Clinical reasoning and cognitive processes.

[Extract] Clinical reasoning may be defined as the cognitive processes involved in arriving at a diagnosis or treatment plan. It is central to effective medical practice, yet it remains elusive and continues to present a challenge to clinical teachers and learners. The antemortem misdiagnosis rate at autopsies and audits of adverse events in hospitals attest to the continuing importance of clinical reasoning, despite the introduction of guidelines and advances in technology. The level of quality and accuracy of the clinical reasoning that underlies diagnostic and management decisions is the difference between trainees and expert clinicians. The process of learning clinical reasoning may be assisted by using think aloud.

Introduction An objective of undergraduate medical education is to teach students how to think like physicians through a process called clinical reasoning. Currently, clerkship directors often feel that students enter their clinical years with a marginal comprehension of clinical reasoning concepts; instruction in this area could be improved. Although there have been previous educational studies assessing curricular interventions to improve the instruction of clinical reasoning, it is not yet known what happens at an individual level between an instructor and a small group of students in the teaching of clinical reasoning. This research will identify how clinical reasoning is being taught in a longitudinal clinical reasoning course. Methods The Introduction to Clinical Reasoning course is a 15-month-long case-based course held in the preclinical curriculum of the USU. Individual sessions involve small-group learning with approximately seven students per group. Throughout the academic year of 2018-2019, 10 of these sessions were videotaped and transcribed. All participants provided informed consent. A thematic analysis was performed using a constant comparative approach. Transcripts were analyzed until thematic sufficiency was reached. Results Over 300 pages of text were analyzed; new themes ceased to be identified after the eighth session. Topics included obstetrics, general pediatric issues, jaundice, and chest pain; these sessions were taught either by attendings, fellows, or fourth-year medical students with attending supervision. The thematic analysis revealed themes associated with clinical reasoning processes, themes associated with knowledge organization, and a theme associated with clinical reasoning in the military. The clinical reasoning process themes included problem list construction and refinement, differential diagnosis, naming and defending a leading diagnosis, and clinical reasoning heuristics. The knowledge organization themes included illness script development and refinement and semantic competence. The final theme was military relevant care. Conclusions In individual teaching sessions, preceptors emphasized problem lists, differential diagnoses, and leading diagnoses in a course designed to strengthen diagnostic reasoning in preclerkship medical students. The use of illness scripts was more often implicitly used rather than explicitly stated, and students used these sessions to use and apply new vocabularies related to a clinical presentation. Instruction in clinical reasoning could be improved by encouraging faculty to provide further context to their thinking, by encouraging the comparing and contrasting of illness scripts, and by using a shared vocabulary for clinical reasoning. Limitations of this study include that it was done in the context of a clinical reasoning course and that it was done at a military medical school, which may limit generalizability. Future studies could determine if faculty development could improve the frequency of references to the clinical reasoning processes that could improve student readiness for clerkship.

To explore the clinical reasoning process of experienced registered nurses during care planning and documentation of nursing in the electronic health records of residents in long-term dementia care. Clinical reasoning is an essential element in nursing practice. Registered nurses' clinical reasoning process during the documentation of nursing care in electronic health records has received little attention in nursing literature. Further research is needed to understand registered nurses' clinical reasoning, especially for care planning and documentation of dementia care due to its complexity and a large amount of information collected. A qualitative explorative design was used with a concurrent think-aloud technique. The transcribed verbalisations were analysed using protocol analysis with referring phrase, assertional and script analyses. Data were collected over ten months in 2019-2020 from 12 registered nurses in three nursing homes offering special dementia care. The COREQ checklist for qualitative studies was used. The nurses primarily focused on assessments and interventions during documentation. Most registered nurses used their experience and heuristics when reasoning about the residents' current health and well-being. They also used logical thinking or followed local practice rules when reasoning about planned or implemented interventions. The registered nurses moved back and forth among all the elements in the nursing process. They used a variety of clinical reasoning attributes during care planning and nursing documentation. The most used clinical reasoning attributes were information processing, cognition and inference. The most focused information was planned and implemented interventions. Knowledge of the clinical reasoning process of registered nurses during care planning and documentation should be used in developing electronic health record systems that support the workflow of registered nurses and enhance their ability to disseminate relevant information.

Formulating an appropriate working diagnosis and plausible differential diagnoses is the hallmark of good clinical practice. Clini­cal reasoning is defined as the cognitive process that leads to a diagnosis and the formulation of a diagnostic plan. The process of clinical reasoning is discussed in terms of analytic, nonanalytic, and dual-process theories. Nonanalytic processes are experiential, intuitive, and are often triggered automatically. Analytic processes are hypothetico-deductive, and they operate during unfamiliar or complex scenarios. Both process categories are at play in the dual-process theory of clinical reasoning, which is often associated with better diagnostic competence. Developers of medical education curricula, therefore, should use heuristic techniques that trigger dual-process clinical reasoning.

