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

Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition

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.

Physicians have feelings: illuminating the relationship between emotional valence, clinical reasoning and context specificity

INTRODUCTION

Research demonstrates that emotions play an important role in clinical reasoning (CR); however, the relationship between emotional valence, CR, and the context in which reasoning takes place, remains to be empirically explored. While situated cognition has been used to investigate CR and context specificity (e.g. the presence of contextual factors, things other than the information directly related to establishing a diagnosis), it has not explicitly examined the role of emotional valence during CR encounters. Our research question was how do emotional valence and arousal emerge in CR, particularly in the presence or absence of contextual factors?

METHODS

Physicians (n = 45) reviewed two video cases, one with contextual factors and one without. Immediately afterwards, participants completed a 'think-aloud' while reviewing cases. Thematic analysis was used to code transcribed think-alouds for CR activities, emotional valence (positive, neutral or negative) and arousal by three researchers. Frequencies and relationships between codes were compared, both in the presence or absence of contextual factors.

RESULTS

The majority of emotional valence codes were neutral (85.2%), with negative valence more frequent (11.2%) than positive valence (3.5%). Five CR themes were consistently demonstrated: knowledge organization (with two sub-themes of linking and differential diagnosis formation), proceeding with caution, curiosity, assumption, and reflection. In the presence of contextual factors, there was an increase in negative valence with a decrease in positive valence, as well as a shift in CR from knowledge organization to curiosity and proceeding with caution.

DISCUSSION

The complex interaction between clinical reasoning themes, emotional valence, and changes with contextual factors have important implications for clinical practice, education, and future research on CR.

Interprofessional clinical reasoning education

Clinical reasoning is considered one of the most important competencies but is not included in most healthcare curricula. The number and diversity of patient encounters are the decisive factors in the development of clinical reasoning competence. Physical real patient encounters are considered optimal, but virtual patient cases also promote clinical reasoning. A high-volume, low-fidelity virtual patient library thus can support clinical reasoning training in a safe environment and can be tailored to the needs of learners from different health care professions. It may also stimulate interprofessional understanding and team shared decisions. Implementation will be challenged by tradition, the lack of educator competence and prior experience as well as the high-density curricula at medical and veterinary schools and will need explicit address from curriculum managers and education leads.

Going beyond competencies: Building blocks for a patient- and population-centered medical curriculum

Introduction: Changing health care requires changing medical education. In this position paper it is suggested that subsequent innovations in medical education each had their specific strengths and shortcomings. What they have, however, in common is that they place the medical student and their competencies at their center. Innovation in medical education is inward looking. Discussion: The authors propose a perspective on the medical curriculum in which the patient, their family, and the surrounding community take center stage. They argue that present medical education cannot adequately respond to the great challenges to population health: an aging population, the obesity epidemic, and future pandemics of new diseases due to population growth, urbanization, and antimicrobial resistance, particularly because these challenges cannot be dealt with by the medical sciences alone but need deep understanding of the social sciences as well. In addition, the practice of health care is changing: effective health care demands a close partnership between the health care system and the medical school which is mostly lacking, cooperation with other health professions is becoming more and more necessary in response to the increasing complexity of health care, patients and their families are required to play a more active role in their health, medical error threatening patient safety is becoming to be seen as a huge problem, and the emergence of artificial intelligence in education and practice, all requiring transformation of medical education. Conclusion: The present contribution suggests eight such transformations necessary to create a truly patient- and population-centered medical curriculum.

Diagnostic reasoning and cognitive error in emergency medicine: Implications for teaching and learning

BACKGROUND

Accurate diagnosis in emergency medicine (EM) is high stakes and challenging. Research into physicians' clinical reasoning has been ongoing since the late 1970s. The dual-process theory has established itself as a valid model, including in EM. It is based on the distinction between two information-processing systems. System 1 rapidly generates one or more diagnostic hypotheses almost instantaneously, driven by experiential knowledge, while System 2 proceeds more slowly and analytically, applying formal rules to arrive at a final diagnosis.

METHODS

We reviewed the literature on dual-process theory in the fields of cognitive science, medical education and emergency medicine.

RESULTS AND CONCLUSION

The literature reflects two prominent interpretations regarding the relationship between the fast and slow phases and these interpretations carry very different implications for the training of clinical learners. One interpretation, prominent in the EM community, presents it as a "check-and-balance" framework in which most diagnostic error is caused by cognitive biases originating within System 1. As a result, EM residents are frequently advised to deploy analytical (System 2) strategies to correct such biases. However, such teaching approaches are not supported by research into the nature of diagnostic reasoning. An alternative interpretation assumes a harmonious relationship between Systems 1 and 2 in which both fast and slow processes are driven by underlying knowledge that conditions performance and the occurrence of errors. Educational strategies corresponding to this alternative have not been explored in the EM literature. In this paper, we offer proposals for improving the teaching and learning of diagnostic reasoning by EM residents.

J. P. Rikers R, Pourahmadi M, Soltani Arabshahi SK, Keshtkar A, Dargahi H, Yaghmaei M, Monajemi A. Teaching and learning clinical reasoning skill in undergraduate medical students: A scoping review

BACKGROUND

Clinical reasoning involves the application of knowledge and skills to collect and integrate information, typically to arrive at a diagnosis, implement appropriate interventions, solve clinical problems, and improve the quality of health care and patient outcomes. It is a vital competency that medical students must acquire, as it is considered the heart of medicine.

PURPOSE

This scoping review aimed to identify and summarize the existing literature on learning and teaching strategies for improving clinical reasoning skill in undergraduate medical education.

METHODS

We conducted electronic searches in Scopus, PubMed/Medline (NLM), Web of Science (WOS), and ERIC to retrieve articles published between January 1, 2010, and March 23, 2024. We also performed hand searches by scanning the reference lists of included studies and similar reviews and searching three key journals. After removing duplicates, two reviewers independently extracted data from primary articles using a standard data extraction form. The authors used Arksey and O'Malley's framework.

RESULTS

Among the 46581 retrieved records, 54 full-text articles were included in the present review. We categorized the educational strategies based on their aspects, focus, and purpose. Included studies used various educational strategies for improving clinical reasoning skill in undergraduate medical education by serial cue or whole clinical cases that presented as process-oriented or knowledge-oriented.

CONCLUSION

This scoping review investigated various dimensions of educational intervention for improving clinical reasoning skill in undergraduate medical education. There is a need for more precision studies with larger sample sizes, designing studies according to randomized controlled trials standards, determining MCID, or performing meta-analyses to acquire robust and conclusive results.

