How clinical reasoning is taught and learned: Cultural perspectives from the University of Melbourne and Universitas Indonesia

Exploring context and culture in clinical reasoning medical education: A qualitative exploratory study

BACKGROUND

Clinical reasoning processes are complex and interwoven with culture and context. While these relationships have been explored to understand the outcomes of clinical reasoning, there has been little exploration of how to integrate these relationships when teaching and learning clinical reasoning.

METHODS

Using semi-structured interviews, this research explored the role of context and culture in clinical reasoning medical education. Participants were clinical teachers recruited from across Northern Ontario. The data were analysed independently by two reviewers using both thematic analysis and critical discourse analysis, and peer reviewed by a third researcher.

RESULTS

The role of context and culture is inherent to the personal, professional and pedagogical aspects of clinical reasoning, especially when teaching about the complexities of Northern Ontario. The major themes that came through were: 1) teaching and learning clinical reasoning needs reflexivity, 2) developing clinical reasoning skills needs time and 3) clinical reasoning pedagogy should acknowledge and encompass practice variation and patient diversity.

CONCLUSION

Teaching clinical reasoning in Northern Ontario involves being aware of the complexities that are inherent in interacting with patients and communities. Through personal, professional and pedagogical models, the students and teachers can address the complexities of cultural and contextual clinical reasoning.

Exploring clinical reasoning in child language assessment through decoloniality

PURPOSE

Clinical reasoning has been taught, practised, and researched under Western epistemologies, which have been fallible in addressing the complexity of clinical reasoning within Indigenous cultures and societies. We explored how speech-language pathologists in Sri Lanka negotiate and value Indigenous and Western perspectives in clinical reasoning within a decolonial framework.

METHOD

This study used participatory research methodology within the decolonised qualitative research paradigm to produce data collaboratively with eight Sri Lankan speech-language pathologists. Oral history narratives and object-based textual reflections generated the necessary data for the study. Systematic visual-textual analysis and reflexive thematic analysis were carried out iteratively, and the data analysis and interpretation were undertaken collaboratively with the participants.

RESULT

We generated four key themes about professional education, individuality in practice, holistic thinking, and balancing interests and priorities. The results demonstrate that social, political, and economic forces impact practitioners' clinical reasoning.

CONCLUSION

Practising science in its original form within Indigenous contexts is challenging. Colonial roots and imperialism impact the delivery of appropriate services in socially and politically marginalised communities. Practitioners' self-awareness about authentic identities and practical wisdom can develop culturally relevant knowledge for equitable practice.

Challenges and opportunities in cultivating medical students' competencies: Participatory action research from a hierarchical cultural setting

BACKGROUNDS

Research concerning student-centered learning (SCL) recommends a comprehensive assessment of medical students' competencies including their personal and professional characters. Accordingly, nurturing future doctors should be in a continuous mentorship program. However, in a hierarchical culture, communication is one-way with limited feedback and reflection. We aimed to explore challenges and opportunities for SCL implementation in medical schools in this cultural setting necessary for a globally interdependent world.

METHODS

Two cycles of participatory action research (PAR) were conducted, involving medical students and teachers in Indonesia. A national conference on SCL principles was conducted between the cycles, also the SCL modules were developed for each institution and feedback was shared. Twelve focus group discussions were conducted (before and after the module development), with 37 medical teachers and 48 medical students from 7 faculties of medicine across Indonesia at various levels accreditation. Following verbatim transcriptions, a thematic analysis was conducted.

RESULTS AND DISCUSSIONS

In cycle 1 PAR, some challenges in implementing SCL were identified: lack of constructive feedback, overloaded content, summative-based assessment, hierarchical culture environment, and teachers' dilemma of committed time between patient-care and education. In cycle 2, several opportunities to approach the SCL were proposed: a faculty development program on mentorship, students' reflection guides and training, a more longitudinal assessment system, also a more supportive government policy on the human resources system.

CONCLUSIONS

The main challenge of fostering student-centered learning revealed in this study was a teacher-centered learning tendency in the medical curriculum. The weighting towards summative assessment and the national educational policy drive the curriculum like a 'domino effect', away from the expected student-centered learning principles. However, using a participative method, students and teachers could identify opportunities and articulate their educational needs, i.e., a partnership-mentorship program, as a significant step toward student-centered learning in this cultural context.

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.

Understanding and Embracing Culture in International Faculty Development

Introduction

Research on international faculty development programs (IFDPs) has demonstrated many positive outcomes; however, participants' cultural backgrounds, beliefs, and behaviors have often been overlooked in these investigations. The goal of this study was to explore the influences of culture on teaching and learning in an IFDP.

