risks to patient safety and examiners' own illness scripts. Feedback from examiners indicated that whilst additional training in rubric usage would be beneficial, OD offered a positive approach for examining CR ability. CONCLUSION This pilot study has demonstrated promising results for the use of a novel post-station OD task to evaluate medical students' CR ability in the OSCE setting. Further work is now planned to evaluate how the OD approach can most effectively be implemented into routine assessment practice.
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Affiliation(s)
- Alexis Régent
- Service de médecine interne, Centre de référence maladies auto-immunes et systémiques rares d'ile de France, APHP-CUP, Hôpital Cochin, F-75014, Paris, France.
- Université de Paris, 15 rue de l'école de médecine, F-75006, Paris, France.
| | - Harish Thampy
- Division of Medical Education, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
| | - Mini Singh
- Division of Medical Education, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
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Roberts JK, Sullivan M, Atwater S, Desai K, Prabhu NK, Hertz JT, Buhr GT, Peyser B, Weigle N. Use of Virtual Interactive Patient Encounters to Prepare First-Year Medical Students for Clinical Practice. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:1146-1153. [PMID: 37257029 DOI: 10.1097/acm.0000000000005286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PROBLEM With the dissolution of the Step 2 Clinical Skills exam, medical programs have a greater responsibility to teach and assess clinical skills in the preclerkship years. Clinical teaching this early has traditionally been avoided because of insufficient integration with biomedical sciences, curricular time constraints, and concerns about overwhelming novice learners with clinical learning objectives. To overcome these barriers, the authors created a clinical framework for the biomedical science curriculum by integrating a series of virtual interactive patient (VIP) videos. APPROACH Matriculating first-year medical students were enrolled in a clinically integrated biomedical science course that used VIP videos to teach and assess clinical skills. The VIP videos were enhanced with interactive pop-in windows, and at the conclusion of each video, students performed a clinical documentation task and received immediate feedback. The authors implemented 7 VIP cases during fall 2021 in which first-year medical students wrote the patient care plan, problem representation statement, or clinical reasoning assessment. Student responses were independently evaluated by course faculty using a 4-level scoring scale. The authors calculated the pooled mean scores for each documentation task and examined student feedback. OUTCOMES Seven VIP encounters were assigned to 124 students (mean response rate, 98.5%). Pooled mean scores on the clinical documentation tasks showed that most students were able to achieve levels 3 or 4 when writing the patient care plan (97 [82%] to 113 [94%]), addressing social determinants of health (80 [67%]), writing an accurate problem representation statement (113 [91%] to 117 [94%]), and performing clinical reasoning skills (48 [40%] to 95 [82%]). NEXT STEPS VIP encounters were feasible to produce, effective at integrating course content, successful at assessing student clinical documentation skills, and well received. The authors will continue to produce, implement, and study the VIP as an integrating learning tool in undergraduate medical education.
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Affiliation(s)
- John K Roberts
- J.K. Roberts is associate professor of medicine, Division of Nephrology, Department of Medicine, Duke University Health System, and clinical correlations course director, Duke School of Medicine, Durham, North Carolina
| | - Meghan Sullivan
- M. Sullivan is a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Sierra Atwater
- S. Atwater was a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Katha Desai
- K. Desai was a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Neel K Prabhu
- N.K. Prabhu was a medical student, Duke University School of Medicine, Durham, North Carolina
| | - Julian T Hertz
- J.T. Hertz is assistant professor of emergency medicine, Duke University Health System, and clinical skills training immersion course director, Duke School of Medicine, Durham, North Carolina
| | - Gwendolen T Buhr
- G.T. Buhr is associate professor of medicine, Division of Geriatrics, Department of Medicine, Duke University Health System, Durham, North Carolina
| | - Bruce Peyser
- B. Peyser is professor of medicine, Department of Medicine, Duke University Health System, Durham, North Carolina
| | - Nancy Weigle
- N. Weigle is associate professor in family medicine and community health, Duke University Health System, and clinical skills foundation course director, Duke School of Medicine, Durham, North Carolina
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Staal J, Waechter J, Allen J, Lee CH, Zwaan L. Deliberate practice of diagnostic clinical reasoning reveals low performance and improvement of diagnostic justification in pre-clerkship students. BMC MEDICAL EDUCATION 2023; 23:684. [PMID: 37735677 PMCID: PMC10515060 DOI: 10.1186/s12909-023-04541-5] [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: 02/24/2023] [Accepted: 07/27/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE Diagnostic errors are a large burden on patient safety and improving clinical reasoning (CR) education could contribute to reducing these errors. To this end, calls have been made to implement CR training as early as the first year of medical school. However, much is still unknown about pre-clerkship students' reasoning processes. The current study aimed to observe how pre-clerkship students use clinical information during the diagnostic process. METHODS In a prospective observational study, pre-clerkship medical students completed 10-11 self-directed online simulated CR diagnostic cases. CR skills assessed included: creation of the differential diagnosis (Ddx), diagnostic justification (DxJ), ordering investigations, and identifying the most probable diagnosis. Student performances were compared to expert-created scorecards and students received detailed individualized formative feedback for every case. RESULTS 121 of 133 (91%) first- and second-year medical students consented to the research project. Students scored much lower for DxJ compared to scores obtained for creation of the Ddx, ordering tests, and identifying the correct diagnosis, (30-48% lower, p < 0.001). Specifically, students underutilized physical exam data (p < 0.001) and underutilized data that decreased the probability of incorrect diagnoses (p < 0.001). We observed that DxJ scores increased 40% after 10-11 practice cases (p < 0.001). CONCLUSIONS We implemented deliberate practice with formative feedback for CR starting in the first year of medical school. Students underperformed in DxJ, particularly with analyzing the physical exam data and pertinent negative data. We observed significant improvement in DxJ performance with increased practice.
