Evaluation of the effect of a new clinical reasoning curriculum in a pre-clerkship clinical skills course (original) (raw)
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Perspectives on Medical Education
Introduction Clinical reasoning is often not explicitly taught to novice medical students. Pre-clerkship clinical skills courses are an ideal venue to teach the clinical reasoning process. The aim of the study was to evaluate the impact of a preclinical clinical reasoning curriculum through an end-of-semester objective structured clinical examination. Methods This study was conducted through our longitudinal clinical skills course. Second year medical (M2) students who received the clinical reasoning curriculum in 2018 formed the study cohort. M2 students from the previous year, who did not have the clinical reasoning curriculum, formed the comparison cohort. Several modalities were used to teach clinical reasoning including whole case approach, serial cue approach, self-explanation of pathophysiological mechanisms and comparison of closely related diagnoses. The students interviewed a standardized patient and documented the history along with three likely diagnoses. Results Student...
BMC Medical Education
Purpose Diagnostic errors are a large burden on patient safety and improving clinical reasoning (CR) education could contribute to reducing these errors. To this end, calls have been made to implement CR training as early as the first year of medical school. However, much is still unknown about pre-clerkship students’ reasoning processes. The current study aimed to observe how pre-clerkship students use clinical information during the diagnostic process. Methods In a prospective observational study, pre-clerkship medical students completed 10–11 self-directed online simulated CR diagnostic cases. CR skills assessed included: creation of the differential diagnosis (Ddx), diagnostic justification (DxJ), ordering investigations, and identifying the most probable diagnosis. Student performances were compared to expert-created scorecards and students received detailed individualized formative feedback for every case. Results 121 of 133 (91%) first- and second-year medical students consen...
Medical Teacher
Introduction: Effective clinical reasoning is required for safe patient care. Students and postgraduate trainees largely learn the knowledge, skills and behaviours required for effective clinical reasoning implicitly, through experience and apprenticeship. There is a growing consensus that medical schools should teach clinical reasoning in a way that is explicitly integrated into courses throughout each year, adopting a systematic approach consistent with current evidence. However, the clinical reasoning literature is 'fragmented' and can be difficult for medical educators to access. The purpose of this paper is to provide practical recommendations that will be of use to all medical schools. Methods: Members of the UK Clinical Reasoning in Medical Education group (CReME) met to discuss what clinical reasoning-specific teaching should be delivered by medical schools (what to teach). A literature review was conducted to identify what teaching strategies are successful in improving clinical reasoning ability among medical students (how to teach). A consensus statement was then produced based on the agreed ideas and the literature review, discussed by members of the consensus statement group, then edited and agreed by the authors. Results: The group identified 30 consensus ideas that were grouped into five domains: (1) clinical reasoning concepts, (2) history and physical examination, (3) choosing and interpreting diagnostic tests, (4) problem identification and management, and (5) shared decision making. The literature review demonstrated a lack of effectiveness for teaching the general thinking processes involved in clinical reasoning, whereas specific teaching strategies aimed at building knowledge and understanding led to improvements. These strategies are synthesised and described. Conclusion: What is taught, how it is taught, and when it is taught can facilitate clinical reasoning development more effectively through purposeful curriculum design and medical schools should consider implementing a formal clinical reasoning curriculum that is horizontally and vertically integrated throughout the programme.
Nigerian journal of Paediatrics, 2020
Introduction: Developing the skills of clinical reasoning is a tedious process, especially for the novice learner and requires practice. The clinical reasoning skill is a cognitive process of systematic clinical decision making needed to reduce diagnostic errors. A clinical reasoning tool for diagnosis using the Bloom's tax-onomy of critical thinking has been in use in the Paediatrics Department of the University of Port Harcourt. However, little is known about the difficulties encountered by trainees (medical students and early career doctors) while using the tool during daily clinical clerkship. We aimed to determine aspects of the clinical reasoning process trainees find difficult and ways to make this easier. Methods: A well-structured, pre-tested questionnaire was administered to 67 medical undergraduates and 99 early career medical doctors which assessed responses to the definition of clinical reasoning , matching Bloom's taxon-omy hierarchy with steps in clinical reasoning, functional and structural abnormalities and attitudes towards the use of the clinical reasoning tool. The Likert 5 point scale tool was used to assess attitudes and practice difficulties during the use of the tool. The differences in responses were tested for significance using Stu-dent's T test, and Chi squared test, with p values <0.05 as significant. Results: Of the 166 respondents analysed, 103 (62%) got the correct definition of clinical reasoning with early career doctors having a higher proportion of correct respondents , χ2 = 4.59, p = 0.032. Specific areas of difficulties identified were with making clinical diagnosis in 50 (30.1%) and patho-logic diagnosis (es) in 38 (22.9%). Ninety-nine (59.6%) responded that clinical reasoning was time consuming and 42 (25.3%) thought it was difficult to practice in a busy clinic. One hundred and six (64.1%) respondents suggested a view of basic clinical studies before starting clinical practice in order to improve clinical reasoning. Conclusion/Recommendation: Making clinical diagnosis is difficult for the clinical trainee while using the clinical reasoning tool, therefore the clinical teacher should help trainees move from one cognitive level to the next until the trainee can create logical conclusions from information gathered following clerking.