Method

Using interpretive description as the qualitative methodology, the authors conducted semi-structured interviews with 15 Fellows and 5 Faculty of a US-based IFDP. The authors iteratively performed a constant comparative analysis to identify similar patterns and themes. Transformative Learning Theory informed the analysis and interpretation of the results.

Results

This research identified three themes related to the influences of culture on teaching and learning. First, cultural differences were not seen as a barrier to learning; instead, they tended to act as a bridge to cultural awareness and network building. Second, some cultural differences produced a sense of unease and uncertainty, which led to adaptations, modifications, or mediation. Third, context mattered, as participants' perspectives were also influenced by the program culture and their professional backgrounds and experiences.

Discussion

The cultural diversity of health professions educators in an IFDP did not impede learning. A commitment to future action, together with the ability to reflect critically and engage in dialectical discourse, enabled participants to find constructive solutions to subtle challenges. Implications for faculty development included the value of enhanced cultural awareness and respect, explicit communication about norms and expectations, and building on shared professional goals and experiences.

A comparative study of Chinese and American preservice teachers' intention to teach online based on the Theory of Planned Behavior

Online learning emerged as a solution to continue with teaching and learning during the Coronavirus (COVID-19) pandemic. Nonetheless, teaching online consumes considerable time and put pressure on teachers' daily lives. Thus, the internal mechanism of preservice teachers' intention to teach online is analyzed in this study. Specifically, this study analyzed preservice teachers' intention to teach online in China and America to illuminate the internal mechanism of teachers' intention to teach online in different cultural backgrounds. One hundred seventy-six Chinese preservice teachers and two hundred forty-one American preservice teachers participated in this study. The confirmatory factor analysis supported that the Intention to Teach Online Scale was reliable in three constructs: online teaching attitude, perceived control, and subjective norm. The result demonstrates that there is a significant difference between Chinese and American preservice teachers' intention to teach online in the online teaching attitude and perceived control. In addition, it is supported that there is a significant difference between the effects of Chinese and American preservice teachers' teaching attitude, perceived control, and subjective norm on their intention to teach online. Moreover, there is a difference in the relationships among Chinese and American teachers' online teaching attitudes, perceived control, and subjective norm. The preservice teachers' demographic features can be factors that caused this difference. Research and practice implications of this study are proposed.

Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum

OBJECTIVES

The acquisition of clinical reasoning (CR) skills is essential for future healthcare providers as they advance through their education. There is growing consensus that CR skills should be longitudinally integrated into undergraduate curriculum for acquisition/application of these skills. However, only a minority of schools reported having CR focused teaching sessions, citing a lack of curricular time and faculty expertise as the largest barriers. We describe the design and implementation of this theme and report the effects of its early introduction in Phase One as measured by the Diagnostic Thinking Inventory (DTI).

METHODS

The Carver College of Medicine developed and implemented a longitudinal four-year clinical reasoning theme (CRT) with a special emphasis on introducing concepts in the preclinical years (Phase One). Educational strategies used to implement the theme relied on following principles: 1) new skills are best acquired in context of application; 2) contextual learning stimulates transfer of knowledge; and 3) knowledge of pathophysiology is necessary but alone is not sufficient to develop CR skills. A patient-centered CR schema served as the framework for developing the theme. Specific focus areas, pedagogies and assessment strategies were established for each of the three phases.

RESULTS

The cohort with CRT demonstrated a significant increase in total DTI score after theme implementation compared to the cohort without.

CONCLUSIONS

A formal 4-year longitudinal CR theme is feasible, allowing for integration of pathophysiology, social determinants of health, and clinical skills. Early introduction of CR concepts as assessed by DTI showed improvement in student reasoning skills post-intervention.

Assessing clinical reasoning ability in fourth-year medical students via an integrative group history-taking with an individual reasoning activity

BACKGROUND

The most important factor in evaluating a physician's competence is strong clinical reasoning ability, leading to correct principal diagnoses. The process of clinical reasoning includes history taking, physical examinations, validating medical records, and determining a final diagnosis. In this study, we designed a teaching activity to evaluate the clinical reasoning competence of fourth-year medical students.

METHODS

We created five patient scenarios for our standardized patients, including hemoptysis, abdominal pain, fever, anemia, and chest pain. A group history-taking with individual reasoning principles was implemented to teach and evaluate students' abilities to take histories, document key information, and arrive at the most likely diagnosis. Residents were trained to act as teachers, and a post-study questionnaire was employed to evaluate the students' satisfaction with the training activity.