Learning by playing: A cross-sectional descriptive study of nursing students' experiences of learning clinical reasoning

BackgroundThe 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.MethodsWe 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.ResultsA 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).ConclusionsWe 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.

ABSTRACTIn the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

The objective of this review was to determine whether the use of Personal Digital Assistants (PDAs) would provide greater support in developing undergraduate nursing students' clinical reasoning, in comparison to more traditional resources such as textbooks. The search strategy sought to identify published data from five electronic databases: CINAHL, Medline, Cochrane Library, Meditext and Scopus. Unpublished literature was also sought in digital dissertations, conference proceedings, relevant scholarly websites and reference lists. All undergraduate nursing students were considered eligible for inclusion. Types of interventions considered for this review were inclusive of all forms of PDAs and traditional resources. The research setting of this systematic review reflects the diversity of nursing practice, and includes the classroom, clinical or simulated environment. The process of clinical reasoning was defined by four outcome measures; alterations in theoretical nursing knowledge, clinical skills, problem solving and reflection. Studies of potential significance to the review were assessed for methodological quality independently by two reviewers using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Authorship of the studies was not concealed from the two reviewers. From the nine studies assessed for quality, only data from four studies were included in the review. Four published studies were included in the systematic review of literature. The designs of the studies included a nonrandomised quasi-experimental design, case control study, comparative descriptive design and a pre test post test mixed method study. Four outcomes were identified by the four included studies. These outcomes addressed possible effects of PDA usage on undergraduate nursing students' practice of medication administration, self-efficacy, anticipation to exercise professional nursing judgment and clinical reasoning.This systematic review provides evidence that the use of PDAs is able to improve nursing students' self-efficacy and accuracy in clinical situations that require direct and context-free answers, such as medication administration, but is not as supportive as textbooks in assisting students to apply this knowledge critically in decision making and problem solving. The use of PDAs by undergraduate nursing students can improve students' confidence in the often stressful clinical environment. This bears significance in contemporary nursing education where undergraduates are failing to maximise the clinical experience because of insufficient support or guidance from busy clinicians or supervisory staff. From these findings, PDAs are also beneficial in improving the accuracy and efficiency of medication administration in nursing students. However, the application of the knowledge provided by PDAs is not supported to be used critically in its application to decision making and problem solving. Nursing students need to be educated in methods to develop critical analysis in order to use these resources effectively. This systematic review highlights the poor quantity of literature currently available in nursing and the subsequent need for primary quantitative studies examining the effect of PDAs in developing undergraduate nursing students' clinical reasoning skills.

Clinical reasoning is often not explicitly addressed in the early medical school curriculum. As a result, students observe the process while on clinical placements with little or no understanding of the complex processes underlying it. Clinical reasoning has significant implications for patient safety. Medical errors as a consequence of faulty reasoning contribute to patient morbidity and mortality. Educating medical students at an early stage about the processes of clinical reasoning and strategies to avoid associated errors can have positive impacts upon patient safety. The authors propose that clinical reasoning should be taught as early as the first year of medical school, using frameworks, anatomical knowledge and mnemonics. Using this approach with simulated cases during the pre-clinical years, students will be equipped with an understanding of the clinical reasoning process as it unfolds before them while on clinical placements, enhancing their overall learning experience.

This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students’ perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students’ perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient’s chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one’s own errors and selecting appropriate keywords from the whole aspect of the patient.

Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept. A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive. Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40years, and instructor experience from 1 to 35years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group. This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas.

Clinical reasoning assessment is an essential component of determining a health professional’s competence. Clinical reasoning cannot be assessed directly. It must be gleaned from a health professional’s choices and decisions. Clinical knowledge and knowledge organization, rather than a general problem solving process, serve as the substrate for clinical reasoning ability. Unfortunately, the lack of a gold standard for the clinical reasoning process and the observation of context specificity make it difficult to assess clinical reasoning. Information processing theory, which focuses on the way the brain processes and organizes knowledge, has provided valuable insights into the cognitive psychology of diagnostic and therapeutic reasoning but failed to explain the variance in health professional’s diagnostic performance. Situativity theory has emerged suggesting that this variance relates to context-specific factors that impact a health professional’s clinical reasoning performance. Both information processing and situativity theory inform the way in which we assess clinical reasoning. Current assessment methods focus on standardized testing of knowledge to maximize psychometric parameters and work-based assessments which evaluate clinical reasoning under authentic, uncertain conditions that can decrease the reliability of these measurements. Issues of inter-rater reliability and context specificity require that multiple raters assess multiple encounters in multiple contexts to optimize validity and reliability. No single assessment method can assess all aspects of clinical reasoning; therefore, in order to improve the quality of assessments of clinical reasoning ability, different combinations of methods that measure different components of the clinical reasoning process are needed.