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Affiliation(s)
- Justine Staal
- Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, the Netherlands
| | - Jason Waechter
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jon Allen
- Department of Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Chel Hee Lee
- Department of Mathematics, University of Calgary, Calgary, AB, Canada
| | - Laura Zwaan
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Institute of Medical Education Research, Erasmus Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands.
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Hawks MK, Maciuba JM, Merkebu J, Durning SJ, Mallory R, Arnold MJ, Torre D, Soh M. Clinical Reasoning Curricula in Preclinical Undergraduate Medical Education: A Scoping Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:958-965. [PMID: 36862627 DOI: 10.1097/acm.0000000000005197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
PURPOSE Clinical reasoning is the process of observing, collecting, analyzing, and interpreting patient information to arrive at a diagnosis and management plan. Although clinical reasoning is foundational in undergraduate medical education (UME), the current literature lacks a clear picture of the clinical reasoning curriculum in preclinical phase of UME. This scoping review explores the mechanisms of clinical reasoning education in preclinical UME. METHOD A scoping review was performed in accordance with the Arksey and O'Malley framework methodology for scoping reviews and is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews. RESULTS The initial database search identified 3,062 articles. Of these, 241 articles were selected for a full-text review. Twenty-one articles, each reporting a single clinical reasoning curriculum, were selected for inclusion. Six of the reports included a definition of clinical reasoning, and 7 explicitly reported the theory underlying the curriculum. Reports varied in the identification of clinical reasoning content domains and teaching strategies. Only 4 curricula reported assessment validity evidence. CONCLUSIONS Based on this scoping review, we recommend 5 key principles for educators to consider when reporting clinical reasoning curricula in preclinical UME: (1) explicitly define clinical reasoning within the report, (2) report clinical reasoning theory(ies) used in the development of the curriculum, (3) clearly identify which clinical reasoning domains are addressed in the curriculum, (4) report validity evidence for assessments when available, and (5) describe how the reported curriculum fits into the larger clinical reasoning education at the institution.
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Affiliation(s)
- Matthew K Hawks
- M.K. Hawks is associate professor, Department of Family Medicine, Uniformed Services University, Bethesda, Maryland
| | - Joseph M Maciuba
- J.M. Maciuba is assistant professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Jerusalem Merkebu
- J. Merkebu is assistant professor, Center for Health Professions Education, Uniformed Services University, Bethesda, Maryland
| | - Steven J Durning
- S.J. Durning is professor and vice chair, Department of Medicinedirector, Center for Health Professions Education, Uniformed Services University, Bethesda, Maryland
| | - Renee Mallory
- R. Mallory is assistant professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Michael J Arnold
- M.J. Arnold is associate professor, Department of Family Medicine, Uniformed Services University, Bethesda, Maryland
| | - Dario Torre
- D. Torre is professor and director, Programs of Assessment, University of Central Florida, Orlando, Florida
| | - Michael Soh
- M. Soh is assistant professor, Center for Health Professions Education, Uniformed Services University, Bethesda, Maryland
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Spahic H, Goplerud D, Blatt C, Murphy M, Golden WC, Pahwa A. Promoting clinical reasoning with meta-memory techniques to teach broad differential diagnosis generation in a pediatric core clerkship. Diagnosis (Berl) 2023; 10:242-248. [PMID: 37434439 DOI: 10.1515/dx-2023-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/06/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVES Clinical reasoning with generation and prioritization of differential diagnoses (DDx) is a key skill for medical students, but no consensus exists on the best method to teach these skills. Meta-memory techniques (MMTs) may be useful, but the efficacy of individual MMTs is unclear. METHODS We designed a 3-part curriculum for pediatric clerkship students to teach one of 3 MMTs and provide practice in DDx generation through case-based sessions. Students submitted DDx lists during two sessions and completed pre- and post-curriculum surveys assessing self-reported confidence and perceived helpfulness of the curriculum. Results were analyzed using ANOVA with multiple linear regression. RESULTS A total of 130 students participated in the curriculum, with 96 % (125/130) completing at least one DDx session, and 44 % (57/130) completing the post-curriculum survey. On average, 66 % of students rated all three sessions as "quite helpful" (4/5 on 5-point Likert scale) or "extremely helpful" (5/5) without difference between MMT groups. Students generated an average of 8.8, 7.1 and 6.4 diagnoses using the VINDICATES, Mental CT, and Constellations methods, respectively. When controlling for case, case order, and number of prior rotations, students using VINDICATES produced 2.8 more diagnoses than those using Constellations (95 % CI [1.1,4.5], p<0.001). There was no significant difference between VINDICATES and Mental CT (Δ=1.6, 95 % CI [-0.2,3.4], p=0.11) or Mental CT and Constellations (Δ=1.2, 95 % CI [-0.7,3.1], p=0.36). CONCLUSIONS Medical education should include curricula focused on enhancing DDx development. Although VINDICATES helped students produce the most DDx, further research is needed to identify which MMT generates more accurate DDx.