RESULTS

A total of 76 students, five teachers, and five standardized patients participated in this clinical reasoning training activity. The average history-taking score was 64%, the average key information number was 7, the average diagnosis number was 1.1, and the average correct diagnosis rate was 38%. Standardized patients presenting with abdominal pain (8.3%) and anemia (18.2%) had the lowest diagnosis rates. The scenario of anemia presented the most difficult challenge for students in history taking (3.5/5) and clinical reasoning (3.5/5). The abdominal pain scenario yielded even worse results (history taking: 2.9/5 and clinical reasoning 2.7/5). We found a correlation in the clinical reasoning process between the correct and incorrect most likely diagnosis groups (group history-taking score, p = 0.045; key information number, p = 0.009 and diagnosis number, p = 0.004). The post-study questionnaire results indicated significant satisfaction with the teaching program (4.7/5) and the quality of teacher feedback (4.9/5).

CONCLUSIONS

We concluded that the clinical reasoning skills of fourth-year medical students benefited from this training course, and the lower correction of the most likely diagnosis rate found with abdominal pain, anemia, and fever might be due to a system-based teaching modules in fourth-year medical students; cross-system remedial reasoning auxiliary training is recommended for fourth-year medical students in the future.

A cohort study for the development and validation of a reflective inventory to quantify diagnostic reasoning skills in optometry practice

BACKGROUND

Diagnostic reasoning is an essential skill for optometry practice and a vital part of the curriculum for optometry trainees but there is limited understanding of how diagnostic reasoning is performed in optometry or how this skill is best developed. A validated and reliable self-reflective inventory for diagnostic reasoning in optometry, would enable trainees and registered practitioners to benchmark their diagnostic reasoning skills, identify areas of strength and areas for improvement.

METHODS

A 41 item self-reflective inventory, the Diagnostic Thinking Inventory, used extensively in the medical field was adapted for use in optometry and called the Diagnostic Thinking Inventory for Optometry (DTI-O). The inventory measures two subdomains of diagnostic reasoning, flexibility in thinking and structured memory. Context based changes were made to the original inventory and assessed for face and content validity by a panel of experts. The inventory was administered to two groups, experienced (qualified) optometrists and second-year optometry students to establish validity and reliability of the self-reflective tool in optometry.

RESULTS

Exploratory Factor Analysis uncovered 13 domain specific items were measuring a single construct, diagnostic reasoning. One misfitting item was removed following Rasch analysis. Two unidimensional subdomains were confirmed in the remaining 12 items: Flexibility in Thinking (χ2 = 12.98, P = 0.37) and Structured Memory (χ2 = 8.74, P = 0.72). The 'Diagnostic Thinking Inventory for Optometry Short' (DTI-OS) tool was formed from these items with the total and subdomain scores exhibiting strong internal reliability; Total score C_α = 0.92. External reliability was established by test-retest methodology (ICC 0.92, 95% CI 0.83-0.96, P < .001) and stacked Rasch analysis (one-way ANOVA, F = 0.07, P = 0.80). Qualified optometrists scored significantly higher (P < .001) than students, demonstrating construct validity.

CONCLUSION

This study showed that the DTI-O and DTI-OS are valid and reliable self-reflective inventories to quantify diagnostic reasoning ability in optometry. With no other validated tool to measure this metacognitive skill underpinning diagnostic reasoning a self-reflective inventory could support the development of diagnostic reasoning in practitioners and guide curriculum design in optometry education.

Restructuring education activities for full online learning: findings from a qualitative study with Malaysian nursing students during Covid-19 pandemic

The COVID-19 pandemic and Movement Control Order have restricted learning activities from traditional face-to-face classrooms attendance shifted to full online learning in the student's environment. The present study is aimed to explore pertaining issues on full online learning among nursing students and offer a contingency solution. Nursing students from one Malaysian public institution were recruited. The sessions were conducted online via teleconference and were recorded. The data were analysed using thematic analysis with the assistance of QDA Miner Lite software. Twenty-one students participated, resulting in four focus group discussions and three in-depth interviews. Three themes with a total of ten sub-themes were generated: (i) Full online learning has ramifications on life (it is about life; blurred division on education life and personal life; non-conducive environment for learning; health and well-being; human is an adaptable being while the transition takes time), (ii) full online learning is a medium of teaching and learning delivery but with several concerns (the boon and bane of fully online learning; challenges associated with full online learning; coping strategy in handling full online learning), and (iii) Foundation in teaching and learning is the key (role of the educator; teaching and learning approaches; motivation and regulation). A model of practice for full online learning was developed, consisting of some modifications to create a conducive and healthy learning environment. This study embarks on a more structured and standard online learning practice for making the Internet of Things and Industrial Revolution 4.0 concept a contemporary and mainstream education practice.