Integrating Clinical Reasoning Into Medical Students' First Weeks of Education Improves Understanding of Cranial Nerve Anatomy

Clinical reasoning is essential to the practice of medicine. Such reasoning involves analytical (deductive) and non-analytical (recall) processes. Non-analytical reasoning is taught extensively in medical schools, and it dominates medical students' time as they review question banks and lecture notes, watch videos online, and memorize flashcards, algorithms, and illness scripts. However, few opportunities are provided in the curriculum to develop students' clinical reasoning skills, and when they are, the diverse levels of innate reasoning ability among students often lead to significant learning disparity. To address this deficiency, a pilot module on cranial nerve anatomy was developed to foster analytical clinical reasoning in an individualized manner. It was hypothesized that this module would not only introduce the foundations of an essential medical skill but also improve overall student understanding of the subject and reduce learning disparities among students. A comparative study was conducted using this module in one group and a didactic module in the other, employing pre- and post-testing measures. Results indicated a 26% improvement in average scores following the analytical module, whereas the control module showed no significant improvement. In addition, the disparity between students improving or not improving following the intervention was reduced, with 74% of students improving after the reasoning module and only 33% of students improving after the didactic module. A novel cranial nerve educational module introduced analytical reasoning in medical students' first few weeks of education, facilitating the learning of complex anatomy and reducing learning disparity between students.

Learning by Clinical Reasoning Versus Interactive Lecture: An Analytical and Experimental Study of Teaching Urological Emergencies

OBJECTIVE

To scrutinize the progression of clinical reasoning and theoretical knowledge by comparing the impact of Clinical Reasoning-Based Learning (CRBL) sessions with interactive lectures (IL).

METHODS

In this experimental study conducted from November 15, 2021, to May 7, 2022, we focused on second-year students in the second cycle of medical studies. Four specific urologic emergency scenarios (nephritic colic, macroscopic hematuria, acute scrotal pain, and urinary incontinence in men) were selected for interactive teaching sessions. Four groups were studied. One urology item was taught via CRBL, the rest via IL. Each item was taught once with CRBL and thrice with IL. After instruction, learners took a 10-point evaluative test with multiple-choice questions and clinical scenarios.

RESULTS

Four groups of 14 learners attended our department, for a total number of 56 participants. Each student attended 4 learning sessions (1 CRBL session and 3 ILs) with a number of tests completed at 4 for each. The total number of tests taken was 224. The scoring of each test was out of 10 with theoretical scores between 0 and 10. The overall median score was 7/10. We noted better ratings after the CRBL sessions (n = 56) with a median of 8/10 [4-10] compared to the IL sessions (n = 168) whose median was 6 [3-10] with a significant difference between the 2 learning methods (P <.001).

CONCLUSION

The CRBL sessions were significantly better than the ILs at developing the clinical reasoning and theoretical knowledge in urology of our medical students.

Assisting the Learning of Clinical Reasoning by Veterinary Medical Learners with a Case Example

Effective clinical reasoning is essential for veterinary medical education, particularly in managing complex cases. This review explores strategies for learning clinical reasoning by veterinary medical learners, using a case example of mastitis to illustrate key concepts. Clinical reasoning encompasses cognitive, metacognitive, social, and situational activities, yet the literature on practical applications in veterinary education remains limited. The review discusses various stages of clinical reasoning, including data collection, problem representation, differential diagnosis, and management planning. It emphasizes the importance of integrating client-centered care and iterative evaluation into the clinical decision-making process. Key learning strategies include facilitation in using the domains of clinical reasoning-concepts, data collection, and analysis, taking action, and reflection on encounters. This review highlights best practices such as forward and backward reasoning, reflective practice, and the use of practical examples to enhance learners' diagnostic accuracy and patient outcomes. The insights provided aim to enhance the training of veterinary learners, ensuring they can navigate day 1 as well as complex cases with improved diagnostic accuracy and patient outcomes.

Teaching Clinical Reasoning in the Preclinical Period

INTRODUCTION

Developing the clinical reasoning skills necessary to becoming an astute diagnostician is essential for medical students. While some medical schools offer longitudinal opportunities for students to practice clinical reasoning during the preclinical curriculum, there remains a paucity of literature fully describing what that curriculum looks like. As a result, medical educators struggle to know what an effective clinical reasoning curriculum should look like, how it should be delivered, how it should be assessed, or what faculty development is necessary to be successful. We present our Introduction to Clinical Reasoning course that is offered throughout the preclinical curriculum of the Uniformed Services University of the Health Sciences. The course introduces clinical reasoning through interactive lectures and 28 case-based small group activities over 15 months.The curriculum is grounded in script theory with a focus on diagnostic reasoning. Specific emphasis is placed on building the student's semantic competence, constructing problem lists, comparing and contrasting similar diagnoses, constructing a summary statement, and formulating a prioritized differential diagnosis the student can defend. Several complementary methods of assessment are utilized across the curriculum. These include assessments of participation, knowledge, and application. The course leverages clinical faculty, graduate medical education trainees, and senior medical students as small group facilitators. Feedback from students and faculty consistently identifies the course as a highly effective and engaging way to teach clinical reasoning.

CONCLUSION

Our Introduction to Clinical Reasoning course offers students repeated exposure to well-selected cases to promote their development of clinical reasoning. The course is an example of how clinical reasoning can be taught across the preclinical curriculum without extensive faculty training in medical education or clinical reasoning theory. The course can be adapted into different instructional formats to cover a variety of topics to provide the early learner with sequential exposure and practice in diagnostic reasoning.

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

INTRODUCTION

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

CONTENT

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

SUMMARY

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

OUTLOOK

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

Steps to improve the teaching of clinical reasoning in dermatology: A scoping review and proposal

Clinical reasoning (CR) is an area of active interest since faults in the diagnostic process can result in errors and possibly delays in care or even patient harm. The purpose of this scoping review was to collect information from the medical literature on approaches utilized to teach and assess CR in dermatology, identify gaps, and prepare a proposal on how to enhance the speciality's ability to develop trainee CR skills. We conducted a review of the published literature (1990-2020) from four databases. The initial search yielded 780 papers, and 42 relevant CR publications met inclusion criteria. Demographic, thematic content, theoretical frameworks, continuum of authenticity, competency/milestone, and assessment/educational intervention data were recorded by two screeners. Trainees at different educational levels from 17 different countries have been assessed in the dermatology literature. Most publications were of a single intervention, appeared underpowered, and had small sample sizes. Only two publications examined work-based assessments (use real patients/stimuli). Knowledge-based studies were the dominant theoretical framework with no studies exclusively focused on process-based CR interventions. Simulation was well represented with 23 (55%) investigations. Rigorous studies that examine CR teaching and assessment in dermatology are lacking. Evidence-based best practices for use of work-based assessments, especially direct observation, need to be developed/adapted for dermatology and validated. Dermatology training programs would benefit from longitudinal data on trainee CR development, process-based CR educational programs, metacognition CR exploration specific to skin disease diagnosis, and studies that yield practical recommendations on how to structure multi-faceted assessments that assess CR.