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Affiliation(s)
- Harisa Spahic
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Dana Goplerud
- Department of Pediatrics Baltimore, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine Baltimore, Johns Hopkins University, Baltimore, MD, USA
| | - Carly Blatt
- Department of Pediatrics Baltimore, Johns Hopkins University, Baltimore, MD, USA
| | - Megan Murphy
- Department of Pediatrics Baltimore, Johns Hopkins University, Baltimore, MD, USA
| | | | - Amit Pahwa
- Department of Pediatrics Baltimore, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine Baltimore, Johns Hopkins University, Baltimore, MD, USA
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Torre D, Chamberland M, Mamede S. Implementation of three knowledge-oriented instructional strategies to teach clinical reasoning: Self-explanation, a concept mapping exercise, and deliberate reflection: AMEE Guide No. 150. MEDICAL TEACHER 2023; 45:676-684. [PMID: 35938204 DOI: 10.1080/0142159x.2022.2105200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The teaching of clinical reasoning is essential in medical education. This guide has been written to provide educators with practical advice on the design, development, and implementation of three knowledge-oriented instructional strategies for the teaching of clinical reasoning to medical students: Self-explanation (SE), a Clinical Reasoning Mapping Exercise (CREsME), and Deliberate Reflection (DR). We first synthesize the theoretical tenets that support the use of these strategies, including knowledge organization, and development of illness scripts. We then provide a detailed description of the key components of each strategy, emphasizing the practical applications of each one by sharing specific examples. We also explore the potential for a combined application of these strategies in a longitudinal and developmental approach to teaching clinical reasoning at the undergraduate level. Finally, we discuss enablers and barriers in the implementation and integration of these teaching strategies while taking into consideration curricular needs, context, and resources. We are aware that many strategies exist and are not arguing that SE, CReSME, and DR are the most effective ones or the only ones to be adopted. Nevertheless, we selected these strategies because of overarching theoretical principles, empirical evidence supporting their use, and our own experience with them. We are hoping to provide practical advice on the implementation of these strategies to practicing educators who aim at developing an integrated approach to the teaching of clinical reasoning to medical students at different stages of their development.
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Affiliation(s)
- Dario Torre
- Department of Medical Education, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Martine Chamberland
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Quebec, Canada
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
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van Sassen C, Mamede S, Bos M, van den Broek W, Bindels P, Zwaan L. Do malpractice claim clinical case vignettes enhance diagnostic accuracy and acceptance in clinical reasoning education during GP training? BMC MEDICAL EDUCATION 2023; 23:474. [PMID: 37365590 DOI: 10.1186/s12909-023-04448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Using malpractice claims cases as vignettes is a promising approach for improving clinical reasoning education (CRE), as malpractice claims can provide a variety of content- and context-rich examples. However, the effect on learning of adding information about a malpractice claim, which may evoke a deeper emotional response, is not yet clear. This study examined whether knowing that a diagnostic error resulted in a malpractice claim affects diagnostic accuracy and self-reported confidence in the diagnosis of future cases. Moreover, suitability of using erroneous cases with and without a malpractice claim for CRE, as judged by participants, was evaluated. METHODS In the first session of this two-phased, within-subjects experiment, 81 first-year residents of general practice (GP) were exposed to both erroneous cases with (M) and erroneous cases without (NM) malpractice claim information, derived from a malpractice claims database. Participants rated suitability of the cases for CRE on a five-point Likert scale. In the second session, one week later, participants solved four different cases with the same diagnoses. Diagnostic accuracy was measured with three questions, scored on a 0-1 scale: (1) What is your next step? (2) What is your differential diagnosis? (3) What is your most probable diagnosis and what is your level of certainty on this? Both subjective suitability and diagnostic accuracy scores were compared between the versions (M and NM) using repeated measures ANOVA. RESULTS There were no differences in diagnostic accuracy parameters (M vs. NM next step: 0.79 vs. 0.77, p = 0.505; differential diagnosis 0.68 vs. 0.75, p = 0.072; most probable diagnosis 0.52 vs. 0.57, p = 0.216) and self-reported confidence (53.7% vs. 55.8% p = 0.390) of diagnoses previously seen with or without malpractice claim information. Subjective suitability- and complexity scores for the two versions were similar (suitability: 3.68 vs. 3.84, p = 0.568; complexity 3.71 vs. 3.88, p = 0.218) and significantly increased for higher education levels for both versions. CONCLUSION The similar diagnostic accuracy rates between cases studied with or without malpractice claim information suggests both versions are equally effective for CRE in GP training. Residents judged both case versions to be similarly suitable for CRE; both were considered more suitable for advanced than for novice learners.
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Affiliation(s)
- Charlotte van Sassen
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Rotterdam, The Netherlands
| | - Michiel Bos
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Walter van den Broek
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick Bindels
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
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Kassianos AP, Plackett R, Kambouri MA, Sheringham J. Educators' perspectives of adopting virtual patient online learning tools to teach clinical reasoning in medical schools: a qualitative study. BMC MEDICAL EDUCATION 2023; 23:424. [PMID: 37291557 DOI: 10.1186/s12909-023-04422-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Learning tools using virtual patients can be used to teach clinical reasoning (CR) skills and overcome limitations of using face-to-face methods. However, the adoption of new tools is often challenging. The aim of this study was to explore UK medical educators' perspectives of what influences the adoption of virtual patient learning tools to teach CR. METHODS A qualitative research study using semi-structured telephone interviews with medical educators in the UK with control over teaching materials of CR was conducted. The Consolidated Framework for Implementation Research (CFIR), commonly used in healthcare services implementation research was adapted to inform the analysis. Thematic analysis was used to analyse the data. RESULTS Thirteen medical educators participated in the study. Three themes were identified from the data that influenced adoption: the wider context (outer setting); perceptions about the innovation; and the medical school (inner context). Participants' recognition of situations as opportunities or barriers related to their prior experiences of implementing online learning tools. For example, participants with experience of teaching using online tools viewed limited face-to-face placements as opportunities to introduce innovations using virtual patients. Beliefs that virtual patients may not mirror real-life consultations and perceptions of a lack of evidence for them could be barriers to adoption. Adoption was also influenced by the implementation climate of the setting, including positioning of CR in curricula; relationships between faculty, particularly where faculty were dispersed. CONCLUSIONS By adapting an implementation framework for health services, we were able to identify features of educators, teaching processes and medical schools that may determine the adoption of teaching innovations using virtual patients. These include access to face-to-face teaching opportunities, positioning of clinical reasoning in the curriculum, relationship between educators and institutions and decision-making processes. Framing virtual patient learning tools as additional rather than as a replacement for face-to-face teaching could reduce resistance. Our adapted framework from healthcare implementation science may be useful in future studies of implementation in medical education.