A Meta-synthesis on Technology-Based Learning Among Healthcare Students in Southeast Asia

Healthcare education providers are eager to apply technologies in teaching and learning activities; however, students are the consumers in higher education, and their opinion and experience should be considered. We performed a meta-synthesis of qualitative studies to help inform our understanding of Southeast Asian healthcare students' perceptions and experience of technology-based teaching and learning in their education. Our search strategy located 1599 articles from a dozen electronic research databases. Articles were analyzed for quality using the Hawker's Evidence Appraisal Tool, and 23 qualitative studies were included in the final meta-synthesis. Technologies investigated largely involved online or blended learning, with fewer exploring virtual reality, simulations, telehealth, game-based learning, and videos. Three overarching themes were synthesized: (i) culture does matter in the implementation of technology-based learning; (ii) the values and limitations of technology used for learning; and (iii) technology is part of daily life and creates new challenges in education. Technology is an asset to enhance the learning experience, but educators must be aware of its limitations. Pre-coronavirus disease 2019 (COVID-19) studies were more focused on technology and product, and were optimistically reported, whereas COVID-19-spanning studies focused on life experience and paid more attention to reporting on the inherent challenges. The educational approaches, theories, cultural aspects, and availability of facilities all play a vital role in steering successful technology use in learning.

A scoping review of clinical reasoning research with Asian healthcare professionals

Clinical reasoning is the thought process that guides practice. Although a plethora of clinical reasoning studies in healthcare professionals exists, the majority appear to originate from Western cultures. A scoping review was undertaken to examine clinical reasoning related research across Asian cultures. PubMed, SciVerse Scopus, Web of Science and Airiti Library databases were searched. Inclusion criteria included full-text articles published in Asian countries (2007 to 2019). Search terms included clinical reasoning, thinking process, differential diagnosis, decision making, problem-based learning, critical thinking, healthcare profession, institution, medical students and nursing students. After applying exclusion criteria, n = 240 were included in the review. The number of publications increased in 2012 (from 5%, n = 13 in 2011 to 9%, n = 22) with a steady increase onwards to 12% (n = 29) in 2016. South Korea published the most articles (19%, n = 46) followed by Iran (17%, n = 41). Nurse Education Today published 11% of the articles (n = 26), followed by BMC Medical Education (5%, n = 13). Nursing and Medical students account for the largest population groups studied. Analysis of the articles resulted in seven themes: Evaluation of existing courses (30%, n = 73) being the most frequently identified theme. Only seven comparative articles showed cultural implications, but none provided direct evidence of the impact of culture on clinical reasoning. We illuminate the potential necessity of further research in clinical reasoning, specifically with a focus on how clinical reasoning is affected by national culture. A better understanding of current clinical reasoning research in Asian cultures may assist curricula developers in establishing a culturally appropriate learning environment.

Development and evaluation of clinical reasoning using 'think aloud' approach in pharmacy undergraduates - A mixed-methods study

Introduction

Given the widespread use of clinical reasoning (CR) in the healthcare practice, it is essential to inculcate the CR practice in undergraduate pharmacy education which can not only facilitate their clinical education and clinical rotations but can also help them become better clinical pharmacists. There is very limited CR employed in the pharmacy curriculum and practice in the Middle East countries. This study aimed to develop and evaluate CR practice in pharmacy undergraduates in one college of pharmacy in Saudi Arabia.

Methods

We employed a mixed-methods methodology that included two phases. In Phase I, students were introduced to CR practice ('think aloud' method) and given geriatric clinical cases which they used in two sessions together with a tutor. This was followed by the writing of SOAP notes using the tutor feedback and completion of a survey that included a self-reflection about their experience of using the CR method. Phase II included face-to-face semi-structured interviews involving selected students that were recruited via convenience sampling to further explore the issues identified in Phase I of the study.

Results

Of the 155 students who completed the survey (response rate 94%), the majority of them agreed that CR using the 'think aloud' method was useful in gathering (92%) and interpreting (95%) relevant patient information, identifying medication-related problems (95%), exploring therapeutic options for the problem(s) (93%) and formulating a treatment plan for the patient (90%). Qualitative data analysis of the 12 interviews was consistent with these findings. Furthermore, it provided an insight into the challenges faced by the students in applying this CR method.