Assessment of Clinical Reasoning in Undergraduate Medical Education: A Pragmatic Approach to Programmatic Assessment

PURPOSE

Clinical reasoning, a complex construct integral to the practice of medicine, has been challenging to define, teach, and assess. Programmatic assessment purports to overcome validity limitations of judgments made from individual assessments through proportionality and triangulation processes. This study explored a pragmatic approach to the programmatic assessment of clinical reasoning.

METHOD

The study analyzed data from 2 student cohorts from the University of Utah School of Medicine (UUSOM) (n = 113 in cohort 1 and 119 in cohort 2) and 1 cohort from the University of Colorado School of Medicine (CUSOM) using assessment data that spanned from 2017 to 2021 (n = 199). The study methods included the following: (1) asking faculty judges to categorize student clinical reasoning skills, (2) selecting institution-specific assessment data conceptually aligned with clinical reasoning, (3) calculating correlations between assessment data and faculty judgments, and (4) developing regression models between assessment data and faculty judgments.

RESULTS

Faculty judgments of student clinical reasoning skills were converted to a continuous variable of clinical reasoning struggles, with mean (SD) ratings of 2.93 (0.27) for the 232 UUSOM students and 2.96 (0.17) for the 199 CUSOM students. A total of 67 and 32 discrete assessment variables were included from the UUSOM and CUSOM, respectively. Pearson r correlations were moderate to strong between many individual and composite assessment variables and faculty judgments. Regression models demonstrated an overall adjusted R2 (standard error of the estimate) of 0.50 (0.19) for UUSOM cohort 1, 0.28 (0.15) for UUSOM cohort 2, and 0.30 (0.14) for CUSOM.

CONCLUSIONS

This study represents an early pragmatic exploration of regression analysis as a potential tool for operationalizing the proportionality and triangulation principles of programmatic assessment. The study found that programmatic assessment may be a useful framework for longitudinal assessment of complicated constructs, such as clinical reasoning.

Mock Wards: Incorporating a Theoretical Framework to Create a Blended Virtual and In-Person Clinical Reasoning Education Platform

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.

Teaching and Learning Clinical Reasoning in Nursing Education: A Student Training Course

Clinical reasoning is an essential component of nursing. It has emerged as a concept that integrates the core competencies of quality and safety education for nurses. In cooperation with five European partners, Instituto Politécnico de Setúbal (IPS) realized the "Clinical Reasoning in Nursing and Midwifery Education and Practice" project as part of the Erasmus+ project. As a partner, our team designed a multiplier event-the student training course. The aim of this report is to describe the construction and development of this clinical reasoning training course for nursing students. We outline the pedagogical approach of an undergraduate training course on clinical reasoning in 2023, which we separated into four stages: (i) welcoming, (ii) knowledge exploration, (iii) pedagogical learning, and (iv) sharing experience. This paper presents the learning outcomes of the collaborative reflection on and integration of the clinical reasoning concept among nursing students. This educational experience fostered reflection and discussion within the teaching team of the nursing department regarding the concept, models, and teaching/learning methods for clinical reasoning, with the explicit inclusion of clinical reasoning content in the nursing curriculum. We highlight the importance of implementing long-term pedagogical strategies in nursing education.

Fostering clinical reasoning ability in preclinical students through an illness script worksheet approach in flipped learning: a quasi-experimental study

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.

Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Promoting Longitudinal and Developmental Computer-Based Assessments of Clinical Reasoning: Validity Evidence for a Clinical Reasoning Mapping Exercise

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.

Test for clinical reasoning evaluation in Speech-Language Pathology: content validity

PURPOSE

To validate the content of the Speech-Language Pathology Concordance Test called FonoTCS.

METHODS

This is a content validation study of the instrument. Five speech-language pathologists, all with doctoral degrees and teaching experience, averaging 24.8 years of professional practice, participated in the development of FonoTCS and reached a consensus during the process. Thirty questions and 120 items were created, covering seven areas of speech-language pathology expertise across three domains. For content validation, FonoTCS was electronically sent to 15 evaluators to respond to a questionnaire with five questions, rated on a five-point scale, regarding the criteria of clarity, ethics, and relevance of the questions. The Corrected Content Validity Coefficient was calculated for all statements to analyze the responses. Questions with agreement percentages equal to or less than 80% were revised.

RESULTS

Thirteen evaluators, all female, with an average age of 39.07 years, including eight with master's degrees and five with doctoral degrees, and an average clinical practice experience of 15.38 years, participated in the analysis. The average Corrected Content Validity Coefficient values for the clarity criterion were 0.93 and 0.95, for the relevance criterion 0.98 and 0.92, and for the ethics criterion 0.99. Two questions received scores of 0.78 and 0.80, both related to the audiology area in the assessment/diagnosis domain, specifically question 2 regarding the relevance criterion. These questions were reviewed and restructured by the judges.

CONCLUSION

FonoTCS is a valid instrument from a content perspective.

Programmatic Assessment of Clinical Reasoning: New Opportunities to Meet an Ongoing Challenge

Issue: Clinical reasoning is essential to physicians' competence, yet assessment of clinical reasoning remains a significant challenge. Clinical reasoning is a complex, evolving, non-linear, context-driven, and content-specific construct which arguably cannot be assessed at one point in time or with a single method. This has posed challenges for educators for many decades, despite significant development of individual assessment methods. Evidence: Programmatic assessment is a systematic assessment approach that is gaining momentum across health professions education. Programmatic assessment, and in particular assessment for learning, is well-suited to address the challenges with clinical reasoning assessment. Several key principles of programmatic assessment are particularly well-aligned with developing a system to assess clinical reasoning: longitudinality, triangulation, use of a mix of assessment methods, proportionality, implementation of intermediate evaluations/reviews with faculty coaches, use of assessment for feedback, and increase in learners' agency. Repeated exposure and measurement are critical to develop a clinical reasoning assessment narrative, thus the assessment approach should optimally be longitudinal, providing multiple opportunities for growth and development. Triangulation provides a lens to assess the multidimensionality and contextuality of clinical reasoning and that of its different, yet related components, using a mix of different assessment methods. Proportionality ensures the richness of information on which to draw conclusions is commensurate with the stakes of the decision. Coaching facilitates the development of a feedback culture and allows to assess growth over time, while enhancing learners' agency. Implications: A programmatic assessment model of clinical reasoning that is developmentally oriented, optimizes learning though feedback and coaching, uses multiple assessment methods, and provides opportunity for meaningful triangulation of data can help address some of the challenges of clinical reasoning assessment.