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Affiliation(s)
- A P Kassianos
- Department of Applied Health Research, University College London (UCL), 1-19 Torrington Place, London, WC1E 7HB, UK
| | - R Plackett
- Department of Applied Health Research, University College London (UCL), 1-19 Torrington Place, London, WC1E 7HB, UK
| | - M A Kambouri
- Institute of Education, University College London (UCL), London, UK
| | - J Sheringham
- Department of Applied Health Research, University College London (UCL), 1-19 Torrington Place, London, WC1E 7HB, UK.
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Khazen M, Sullivan EE, Arabadjis S, Ramos J, Mirica M, Olson A, Linzer M, Schiff GD. How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care. BMJ Open 2023; 13:e071241. [PMID: 37147090 PMCID: PMC10163453 DOI: 10.1136/bmjopen-2022-071241] [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] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES The quest to measure and improve diagnosis has proven challenging; new approaches are needed to better understand and measure key elements of the diagnostic process in clinical encounters. The aim of this study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters' recorded transcripts. Additionally, we aimed to correlate and contextualise these findings with measures of encounter time and physician burnout. DESIGN We audio-recorded encounters, reviewed their transcripts and associated them with their clinical notes and findings were correlated with concurrent Mini Z Worklife measures and physician burnout. SETTING Three primary urgent-care settings. PARTICIPANTS We conducted in-depth evaluations of 28 clinical encounters delivered by seven physicians. RESULTS Comparing encounter transcripts with clinical notes, in 24 of 28 (86%) there was high note/transcript concordance for the diagnostic elements on our tool. Reliably included elements were red flags (92% of notes/encounters), aetiologies (88%), likelihood/uncertainties (71%) and follow-up contingencies (71%), whereas psychosocial/contextual information (35%) and mentioning common pitfalls (7%) were often missing. In 22% of encounters, follow-up contingencies were in the note, but absent from the recorded encounter. There was a trend for higher burnout scores being associated with physicians less likely to address key diagnosis items, such as psychosocial history/context. CONCLUSIONS A new tool shows promise as a means of assessing key elements of diagnostic quality in clinical encounters. Work conditions and physician reactions appear to correlate with diagnostic behaviours. Future research should continue to assess relationships between time pressure and diagnostic quality.
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Affiliation(s)
- Maram Khazen
- Harvard Medical School, Center for Primary Care, Boston, Massachusetts, USA
- The Max Stern Yezreel Valley College, Emek Yezreel, Northern, Israel
| | - Erin E Sullivan
- Suffolk University Sawyer Business School, Boston, Massachusetts, USA
- Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Sophia Arabadjis
- University of California Santa Barbara, Santa Barbara, California, USA
| | - Jason Ramos
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maria Mirica
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew Olson
- University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
| | - Mark Linzer
- Hennepin Healthcare System Inc, Minneapolis, Minnesota, USA
| | - Gordon D Schiff
- Harvard Medical School, Center for Primary Care, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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Ishizuka K, Shikino K, Tamura H, Yokokawa D, Yanagita Y, Uchida S, Yamauchi Y, Hayashi Y, Kojima J, Li Y, Sato E, Yamashita S, Hanazawa N, Tsukamoto T, Noda K, Uehara T, Ikusaka M. Hybrid PBL and Pure PBL: Which one is more effective in developing clinical reasoning skills for general medicine clerkship?-A mixed-method study. PLoS One 2023; 18:e0279554. [PMID: 36689416 PMCID: PMC9870130 DOI: 10.1371/journal.pone.0279554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 12/09/2022] [Indexed: 01/24/2023] Open
Abstract
This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students' perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students' perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient's chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one's own errors and selecting appropriate keywords from the whole aspect of the patient.