A developmental assessment of clinical reasoning in preclinical medical education
Medical Education Online
Background: Clinical reasoning is an essential skill to be learned during medical education. A developmental framework for the assessment and measurement of this skill has not yet been described in the literature. Objective: The authors describe the creation and pilot implementation of a rubric designed to assess the development of clinical reasoning skills in pre-clinical medical education. Design: The multi-disciplinary course team used Backwards Design to develop course goals, objectives, and assessment for a new Clinical Reasoning Course. The team focused on behaviors that students were expected to demonstrate, identifying each as a 'desired result' element and aligning these with three levels of performance: emerging, acquiring, and mastering. Results: The first draft of the rubric was reviewed and piloted by faculty using sample student entries; this provided feedback on ease of use and appropriateness. After the first semester, the course team evaluated whether the rubric distinguished between different levels of student performance in each competency. A systematic approach based on descriptive analysis of mid-and end of semester assessments of student performance revealed that from mid-to end-of-semester, over half the students received higher competency scores at semester end. Conclusion: The assessment rubric allowed students in the early stages of clinical reasoning development to understand their trajectory and provided faculty a framework from which to give meaningful feedback. The multi-disciplinary background of the course team supported a systematic and robust course and assessment design process. The authors strongly encourage other colleges to support the use of collaborative and multi-disciplinary course teams.
Teaching Clinical Reasoning Among Undergraduate Medical Students: a Crossover Randomised Trial
Background: clinical reasoning is a mandatory competency in medical curriculum. Many techniques have been reported in order to teach it. The authors focused on 2 student-centered techniques, SNAPPS and collaborative critical reasoning learning (CCRL) technique, and compared their efficiency in order to improve the clinical reasoning competencies of third year medical education students.Methods: the authors performed a prospective randomised, controlled, non blinded crossover trial including year-3 undergraduate medical students. Judgement criteria consisted in the scores attributed to a structured summary performed by the students after each session. Besides, a satisfaction likert-scale questionnaire was fulfilled by the students. Statistical analysis was performed using SPSS software (version 20.0).Results: 72 students were included with a mean age of 21 years. The mean scores of CCRL reached 4.62 versus 4.99 for SNAPPS. No significant statistical difference was observed between th...
Teaching and assessing clinical reasoning skills
Indian Pediatrics, 2015
Clinical reasoning is a core competency expected to be acquired by all clinicians. It is the ability to integrate and apply different types of knowledge, weigh evidence critically and reflect upon the process used to arrive at a diagnosis. Problems with clinical reasoning often occur because of inadequate knowledge, flaws in data gathering and improper approach to information processing. Some of the educational strategies which can be used to encourage acquisition of clinical reasoning skills are: exposure to a wide variety of clinical cases, activation of previous knowledge, development of illness scripts, sharing expert strategies to arrive at a diagnosis, forcing students to prioritize differential diagnoses; and encouraging reflection, metacognition, deliberate practice and availability of formative feedback. Assessment of clinical reasoning abilities should be done throughout the training course in diverse settings. Use of scenario based multiple choice questions, key feature test and script concordance test are some ways of theoretically assessing clinical reasoning ability. In the clinical setting, these skills can be tested in most forms of workplace based assessment. We recommend that clinical reasoning must be taught at all levels of medical training as it improves clinician performance and reduces cognitive errors.