Perceived opportunities of clinical reasoning learning in postgraduate psychiatry training: Trainees' and faculty's perspectives

BACKGROUND

Learning clinical reasoning is less effective in isolation of clinical environments because contextual factors are a significant component in the clinical reasoning process. This study investigated the differences in opinions between novice and expert clinicians on learning clinical reasoning in the workplace.

MATERIALS AND METHODS

The author used a cross-sectional online survey design to investigate the perceived learning of six clinical reasoning skills in 13 learning opportunities. Questionnaires were emailed to 41 postgraduate psychiatry trainee doctors and 37 faculty members. Data were analyzed descriptively. The Chi-square test was used to compare the responses of the two groups. Statistical significance was set at P < 0.05.

RESULTS

The combined response rate was 73.07%. The two groups perceived the learning of advanced clinical reasoning skills to be lower than that of basic skills. There were significant differences in the perceived learning of basic clinical reasoning skills in self-study/exam preparations (P = 0.032), general hospital grand rounds (P = 0.049), and clinical rounds (P = 0.024 for consultant-led rounds and P = 0.038 for senior peer-led rounds). There were also significant differences in the perceived learning of advanced clinical reasoning skills among peer-led tutorials (P = 0.04), journal clubs (P = 0.006), morning reports (P = 0.002), and on-call duties (P = 0.031).

CONCLUSIONS

The trainees showed a significant preference for structured learning environments rather than clinical environments, especially for advanced clinical reasoning skills. Trainees likely struggled with cognitive overload in clinical environments. Local postgraduate psychiatry programs will likely benefit from implementing multiple educational interventions that facilitate teaching and learning clinical reasoning in complex clinical environments.

Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study

BACKGROUND

The consultation process, where a clinician seeks an opinion from another clinician, is foundational in medicine. However, the effectiveness of group diagnosis has not been studied.

OBJECTIVE

To compare individual diagnosis to group diagnosis on two dimensions: group size (n=3 or 6) and group process (interactive or artificial groups).

METHODOLOGY

Thirty-six internal or emergency medicine residents participated in the study. Initially, each resident worked through four written cases on their own, providing a primary diagnosis and a differential diagnosis. Next, participants formed into groups of three. Using a videoconferencing platform, they worked through four additional cases, collectively providing a single primary diagnosis and differential diagnosis. The process was repeated using a group of six with four new cases. Cases were all counterbalanced. Retrospectively, nominal (ie, artificial) groups were formed by aggregating individual participant data into subgroups of three and six and analytically computing scores. Presence of the correct diagnosis as primary diagnosis or included in the differential diagnosis, as well as the number of diagnoses mentioned, was calculated for all conditions. Means were compared using analysis of variance.

RESULTS

For both authentic and nominal groups, the diagnostic accuracy of group diagnosis was superior to individual for both the primary diagnosis and differential diagnosis. However, there was no improvement in diagnostic accuracy when comparing a group of three to a group of six. Interactive and nominal groups were equivalent; however, this may be an artefact of the method used to combine data.

CONCLUSIONS

Group diagnosis improves diagnostic accuracy. However, a larger group is not necessarily superior to a smaller group. In this study, interactive group discussion does not result in improved diagnostic accuracy.

Clinical reasoning in pharmacy: What do eye movements and verbal protocols tell us about the processing of a case task?

This study investigates pharmacy students' reasoning while solving a case task concerning an acute patient counselling situation in a pharmacy. Participants' (N = 34) reasoning processes were investigated with written tasks utilizing eye-tracking in combination with verbal protocols. The case was presented in three pages, each page being followed by written questions. Eye movements were recorded during case processing. Success in the task required differentiating the relevant information from the task redundant information, and initial activation of several scripts and verification of the most likely one, when additional information became available. 2nd (n = 16) and 3rd (n = 18)-year students' and better and worse succeeding students' processes were compared. The results showed that only a few 2nd-year students solved the case correctly, whereas almost all of the 3rd-year students were successful. Generally, the average total processing times of the case material did not differ between the groups. However, better-succeeding and 3rd-year students processed the very first task-relevant sentences longer, indicating that they were able to focus on relevant information. Differences in the written answers to the 2nd and 3rd question were significant, whereas differences regarding the first question were not. Thus, eye-tracking seems to be able to capture illness script activation during case processing, but other methods are needed to depict the script verification process. Based on the results, pedagogical suggestions for advancing pharmacy education are discussed.

Validating the Korean shorter Diagnostic Thinking Inventory in medical education: a pilot study

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.

The Psychological Impact of Exposure to Battle on Medics: A Cross-Sectional Study of Ex-Soldiers Who Sought Help From the IDF Combat Reaction Unit

INTRODUCTION

The present study's central aim was to examine two questions: (1) Will there be differences in mental health outcomes between medics and non-medics who sought help at the Israeli Combat Reaction Unit (CRU)? (2) Will there be differences in mental health outcomes between combatants and non-combatants?

MATERIALS AND METHODS

This cross-sectional study included files of 1,474 Israeli Defense Forces ex-service members (89% combatants, of whom 13% were medics; 11% non-combatants, of whom 6% were medics), who filled out questionnaires on admission for evaluation at the CRU.Dependent variables were mental health measures and included two PTSD measures (Clinician-Administered PTSD Scale and PTSD Checklist for DSM-5), Beck Depression Inventory, Dissociative Experience Scale, and Brief Symptom Inventory. Military profession (medics vs. non-medics) and status (combatant vs. non-combatant) were the independent variables. Background variables were also examined.

RESULTS

We found no substantial differences between medics and non-medics in the mental health measures. When looking at combat and non-combat separately, the non-combat medics (CMs), in general, were in better mental health conditions than the other three groups- CMs, non-medic combatants, and non-medic non-combatants-all of whom had similar scores in the mental health measures. However, compared to the rest, non-CMs took considerably longer years before approaching the CRU.

CONCLUSIONS

The elapsed time to seek help for non-MCs was explained by their reluctance to seek help, not being combatants, and being medics who are portrayed as resilient. Recommendations for encouraging this subgroup to seek help were given.