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Affiliation(s)
- Kosuke Ishizuka
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Hiroki Tamura
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yasutaka Yanagita
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Shun Uchida
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yosuke Yamauchi
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yasushi Hayashi
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Jumpei Kojima
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yu Li
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Eri Sato
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Shiho Yamashita
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Nao Hanazawa
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
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Ross L, Semaan E, Gosling CM, Fisk B, Shannon B. Clinical reasoning in undergraduate paramedicine: utilisation of a script concordance test. BMC MEDICAL EDUCATION 2023; 23:39. [PMID: 36658560 PMCID: PMC9849838 DOI: 10.1186/s12909-023-04020-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/11/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Clinical reasoning is a complex cognitive and metacognitive process paramount to patient care in paramedic practice. While universally recognised as an essential component of practice, clinical reasoning has been historically difficult to assess in health care professions. Is the Script Concordance Test (SCT) an achievable and reliable option to test clinical reasoning in undergraduate paramedic students? METHODS This was a single institution observational cohort study designed to use the SCT to measure clinical reasoning in paramedic students. Clinical vignettes were constructed across a range of concepts with varying shades of clinical ambiguity. A reference panel mean scores of the test were compared to that of students. Test responses were graded with the aggregate scoring method with scores awarded for both partially and fully correct responses. RESULTS Eighty-three student paramedic participants (mean age: 21.8 (3.5) years, 54 (65%) female, 27 (33%) male and 2 (2%) non-binary) completed the SCT. The difference between the reference group mean score of 80 (5) and student mean of score of 65.6 (8.4) was statistically significant (p < 0.001). DISCUSSION Clinical reasoning skills are not easily acquired as they are a culmination of education, experience and the ability to apply this in the context to a specific patient. The SCT has shown to be reliable and effective in measuring clinical reasoning in undergraduate paramedics as it has in other health professions such as nursing and medicine. More investigation is required to establish effective pedogeological techniques to optimise clinical reasoning in student and novice paramedics who are devoid of experience.
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Affiliation(s)
- Linda Ross
- Department of Paramedicine, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, PO Box 527, Peninsula Campus, McMahons Road, Frankston, Melbourne, Victoria, 3199, Australia.
| | - Eli Semaan
- Ambulance Victoria, Melbourne, Australia
| | - Cameron M Gosling
- Department of Paramedicine, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, PO Box 527, Peninsula Campus, McMahons Road, Frankston, Melbourne, Victoria, 3199, Australia
| | - Benjamin Fisk
- Department of Paramedicine, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, PO Box 527, Peninsula Campus, McMahons Road, Frankston, Melbourne, Victoria, 3199, Australia
- Ambulance Victoria, Melbourne, Australia
| | - Brendan Shannon
- Department of Paramedicine, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, PO Box 527, Peninsula Campus, McMahons Road, Frankston, Melbourne, Victoria, 3199, Australia
- Ambulance Victoria, Melbourne, 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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van Sassen CGM, van den Berg PJ, Mamede S, Knol L, Eikens-Jansen MP, van den Broek WW, Bindels PJE, Zwaan L. Identifying and prioritizing educational content from a malpractice claims database for clinical reasoning education in the vocational training of general practitioners. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022:10.1007/s10459-022-10194-8. [PMID: 36529764 DOI: 10.1007/s10459-022-10194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
Diagnostic reasoning is an important topic in General Practitioners' (GPs) vocational training. Interestingly, research has paid little attention to the content of the cases used in clinical reasoning education. Malpractice claims of diagnostic errors represent cases that impact patients and that reflect potential knowledge gaps and contextual factors. With this study, we aimed to identify and prioritize educational content from a malpractice claims database in order to improve clinical reasoning education in GP training. With input from various experts in clinical reasoning and diagnostic error, we defined five priority criteria that reflect educational relevance. Fifty unique medical conditions from a malpractice claims database were scored on those priority criteria by stakeholders in clinical reasoning education in 2021. Subsequently, we calculated the mean total priority score for each condition. Mean total priority score (min 5-max 25) for all fifty diagnoses was 17,11 with a range from 13,89 to 19,61. We identified and described the fifteen highest scoring diseases (with priority scores ranging from 18,17 to 19,61). The prioritized conditions involved complex common (e.g., cardiovascular diseases, renal insufficiency and cancer), complex rare (e.g., endocarditis, ectopic pregnancy, testicular torsion) and more straightforward common conditions (e.g., tendon rupture/injury, eye infection). The claim cases often demonstrated atypical presentations or complex contextual factors. Including those malpractice cases in GP vocational training could enrich the illness scripts of diseases that are at high risk of errors, which may reduce diagnostic error and related patient harm.
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Affiliation(s)
- Charlotte G M van Sassen
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Pieter J van den Berg
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Rotterdam, The Netherlands
| | - Lilian Knol
- VvAA, Orteliuslaan 750, 3528 BB, Utrecht, The Netherlands
| | | | - Walter W van den Broek
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Smith SK, Benbenek MM, Bakker CJ, Bockwoldt D. Scoping review: Diagnostic reasoning as a component of clinical reasoning in the U.S. primary care nurse practitioner education. J Adv Nurs 2022; 78:3869-3896. [PMID: 35986584 PMCID: PMC9805128 DOI: 10.1111/jan.15414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/26/2022] [Accepted: 08/03/2022] [Indexed: 01/09/2023]
Abstract
AIMS Diagnostic Reasoning (DR) is an essential competency requiring mastery for safe, independent Nurse Practitioner (NP) practice, but little is known about DR content included in NP education programs. The aims of this study were to identify whether and how the concept of DR is addressed in NP education. DESIGN We conducted a scoping review on DR-related content and teaching innovations in U.S. primary care NP education programs, with implications for NP education programs worldwide. Concepts and principles with global applicability include: conducting focused and hypothesis-directed histories and exams, generating the problem statement, formulating the differential diagnosis, appropriate and relevant diagnostic testing, determining the working diagnosis and developing evidence-based, patient-centred management plans. DATA SOURCES N = 1115 articles retrieved from Medline, Embase, PsycINFO, and CINAHL for the period 2005-2021. Forty-one scholarly articles met inclusion/exclusion criteria. REVIEW METHODS Data were extracted, synthesized and grouped by theoretical frameworks, content included, educational interventions and assessment measures. RESULTS Most articles provided descriptions of approaches for teaching NP clinical or diagnostic reasoning. Ten papers directly referenced the current science and theory of DR. CONCLUSION The US NP education literature addressing DR is limited and demonstrates a lack of shared conceptualizations of DR. Whilst numerous components of DR are identifiable in the literature, a robust teaching/learning scholarship for DR has not yet been established in the US NP education literature. IMPACT Whilst primary care NP education programs are beginning to incorporate DR education into their curricula, little research has been conducted to demonstrate the effectiveness of educational outcomes. Increased integration of DR content into NP education is needed, including increased educational research on teaching DR competencies. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution was included in this review, as the public is generally not familiar with DR or its teaching approaches.