Conclusions

Students found the practice of CR using the 'think aloud' method helpful in working through given cases and taking clinical decisions. This method can be widely employed in pharmacy education and practice.

Contextualising clinical reasoning within the clinical swallow evaluation: A scoping review and expert consultation

Background

This study explored the available literature on the phenomenon of clinical reasoning and described its influence on the clinical swallow evaluation. By exploring the relationship between clinical reasoning and the clinical swallow evaluation, it is possible to modernise the approach to dysphagia assessment.

Objectives

This study aimed to contextualise the available literature on clinical reasoning and the CSE to low-middle income contexts through the use of a scoping review and expert consultation.

Method

A scoping review was performed based on the PRISMA-ScR framework. The data was analysed using thematic analysis. Articles were considered if they discussed the clinical swallow evaluation and clinical reasoning, and were published in the last 49 years.

Results

Through rigorous electronic and manual searching, 12 articles were identified. This review made an argument for the value of clinical reasoning within the clinical swallow evaluation. The results of the study revealed three core themes related to the acquisition, variability and positive impact of clinical reasoning in the clinical swallow evaluation.

Conclusion

The results of this review showed that the clinical swallow evaluation is a complex process with significant levels of variability usually linked to the impact of context. This demonstrates that in order to deliver effective and relevant services, despite challenging conditions, healthcare practitioners must depend on clinical reasoning to make appropriate modifications to the assessment process that considers these salient factors.

The relationship between empathy and stress: a cross-sectional study among undergraduate medical students

PURPOSE

Empathy is critical for medical doctors, as it enables them to conduct good patient-centred care. Medical students are expected to learn this ability as part of their education and training.

METHODS

Using a cross-sectional design, the present study was conducted to identify whether the empathy levels of medical students are affected by their stress levels. A translated version of the Perceived Stress Scale-10 was used to measure the students' stress levels, while the Jefferson Scale of Physician Empathy was used to measure their empathy levels.

RESULTS

A total of 464 students from one medical school in Indonesia participated in the study. Stress levels among medical students peak in their first year of study and maintain a downward trend over the following years. The students' empathy levels increased during their first 3 years, declined significantly upon entering the first clinical year, and increased during the second clinical year. However, no correlations were found between stress level and empathy level.

CONCLUSION

These findings suggest that there may be other underlying factors that contribute to empathy decline among medical students upon entering their first clinical year. Further research should be conducted to identify these factors. The bounced-back of empathy level to a higher level in the second year highlights the importance of student adaptation in the clinical learning environment and the support system.

Learning global health: a pilot study of an online collaborative intercultural peer group activity involving medical students in Australia and Indonesia

BACKGROUND

There is limited research to inform effective pedagogies for teaching global health to undergraduate medical students. Theoretically, using a combination of teaching pedagogies typically used in 'international classrooms' may prove to be an effective way of learning global health. This pilot study aimed to explore the experiences of medical students in Australia and Indonesia who participated in a reciprocal intercultural participatory peer e-learning activity (RIPPLE) in global health.

METHODS

Seventy-one third year medical students (49 from Australia and 22 from Indonesia) from the University of Tasmania (Australia) and the University of Nusa Cendana (Indonesia) participated in the RIPPLE activity. Participants were randomly distributed into 11 intercultural 'virtual' groups. The groups collaborated online over two weeks to study a global health topic of their choice, and each group produced a structured research abstract. Pre- and post-RIPPLE questionnaires were used to capture students' experiences of the activity. Descriptive quantitative data were analysed with Microsoft Excel and qualitative data were thematically analysed.

RESULTS

Students' motivation to volunteer for this activity included: curiosity about the innovative approach to learning; wanting to expand knowledge of global health; hoping to build personal and professional relationships; and a desire to be part of an intercultural experience. Afer completing the RIPPLE program, participants reported on global health knowledge acquisition, the development of peer relationships, and insight into another culture. Barriers to achieving the learning outcomes associated with RIPPLE included problems with establishing consistent online communication, and effectively managing time to simultaneously complete RIPPLE and other curricula activities.

CONCLUSIONS

Medical students from both countries found benefits in working together in small virtual groups to complement existing teaching in global health. However, our pilot study demonstrated that while intercultural collaborative peer learning activities like RIPPLE are feasible, they require robust logistical support and an awareness of the need to manage curriculum alignment in ways that facilitate more effective student engagement.