Exploring medical students' perceptions of individual and group-based clinical reasoning with virtual patients: a qualitative study

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.

Cognitive processes in pharmacists' clinical decision-making

BACKGROUND

Pharmacists' clinical decision-making is a core process in pharmaceutical care. However, the practical aspects and effective teaching methods of this process remain largely unexplored.

OBJECTIVE

To examine the cognitive processes involved in pharmacists' perceptions of how they make clinical decisions in pharmacy practice.

METHODS

Semi-structured, face-to-face interviews were conducted with pharmacists working in community, outpatient, and hospital care in the Netherlands between August and December 2021. Participants were explicitly asked for examples when asked how they make clinical decisions in practice and how they teach this to others. After transcribing audio-recorded interviews, an inductive thematic analysis was conducted to identify cognitive processes. A theoretical model of clinical decision-making was then used and adapted to structure the identified processes.

RESULTS

In total, 21 cognitive processes were identified from interviews with 16 pharmacists working in community (n = 5), outpatient (n = 2), and hospital care (n = 9). These cognitive processes were organized into 8 steps of the adapted theoretical model, i.e. problem and demand for care consideration, information collection, clinical reasoning, clinical judgment, shared decision-making, implementation, outcomes evaluation, and reflection. Pharmacists struggled to articulate their clinical decision-making and went back-and-forth in their explanations of this process. All pharmacists emphasized the importance of identifying the problem and described how they collect information through reviewing, gathering, recalling, and investigating. Clinical reasoning entailed various cognitive processes, of which comprehending the problem in the patient's context was deemed challenging at times. Pharmacists seemed least active in evaluating patient outcomes and reflecting on these outcomes.

CONCLUSIONS

Pharmacists use multiple cognitive processes when making clinical decisions in pharmacy practice, and their back-and-forth explanations emphasize its dynamic nature. This study adds to a greater understanding of how pharmacists make clinical decisions and to the development of a theoretical model that describes this process, which can be used in pharmacy practice and education.

Novice learners' perspectives on obstetric airway crisis decision-making training using virtual reality simulation

BACKGROUND

Current training on managing an obstetric difficult airway crisis is likely inadequate, as real-life opportunities to practice are rare. Frequent simulation training sessions could be helpful but are resource intensive. Virtual reality (VR) simulation training may be a potential tool to complement existing simulation curricula.

METHODS

In this pilot qualitative study, a VR simulation scenario of an obstetric airway crisis was designed to test the decision-making of novice learners rotating through obstetric anesthesia training. Individual interviews were conducted pre-VR to assess learning needs and post-VR to assess perspectives on utilizing the VR teaching tool. The interviews were transcribed and thematically analyzed.

RESULTS

Twenty-one residents were recruited and participated in the study. Analysis of pre-VR interviews identified three major themes, including gaps in the current curriculum, lack of confidence in managing obstetric difficult airway crises, and recognition that simulation is resource intensive. Post-VR interview themes revealed that VR could be helpful in learning decision-making under stress. Suggested improvements included better video and audio quality, and adding haptic feedback and potential multiplayer features in the future.

CONCLUSION

We identified the advantages of VR simulation and its potential as an intervention to address gaps in our curriculum. Areas of improvement were identified for more effective future implementation.

Comparison of Peyton's Four-Step Approach With the Conventional Bedside Technique in Teaching Clinical Examination Skills to Medical Students

BACKGROUND

 Conventional bedside teaching (CBT) is an integral and classical method for imparting clinical skills to undergraduates in medical schools. It is a traditionally successful approach, especially when it comes to imparting patient-doctor relationship skills and knowledge on clinical management. Peyton's four-step approach (PFSA) is one of the newer structured instructional approaches for teaching-learning, especially for imparting procedural and complex psychomotor skills. The present study compares the application of PFSA in teaching complex systemic examination skills to the CBT technique in teaching the same skill to MBBS students. The impact of the acquisition of this examination skill was assessed statistically to compare PFSA and CBT methodologies.

METHODOLOGY

 The target population was MBBS (Bachelor of Medicine and Bachelor of Surgery) students; for this study, the phase II MBBS students were considered as the study population since they were relatively naïve to clinical bedside examination skills. Students were allotted groups and they were taught clinical skills through CBT and PFSA separately. Using the OpenEpi toolkit Version 3 open-source sample size calculator for comparing two means, the sample size was 30 students in each group. The students were assessed for their competency and were also made to fill out a feedback questionnaire to compare the two methods of education dispensing.  Results: The results of this study showed that PFSA is definitely suitable for teaching clinical examination skills. The acquisition of skills was found non-inferior to CBT while the retention of these skills was found to be equally good or even superior with PFSA than with CBT.  Conclusion: PFSA has already been proven to be a good teaching method for the acquisition of complex procedural skills. This study expands the role of PFSA in teaching clinical bedside examination skills to medical students. Further large-scale studies may clarify the learning impact and outcomes of PFSA in clinical bedside teaching.

Enhancing Anatomy Education Throu€gh Flipped Classroom and Adaptive Learning A Pilot Project on Liver Anatomy

OBJECTIVES

Anatomy education plays a critical role in medical practice, and the level of anatomical knowledge among students and physicians significantly impacts patient care. This article presents a pilot project aimed at exploring the effectiveness of the Area9's Rhapsode platform, an intelligent tutoring system that uses artificial intelligence (AI) to personalize learning and collect data on mastery acquisition.

METHODS

The study focused on liver anatomy (microscopic and macroscopic anatomy, embryology, clinical anatomy) and employed a flipped classroom approach, incorporating adaptive learning modules and an interactive in-class session. A total of 123 first-year medicine students (55 M/68F) participated to the study. Content and resources of the module were adaptable to various digital devices. Statistics were compiled based, on the one hand, on the measurement of mastery for every single learning objective provided automatically by the platform via the student interactions with the system probes (questions); on the other hand, metacognition data were worked out by crossing mastery data with the self-awareness declared in every question and learning resource by each learner.

RESULTS AND CONCLUSIONS

At the outset of the study, students displayed a 18.11% level of conscious incompetence and a 19.43% level of unconscious incompetence. Additionally, 50.86% of students demonstrated conscious competence. By the conclusion of the learning module, the level of conscious incompetence had decreased to 1.87%, and 98.73% of students exhibited conscious mastery of the materials. The results demonstrated improved learning quality, positive repurposing of study time, enhanced metacognitive awareness among students, with most students demonstrating conscious mastery of the materials and a clear understanding of their level of competence. This approach, by providing valuable insights into the potential of AI-based adaptive learning systems in anatomy education, could address the challenges posed by limited teaching hours, shortage of anatomist, and the need for individualized instruction.