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Affiliation(s)
- Sheila K. Smith
- School of NursingUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | | | - Denise Bockwoldt
- School of NursingUniversity of Illinois ChicagoChicagoIllinoisUSA
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Oliveira JDCV, Peixoto AB, Marinho GEM, Peixoto JM. Ensino do Raciocínio Clínico Orientado pela Teoria dos Scripts de Doenças. Arq Bras Cardiol 2022; 119:14-21. [DOI: 10.36660/abc.20220419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
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Rowat J, Suneja M. Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum. Diagnosis (Berl) 2022; 9:468-475. [PMID: 36082516 DOI: 10.1515/dx-2022-0046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/12/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The acquisition of clinical reasoning (CR) skills is essential for future healthcare providers as they advance through their education. There is growing consensus that CR skills should be longitudinally integrated into undergraduate curriculum for acquisition/application of these skills. However, only a minority of schools reported having CR focused teaching sessions, citing a lack of curricular time and faculty expertise as the largest barriers. We describe the design and implementation of this theme and report the effects of its early introduction in Phase One as measured by the Diagnostic Thinking Inventory (DTI). METHODS The Carver College of Medicine developed and implemented a longitudinal four-year clinical reasoning theme (CRT) with a special emphasis on introducing concepts in the preclinical years (Phase One). Educational strategies used to implement the theme relied on following principles: 1) new skills are best acquired in context of application; 2) contextual learning stimulates transfer of knowledge; and 3) knowledge of pathophysiology is necessary but alone is not sufficient to develop CR skills. A patient-centered CR schema served as the framework for developing the theme. Specific focus areas, pedagogies and assessment strategies were established for each of the three phases. RESULTS The cohort with CRT demonstrated a significant increase in total DTI score after theme implementation compared to the cohort without. CONCLUSIONS A formal 4-year longitudinal CR theme is feasible, allowing for integration of pathophysiology, social determinants of health, and clinical skills. Early introduction of CR concepts as assessed by DTI showed improvement in student reasoning skills post-intervention.
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Affiliation(s)
- Jane Rowat
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Manish Suneja
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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Waechter J, Allen J, Lee CH, Zwaan L. Development and Pilot Testing of a Data-Rich Clinical Reasoning Training and Assessment Tool. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1484-1488. [PMID: 35612911 DOI: 10.1097/acm.0000000000004758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PROBLEM Clinical reasoning is a core competency for physicians and also a common source of errors, driving high rates of misdiagnoses and patient harm. Efforts to provide training in and assessment of clinical reasoning skills have proven challenging because they are either labor- and resource-prohibitive or lack important data relevant to clinical reasoning. The authors report on the creation and use of online simulation cases to train and assess clinical reasoning skills among medical students. APPROACH Using an online library of simulation cases, they collected data relevant to the creation of the differential diagnosis, analysis of the history and physical exam, diagnostic justification, ordering tests; interpreting tests, and ranking of the most probable diagnosis. These data were compared with an expert-created scorecard, and detailed quantitative and qualitative feedback were generated and provided to the learners and instructors. OUTCOMES Following an initial pilot study to troubleshoot the software, the authors conducted a second pilot study in which 2 instructors developed and provided 6 cases to 75 second-year medical students. The students completed 376 cases (average 5.0 cases per student), generating more than 40,200 data points that the software analyzed to inform individual learner formative feedback relevant to clinical reasoning skills. The instructors reported that the workload was acceptable and sustainable. NEXT STEPS The authors are actively expanding the library of clinical cases and providing more students and schools with formative feedback in clinical reasoning using our tool. Further, they have upgraded the software to identify and provide feedback on behaviors consistent with premature closure, anchoring, and confirmation biases. They are currently collecting and analyzing additional data using the same software to inform validation and psychometric outcomes for future publications.