Background The cognitive pathways that lead to an accurate diagnosis and efficient management plan can touch on various clinical reasoning tasks (1). These tasks can be employed at any point during the clinical reasoning process and though the four distinct categories of framing, diagnosis, management, and reflection provide some insight into how these tasks map onto clinical reasoning, much is still unknown about the task-based clinical reasoning process. For example, when and how are these tasks typically used? And more importantly, do these clinical reasoning task processes evolve when patient encounters become complex and/or challenging (i.e. with contextual factors)? Methods We examine these questions through the lens of situated cognition, context specificity, and cognitive load theory. Sixty think-aloud transcripts from 30 physicians who participated in two separate cases - one with a contextual factor and one without - were coded for 26 clinical reasoning tasks (1). These tasks were organized temporally, i.e. when they emerged in their think-aloud process. Frequencies of each of the 26 tasks were aggregated, categorized, and visualized in order to analyze task category sequences. Results We found that (a) as expected, clinical tasks follow a general sequence, (b) contextual factors can distort this emerging sequence, and (c) the presence of contextual factors prompts more experienced physicians to clinically reason similar to that of less experienced physicians. Conclusions These findings add to the existing literature on context specificity in clinical reasoning and can be used to strengthen teaching and assessment of clinical reasoning.

Background Applying an appropriate physiotherapy intervention to a hospitalised patient can be challenging because the clinical status can change rapidly, affecting the patient’s physical capacity. Determining the appropriate type and dose of the physiotherapy intervention requires dynamic assessment of physical capacity and adequate clinical reasoning by the physiotherapist. Purpose To develop a framework for determining physical capacity to support physiotherapists in their clinical reasoning process when treating hospitalised patients. Methods A framework was developed using a multi-method approach. First, the scientific literature was searched for existing frameworks for clinical reasoning in physiotherapy. These methods were inventoried and relevant elements were extracted. Second, a first draft of the framework was developed by a group of experts. Third, the framework was tested in practice, leading to a final version. Results A total of 17 frameworks were identified from the literature. No framework was found for generic use in the hospital for the purpose of determining patient’s physical capacity. Relevant elements from the identified frameworks were: the use of ICF terminology, the use of a patient management model, and frequent monitoring of clinical parameters. Field testing of the first draft of the framework led to improvement of the framework for use in clinical practice. Conclusion A framework was developed to support physiotherapists in their clinical reasoning process when treating hospitalised patients. The framework can provide guidance for determining the patient’s physical capacity to allow for an adequate training stimulus.

Connecting resident physician work hours and sleep deprivation to adverse outcomes has been difficult. Our study explores clinical reasoning rather than outcomes. Diagnostic errors are a leading cause of medical error and may result from deficits in clinical reasoning. We used simulated cases to explore relationships between sleep duration and diagnostic reasoning. Residents were recruited for a 2-month study (inpatient/outpatient). Each participant's sleep was tracked (sleep diary/actigraphy). At the end of each month, residents watched 2 brief simulated clinical encounters and performed "think alouds" of their clinical reasoning. In each session, 1 video was straightforward and the other video contained distracting contextual factors. Sessions were recorded, transcribed, and interpreted. We conducted a thematic analysis using a constant comparative approach. Themes were compared based on sleep duration and contextual factors. Residents (n = 17) slept more during outpatient compared with inpatient months (450.5 ± 7.13 vs 425.6 ± 10.78 hours, P = .02). We found the following diagnostic reasoning themes: uncertainty, disorganized knowledge, error, semantic incompetence, emotional content, and organized knowledge. Themes reflecting suboptimal clinical reasoning (disorganized knowledge, error, semantic incompetence, uncertainty) were observed more in cases with contextual factors (distractors). "Think alouds" from cases with contextual factors following sleep restriction had a greater number of themes concerning for problematic diagnostic reasoning. Residents obtained significantly more sleep during outpatient compared with inpatient months. Several negative clinical reasoning themes emerged with less sleep combined with cases containing contextual distractors. Our findings reinforce the importance of adequate sleep and supervision in house officers, particularly in cases with distracting elements. Collen J, Durning S, Berk J, Mang J, Alcover K, Jung E. Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis. J Clin Sleep Med. 2024;20(8):1279-1289.