Development of complex pedagogical competencies and reflexivity in clinical teachers via distance learning: a mixed methods study

Clinical reasoning is the cornerstone to healthcare practice and teaching it appropriately is of utmost importance. Yet there is little formal training for clinical supervisors in supervising this reasoning process. Distance education provides interesting opportunities for continuous professional development of healthcare professionals. This mixed methods study aimed at gaining in-depth understanding about whether and how clinical teachers can develop complex pedagogical competencies through participation in a Massive Open Online Course on the supervision of clinical reasoning (MOOC SCR). Participants self-assed their clinical supervision skills before and after partaking in the MOOC SCR through the Maastricht Clinical Teachers Questionnaire. Item scores and the distribution of response proportions before and after participation were compared using paired t-tests and McNemar's tests respectively. In parallel, the evolution of a subset of MOOC participants' pedagogical practice and posture was explored via semi-structured interviews throughout and beyond their MOOC participation using simulated and personal situational recalls. The verbatim were analysed with standard thematic analysis. Quantitative and qualitative findings converged and their integration demonstrated that partaking in the MOOC SCR promoted the development of complex pedagogical competencies and reflexivity with the participants. This was quantitatively evidenced by significantly higher self-assessed supervision skills and corresponding attitudes after completing the MOOC. The qualitative data provided rich descriptions of how this progression in pedagogical practice and posture occurred in the field and how it was shaped by participants' interaction with the MOOC's content and their motivations to progress. Our findings provide evidence for the development of pedagogical skills and corresponding attitudes for the supervision of clinical reasoning through participation in the MOOC SCR and contribute to the literature body on the opportunities that distance learning provides for the development of pedagogical competencies. The extent to which the pedagogical underpinnings of the MOOC contributed to these developments remains to be determined.

A suggestive approach for assessing item quality, usability and validity of Automatic Item Generation

Automatic Item Generation (AIG) refers to the process of using cognitive models to generate test items using computer modules. It is a new but rapidly evolving research area where cognitive and psychometric theory are combined into digital framework. However, assessment of the item quality, usability and validity of AIG relative to traditional item development methods lacks clarification. This paper takes a top-down strong theory approach to evaluate AIG in medical education. Two studies were conducted: Study I-participants with different levels of clinical knowledge and item writing experience developed medical test items both manually and through AIG. Both item types were compared in terms of quality and usability (efficiency and learnability); Study II-Automatically generated items were included in a summative exam in the content area of surgery. A psychometric analysis based on Item Response Theory inspected the validity and quality of the AIG-items. Items generated by AIG presented quality, evidences of validity and were adequate for testing student's knowledge. The time spent developing the contents for item generation (cognitive models) and the number of items generated did not vary considering the participants' item writing experience or clinical knowledge. AIG produces numerous high-quality items in a fast, economical and easy to learn process, even for inexperienced and without clinical training item writers. Medical schools may benefit from a substantial improvement in cost-efficiency in developing test items by using AIG. Item writing flaws can be significantly reduced thanks to the application of AIG's models, thus generating test items capable of accurately gauging students' knowledge.

Physical therapy student perception of self-reflection activities in a musculoskeletal course: A mixed-method study

BACKGROUND

Deliberate reflection is an effective method to aid in professional development. Most documented self-reflection activities (SRA) occur during clinical experiences. Literature on SRA within the didactic component of entry-level physical therapy education is lacking.

PURPOSE

The purpose of this mixed-method study was to evaluate student perception of in-class SRA.

METHODS

A convenience sample of 61 students in a DPT program was recruited. Students were enrolled in a musculoskeletal course and participated in six 10-minute SRA. At the end of the course, students completed a survey to assess perception.

RESULTS

Fifty-nine (97%) students completed the anonymous survey. Most reported they would continue SRA in future courses (92%, 55/60) and as a professional (95%, 57/60). Thematic analysis identified SRA promote the professional qualities of self-evaluation, confidence, and clinical excellence. Quiet time, self-evaluation, and sharing with others were identified as benefits of SRA. Curricular threading of SRA in entry-level physical therapy education was strongly suggested.

CONCLUSION

Self-reflection activities can be implemented into the didactic portion of entry-level physical therapy education and be perceived positively by students. Future research can assess the impact of SRA on clinical reasoning development during the didactic portion of entry-level physical therapy education.

Development of higher-order thinking skills in nursing students through online problem-based assessment

Background

The development of higher-order thinking skills (HOTS) in problem-based learning (PBL) is not confined to teaching and learning but extends to authentic assessment methods, similar to real-life situations. The assessments aligned to PBL attempt to eliminate the students' tendency towards memorisation. Rather, it instils and encourages their ability to analyse, interpret, synthesise, and evaluate knowledge and its sources.

Aim

The study had two primary aims: (1) to describe undergraduate nursing students' experiences of an online problem-based assessment (PBA), and (2) to explore how online PBA assessment contributed to the development of undergraduate student nurses' HOTS.

Setting

An urban-based South African higher education institution (HEI) in KwaZulu-Natal, Durban, South Africa.

Methods

A descriptive, exploratory qualitative approach was used. The target population was 4th-year psychiatric nursing students (N = 39) studying for the degree of Bachelor of Nursing at the preselected university, utilising two focus groups (n = 5, n = 7). Data were analysed through content analysis using the clinical reasoning model as a framework.

Results

Three categories (trigger problem, re-visioning the cues, treatment direction) and seven sub-categories (trigger problem posing, early cue identification, cue interpretation and clustering, focussed cue investigation, information processing and interpretation, reprioritise hypotheses, and diverse intervention[s]) emerged.

Conclusion

Psychiatry, Nursing and Midwifery practices require a practitioner skilled in HOTS to provide quality, efficient and cost-effective patient care.

Contribution

The findings in this study can benefit nursing education, particularly learning interruptions in HEIs.

Assessing clinical reasoning in the OSCE: pilot-testing a novel oral debrief exercise

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.