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Affiliation(s)
- Jason Waechter
- J. Waechter is clinical associate professor, Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jon Allen
- J. Allen is professor, Department of Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota
| | - Chel Hee Lee
- C.H. Lee is assistant professor, Department of Mathematics, University of Calgary, Calgary, Alberta, Canada
| | - Laura Zwaan
- L. Zwaan is assistant professor, Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, the Netherlands
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Sartania N, Sneddon S, Boyle JG, McQuarrie E, de Koning HP. Increasing Collaborative Discussion in Case-Based Learning Improves Student Engagement and Knowledge Acquisition. MEDICAL SCIENCE EDUCATOR 2022; 32:1055-1064. [PMID: 36276760 PMCID: PMC9584010 DOI: 10.1007/s40670-022-01614-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND In the transition from academic to clinical learning, the development of clinical reasoning skills and teamwork is essential, but not easily achieved by didactic teaching only. Case-based learning (CBL) was designed to stimulate discussions of genuine clinical cases and diagnoses but in our initial format (CBL'10) remained predominantly tutor-driven rather than student-directed. However, interactive teaching methods stimulate deep learning and consolidate taught material, and we therefore introduced a more collaborative CBL (cCBL), featuring a structured format with discussions in small breakout groups. This aimed to increase student participation and improve learning outcomes. METHOD A survey with open and closed questions was distributed among 149 students and 36 tutors that had participated in sessions of both CBL formats. A statistical analysis compared exam scores of topics taught via CBL'10 and cCBL. RESULTS Students and tutors both evaluated the switch to cCBL positively, reporting that it increased student participation and enhanced consolidation and integration of the wider subject area. They also reported that the cCBL sessions increased constructive discussion and stimulated deep learning. Moreover, tutors found the more structured cCBL sessions easier to facilitate. Analysis of exam results showed that summative assessment scores of subjects switched to cCBL significantly increased compared to previous years, whereas scores of subjects that remained taught as CBL'10 did not change. CONCLUSIONS Compared to our initial, tutor-led CBL format, cCBL resulted in improved educational outcomes, leading to increased participation, confidence, discussion and higher exam scores.
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Affiliation(s)
- Nana Sartania
- Undergraduate Medical School, School of Medicine, University of Glasgow, Glasgow, UK
| | - Sharon Sneddon
- Undergraduate Medical School, School of Medicine, University of Glasgow, Glasgow, UK
| | - James G. Boyle
- Undergraduate Medical School, School of Medicine, University of Glasgow, Glasgow, UK
| | - Emily McQuarrie
- Undergraduate Medical School, School of Medicine, University of Glasgow, Glasgow, UK
| | - Harry P. de Koning
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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Si J. Strategies for developing pre-clinical medical students' clinical reasoning based on illness script formation: a systematic review. KOREAN JOURNAL OF MEDICAL EDUCATION 2022; 34:49-61. [PMID: 35255616 PMCID: PMC8906925 DOI: 10.3946/kjme.2022.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/27/2022] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Abstract
Clinical reasoning training in the pre-clinical phase has recently been considered important; however, when it comes to specific instructional methods for pre-clinical students, much is unknown. Thus, the aim of this review is to explore learning and teaching methods for pre-clinical students' clinical reasoning development based on illness script formation, their results, and strategies. A systematic review was conducted in accordance with the guidelines of the Association for Medical Education in Europe. The literature search was performed using the Cochrane Library, PubMed, EMBASE, Web of Science, and ERIC databases based on keywords, including "illness script*" AND ("medical student*" OR pre-clinical OR undergraduate). Then, 10 studies among the 91 studies were included in the final analysis. The quality of the selected studies was also appraised using the Medical Education Research Study Quality Instrument. Diverse teaching and learning methods were used to support the integration of biomedical and clinical knowledge working with patient cases, and their effects were assessed through diverse methods, including illness script richness and maturity, to learner responses. The effects of these interventions were effective in terms of the clinical reasoning development of pre-clinical students. Learning and teaching strategies were synthesized and described. This review found that explicit attempts to promote illness script formation with a structured program rather than informal training lead to positive results, and such formal clinical reasoning programs can provide smooth transition from pre-clinical to clinical experience.
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Affiliation(s)
- Jihyun Si
- Department of Medical Education, Dong-A University College of Medicine, Busan, Korea
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Neto IG. Palliative care and its own identity, through an autoethnography: do you recognize these patterns? Palliat Care Soc Pract 2022; 16:26323524221122346. [PMID: 36118620 PMCID: PMC9478704 DOI: 10.1177/26323524221122346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: After more than 25 years working in palliative care (PC) observing thousands
of patients and family behaviors, I use my long experience and notes as a
source of data for a qualitative research study. The aim is to identify
frequent families’ behavior patterns in PC and better describe the culture
in PC. Methods: This article is part of a larger project, using autoethnography as
methodology, with the aim of helping doctors and interested health
professionals better understand the culture and reality of PC. The focus is
not the author but patients and families’ patterns of
social behavior – the social context – within the
end-of-life period and how to deal with these professionally.
Confidentiality and privacy of patients’ data were guaranteed. Results: The vast number of treated cases, the regular observation and recording, and
the continuous reflection and analysis over many years have led to these
results. Due to editorial restrictions, in this article I only describe four
of at least eight typical scenarios I have identified. Each is given a short
title and I explore some of their inside-issues, integrating previous
knowledge, research, and explanations, with practical suggestions on how to
deal with them. Significance: As far as we know, these scenarios/patterns have never been described in this
way. This work expands knowledge, innovates, and contributes to better
describing PC culture. The final goal is to create a set of scripts that can
be used to help clinicians quickly identify the clinical situation and how
to deal with it in clinical practice. Reflecting on how patients and
families frequently behave in PC can be very useful and then teach other
professionals to better deal with these challenges.
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Affiliation(s)
- Isabel Galriça Neto
- Palliative Care Unit, Hospital da Luz-Lisboa, Lisbon University Medical School, Catolica University Medical School, Av.Lusíada 100, Lisboa 1500-650, Portugal
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Virtual Wards: A Rapid Adaptation to Clinical Attachments in MBChB During the COVID-19 Pandemic. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1356:95-116. [PMID: 35146619 DOI: 10.1007/978-3-030-87779-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
When the COVID-19 pandemic suddenly prevented medical students from attending their clinical attachments, the faculty involved in the third year of medical school (MBChB3) at the University of Glasgow created Virtual Wards. The focus of the Virtual Wards was to continue teaching of clinical reasoning remotely whilst COVID-19 restrictions were in place. Virtual Wards were mapped to the common and important presentations and conditions and provided opportunity for history-taking, clinical examination skills, requesting investigations, interpreting results, diagnosis and management. The Virtual Wards were successful, and further wards were developed the following academic year for MBChB4 students. This chapter describes the theoretical underpinnings of the Virtual Wards and the technological considerations, followed by a description of the Wards themselves. We then analyse an evaluation of the Virtual Wards and provide both a faculty and student perspective. Throughout the chapter, we provide tips for educators developing Virtual Ward environments.