Case Report-Driven Medical Education in Rural Family Medicine Education: A Thematic Analysis

Case-based education (CBE) is a teaching method in which learners work on real-life cases to learn and apply concepts and skills they have been taught. Case report-driven medical education using the CBE framework can effectively facilitate student and resident learning, and entice them to become involved in actual clinical practice. Specific case report-driven medical education methods and learning outcomes are not clarified. This study aimed to clarify the specific learning processes and outcomes of case report-driven medical education in rural community-based medical education. Using a qualitative design based on a thematic analysis approach, data were collected through semi-structured interviews. The study participants were medical students and residents in training at a rural Japanese community hospital. Fifty-one case reports were completed and published in Cureus from April 2021 to March 2023. Participants learned about various difficulties related to volatility, uncertainty, complexity, and ambiguity (VUCA) in the medical care of various older patients, which increased their interest in family medicine. They appreciated the importance of case reports in academic careers and how their responsibilities as researchers increase with collaboration. Case report-driven medical education in community hospitals can drive medical students' and junior residents' learning regarding family medicine in the VUCA world.

Clinical Reasoning Curricula in Preclinical Undergraduate Medical Education: A Scoping Review

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.

Cognitive perspectives on maintaining physicians' medical expertise: II. Acquiring, maintaining, and updating cognitive skills

Over the course of training, physicians develop significant knowledge and expertise. We review dual-process theory, the dominant theory in explaining medical decision making: physicians use both heuristics from accumulated experience (System 1) and logical deduction (System 2). We then discuss how the accumulation of System 1 clinical experience can have both positive effects (e.g., quick and accurate pattern recognition) and negative ones (e.g., gaps and biases in knowledge from physicians' idiosyncratic clinical experience). These idiosyncrasies, biases, and knowledge gaps indicate a need for individuals to engage in appropriate training and study to keep these cognitive skills current lest they decline over time. Indeed, we review converging evidence that physicians further out from training tend to perform worse on tests of medical knowledge and provide poorer patient care. This may reflect a variety of factors, such as specialization of a physician's practice, but is likely to stem at least in part from cognitive factors. Acquired knowledge or skills gained may not always be readily accessible to physicians for a number of reasons, including an absence of study, cognitive changes with age, and the presence of other similar knowledge or skills that compete in what is brought to mind. Lastly, we discuss the cognitive challenges of keeping up with standards of care that continuously evolve over time.

Implementation of three knowledge-oriented instructional strategies to teach clinical reasoning: Self-explanation, a concept mapping exercise, and deliberate reflection: AMEE Guide No. 150

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.

Do malpractice claim clinical case vignettes enhance diagnostic accuracy and acceptance in clinical reasoning education during GP training?

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.

Educators' perspectives of adopting virtual patient online learning tools to teach clinical reasoning in medical schools: a qualitative study

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.

Promoting medical student's clinical reasoning during COVID-19 pandemic

PURPOSE

The development of students' clinical reasoning skills should be a consideration in the design of instruction and evaluation in medical education. In response to the coronavirus disease 2019 (COVID-19) pandemic, several changes in the medical curriculum have been implemented in promoting clinical reasoning. This study aims to explore medical students' perceptions and experiences with the clinical reasoning curriculum during the COVID-19 pandemic and determine their skills development.

METHODS

The study used a mixed-method design with a concurrent approach. A cross-sectional study was conducted to compare and examine the relationship between the outcomes of the structured oral examination (SOE) and the Diagnostic Thinking Inventory (DTI). Then, the qualitative method was used. A focus group discussion using a semi-structured interview guide with open-ended questions was conducted, then the verbatim transcript was subjected to thematic analysis.

RESULTS

There is an increase in SOE and DTI scores between second-year to fourth-year students. The diagnostic thinking domains and SOE are significantly correlated (r=0.302, 0.313, and 0.241 with p<0.05). The three primary themes from the qualitative analysis are perceptions regarding clinical reasoning, clinical reasoning activities, and the learning component.

CONCLUSION

Even if students are still studying throughout the COVID-19 pandemic, their clinical reasoning skills can improve. The clinical reasoning and diagnostic thinking skills of medical students increase as the length of the school year increases. Online case-based learning and assessment support the development of clinical reasoning skills. The skills are supported in their development by positive attitudes toward faculty, peers, case type, and prior knowledge.

Documentation as composing: how medical students and residents use writing to think and learn

Some educators have described clinical documentation as "scut". Research in medicine has focused on documentation's communicative value and not its function in learning. With time being an important commodity and electronic health records changing how we document, understanding the learning value of documentation is essential. The purpose of this study was to explore how trainee composing practices shape learning. Qualitative methods employing Rhetorical Genre Theory were used to explore clinical documentation practices among medical trainees. Data collection and analysis occurred in iterative cycles. Data included field notes and field interviews from 110 h of observing junior trainees and senior internal medicine residents participating in patient admission and follow-up visits. Analysis was focused on Paré and Smart's framework for studying documentation as composing. From a composing lens, documentation plays a vital role in learning in clinical settings. Junior trainees were observed to be reliant on using writing to support their thinking around patient care. Before patient encounters, writing helped trainees focus on what was already known and develop a preliminary understanding of the patient's problem(s). After encounters, writing helped trainees synthesize the data and develop an assessment and plan. Before and after the encounter, through writing, trainees also identified knowledge and data collection gaps. Our findings highlight clinical documentation as more than a communication task. Rather, the writing process itself appeared to play a pivotal role in supporting thinking. While some have proposed strategies for reducing trainee involvement, we argue that writing can be time well spent.

Do clinical interview transcripts generated by speech recognition software improve clinical reasoning performance in mock patient encounters? A prospective observational study

BACKGROUND

To investigate whether speech recognition software for generating interview transcripts can provide more specific and precise feedback for evaluating medical interviews.

METHODS

The effects of the two feedback methods on student performance in medical interviews were compared using a prospective observational trial. Seventy-nine medical students in a clinical clerkship were assigned to receive either speech-recognition feedback (n = 39; SRS feedback group) or voice-recording feedback (n = 40; IC recorder feedback group). All students' medical interviewing skills during mock patient encounters were assessed twice, first using a mini-clinical evaluation exercise (mini-CEX) and then a checklist. Medical students then made the most appropriate diagnoses based on medical interviews. The diagnostic accuracy, mini-CEX, and checklist scores of the two groups were compared.

RESULTS

According to the study results, the mean diagnostic accuracy rate (SRS feedback group:1st mock 51.3%, 2nd mock 89.7%; IC recorder feedback group, 57.5%-67.5%; F(1, 77) = 4.0; p = 0.049), mini-CEX scores for overall clinical competence (SRS feedback group: 1st mock 5.2 ± 1.1, 2nd mock 7.4 ± 0.9; IC recorder feedback group: 1st mock 5.6 ± 1.4, 2nd mock 6.1 ± 1.2; F(1, 77) = 35.7; p < 0.001), and checklist scores for clinical performance (SRS feedback group: 1st mock 12.2 ± 2.4, 2nd mock 16.1 ± 1.7; IC recorder feedback group: 1st mock 13.1 ± 2.5, 2nd mock 13.8 ± 2.6; F(1, 77) = 26.1; p < 0.001) were higher with speech recognition-based feedback.

CONCLUSIONS

Speech-recognition-based feedback leads to higher diagnostic accuracy rates and higher mini-CEX and checklist scores.

TRIAL REGISTRATION

This study was registered in the Japan Registry of Clinical Trials on June 14, 2022. Due to our misunderstanding of the trial registration requirements, we registered the trial retrospectively. This study was registered in the Japan Registry of Clinical Trials on 7/7/2022 (Clinical trial registration number: jRCT1030220188).

"Fit for the finals" - project report on a telemedical training with simulated patients, peers, and assessors for the licensing exam

Background

Undergraduate medical students take the licensing exam (M3) as a two-day oral-practical examination. The main requirements are to demonstrate history taking skills and coherent case presentations. The aim of this project was to establish a training in which students can test their communication skills during history taking and their clinical reasoning skills in focused case presentations.

Methods

In the newly developed training, final-year students took four telemedical histories in the role of physicians from simulated patients (SP). They received further findings for two SPs and presented these in a handover, in which they also received a handover of two SPs which they had not seen themselves. Each student presented one of the two received SPs in a case discussion with a senior physician. Feedback was given to the participants on their communication and interpersonal skills by the SPs with the ComCare questionnaire and on the case presentation by the senior physician. Sixty-two students from the universities of Hamburg and Freiburg in their final year participated in September 2022 and evaluated the training.

Results

Participants felt that the training was very appropriate for exam preparation. The SPs' feedback on communication and the senior physician's feedback on clinical reasoning skills received the highest ratings in importance to the students. Participants highly valued the practice opportunity for structured history taking and case presentation and would like to have more such opportunities in the curriculum.

Conclusion

Essential elements of the medical licensing exam can be represented, including feedback, in this telemedical training and it can be offered independent of location.

Peer Role-Play Simulation: A Valuable Alternative to Bedside Teaching During the COVID-19 Pandemic

Purpose

The COVID-19 pandemic dramatically affected every aspect of life worldwide. Contact restrictions and social distancing during the epidemic has led to the suspension of bedside teaching (BST) and shifting to online didactic teaching and other methods of active learning. We implemented peer role-play simulation (PRPS) during the pandemic to compensate for the suspended BST. This study aims to explore the effectiveness of PRPS in developing the students' verbal communication, empathy and clinical reasoning skills compared to BST.

Methods

This is a cross-sectional observational study conducted in Jazan University faculty of medicine with the study sample including all medical students enrolled in 5th and 6th year during the academic year 2020-21. Data collection involved using a web-based validated questionnaire.

Results

Most of the students (84.1%) rated bedside teaching (BST) as extremely beneficial or beneficial in developing verbal communication skills compared to 73.3% for peer role-play simulation (PRPS). A similar pattern was found in empathy skills development with 84.1% for bedside compared to 72.2% for PRPS. The pattern is reversed with the development of clinical reasoning skills with 77.7% rating BST as beneficial or extremely beneficial compared to 81.2% for PRPS.

Conclusion

Overall, peer role-play is generally a valuable and trustworthy method in the absence of bedside teaching for enhancing clinical reasoning skills of medical students during the COVID-19 pandemic from students' perspective. It is less efficient than bedside teaching in enhancing communication skills. It cannot wholly replace bedside teaching, although it can be used reliably for that purpose in exceptional circumstances when bedside teaching cannot be implemented.

Learning deliberate reflection in medical diagnosis: does learning-by-teaching help?

Deliberate reflection has been found to foster diagnostic accuracy on complex cases or under circumstances that tend to induce cognitive bias. However, it is unclear whether the procedure can also be learned and thereby autonomously applied when diagnosing future cases without instructions to reflect. We investigated whether general practice residents would learn the deliberate reflection procedure through 'learning-by-teaching' and apply it to diagnose new cases. The study was a two-phase experiment. In the learning phase, 56 general-practice residents were randomly assigned to one of two conditions. They either (1) studied examples of deliberate reflection and then explained the procedure to a fictitious peer on video; or (2) solved cases without reflection (control). In the test phase, one to three weeks later, all participants diagnosed new cases while thinking aloud. The analysis of the test phase showed no significant differences between the conditions on any of the outcome measures (diagnostic accuracy, p = .263; time to diagnose, p = .598; mental effort ratings, p = .544; confidence ratings, p = .710; proportion of contradiction units (i.e. measure of deliberate reflection), p = .544). In contrast to findings on learning-by-teaching from other domains, teaching deliberate reflection to a fictitious peer, did not increase reflective reasoning when diagnosing future cases. Potential explanations that future research might address are that either residents in the experimental condition did not apply the learned deliberate reflection procedure in the test phase, or residents in the control condition also engaged in reflection.

Prueba de concordancia de guiones para entrenar el razonamiento clínico en estudiantes de fonoaudiología

La prueba de concordancia de guiones (PCG) ha sido utilizada en el entrenamiento y evaluación del razonamiento clínico (RC) como una estrategia innovadora en la formación de profesionales. Sin embargo, no se dispone de evidencia de su aplicación en el pregrado de fonoaudiología. El objetivo de esta investigación fue analizar el desempeño y la percepción de estudiantes de fonoaudiología con respecto al uso de scripts. Se diseñó un piloto pre-experimental y multicéntrico, complementado con tres grupos focales. Las variables cuantitativas continuas fueron resumidas a través de medias y desviación estándar. La comparación entre grupos se ejecutó con Anova one way y la prueba post hoc de Bonferroni, considerando un nivel de significancia p<.05. La fase cualitativa incorporó un análisis de contenido mediante la codificación abierta de textos y la identificación e interpretación de familias de significado emergentes. El rendimiento promedio de los estudiantes fue de 4.03 (DS= 0.35), observándose un incremento en el rendimiento de RC durante el semestre (p= 0.03). La percepción de los estudiantes resulto positiva y se identificó cuatro familias de significado relacionadas con: razonamiento clínico, oportunidades de mejora implementación de la estrategia y retroalimentación docente. A modo de conclusión, la incorporación de scripts en estudiantes de pregrado de fonoaudiología es factible, incrementa el rendimiento y apoya el desarrollo del RC.

Clinical Reasoning Curricula in Health Professions Education: A Scoping Review

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.