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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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Parodis I, Andersson L, Durning SJ, Hege I, Knez J, Kononowicz AA, Lidskog M, Petreski T, Szopa M, Edelbring S. Clinical Reasoning Needs to Be Explicitly Addressed in Health Professions Curricula: Recommendations from a European Consortium. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11202. [PMID: 34769721 PMCID: PMC8583438 DOI: 10.3390/ijerph182111202] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/18/2022]
Abstract
Clinical reasoning entails the application of knowledge and skills to collect and integrate information, typically with the goal of arriving at a diagnosis and management plan based on the patient's unique circumstances and preferences. Evidence-informed, structured, and explicit teaching and assessment of clinical reasoning in educational programs of medical and other health professions remain unmet needs. We herein summarize recommendations for clinical reasoning learning objectives (LOs), as derived from a consensus approach among European and US researchers and health professions educators. A four-step consensus approach was followed: (1) identification of a convenience sample of the most relevant and applied national LO catalogues for health professions educational programs (N = 9) from European and US countries, (2) extraction of LOs related to clinical reasoning and translation into English, (3) mapping of LOs into predefined categories developed within the Erasmus+ Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators (DID-ACT) consortium, and (4) synthesis of analysis findings into recommendations for how LOs related to clinical reasoning could be presented and incorporated in LO catalogues, upon consensus. Three distinct recommendations were formulated: (1) make clinical reasoning explicit, (2) emphasize interprofessional and collaboration aspects of clinical reasoning, and (3) include aspects of teaching and assessment of clinical reasoning. In addition, the consortium understood that implementation of bilingual catalogues with English as a common language might contribute to lower heterogeneity regarding amount, structure, and level of granularity of clinical reasoning LOs across countries. These recommendations will hopefully motivate and guide initiatives towards the implementation of LOs related to clinical reasoning in existing and future LO catalogues.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, 702 81 Örebro, Sweden
| | - Lina Andersson
- School of Health Sciences, Örebro University, 702 81 Örebro, Sweden; (L.A.); (S.E.)
| | - Steven J. Durning
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
| | - Inga Hege
- Medical Education Sciences, Medical School, University of Augsburg, 86159 Augsburg, Germany;
| | - Jure Knez
- Division for Gynaecology and Perinatology, University Medical Centre Maribor and Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
| | - Andrzej A. Kononowicz
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, 30 688 Krakow, Poland;
| | - Marie Lidskog
- School of Medical Sciences, Örebro University, 702 81 Örebro, Sweden;
| | - Tadej Petreski
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor and Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
| | - Magdalena Szopa
- Department of Medical Education, Jagiellonian University Medical College, 30 688 Krakow, Poland;
- Department of Metabolic Diseases, Jagiellonian University Medical College, 30 688 Krakow, Poland
| | - Samuel Edelbring
- School of Health Sciences, Örebro University, 702 81 Örebro, Sweden; (L.A.); (S.E.)
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Gay S. Clinical reasoning and primary care. EDUCATION FOR PRIMARY CARE 2021; 32:255. [PMID: 34429037 DOI: 10.1080/14739879.2021.1961611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Simon Gay
- Medical Education (Primary Care), Leicester Medical School, University of Leicester, Leicester, UK,
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Singh M, Collins L, Farrington R, Jones M, Thampy H, Watson P, Warner C, Wilson K, Grundy J. From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme. ACTA ACUST UNITED AC 2021; 9:184-194. [PMID: 34256424 DOI: 10.1515/dx-2021-0031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/08/2021] [Indexed: 11/15/2022]
Abstract
There is consensus that clinical reasoning (CR) is crucial for increasing the value of diagnosis, medical decision-making and error reduction. These skills should be developed throughout medical education, starting with undergraduate study. International guidance provides principles for CR curricula but interventions to date, are short term in nature. In this report, we describe the creation of a longitudinal, spiral CR curriculum within a large UK medical school programme (2500 students). A working group drove systematic evidence-based reform of existing structures. We utilised recognised models for curriculum development and mapping, relating learning outcomes to competency frameworks. Application of multiple teaching methodologies, rooted in enquiry-based learning and reported in CR literature, encourage metacognition for information-processing and illness script development. Development of CR is emphasised with recurrent, progressive learning opportunities, each stage purposefully building upon previous experiences. Formative and summative assessment approaches to drive learning, encouraging students' ability to apply and articulate CR, is constructed via Miller's Prism of Clinical Competence. Implementation of pedagogy is contingent on faculty development. Whilst many clinicians practice sound CR, the ability to articulate it to students is often a novel skill. Engagement in faculty development was strengthened through cross-institutional recognition of teaching workload and flexibility of delivery. We report lessons learned from the implementation phase and plans for measuring impact.
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Affiliation(s)
- Mini Singh
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| | - Lisa Collins
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
| | - Rebecca Farrington
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Matthew Jones
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| | - Harish Thampy
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
| | - Pippa Watson
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Christian Warner
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Kurt Wilson
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
| | - Jessica Grundy
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
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