Understanding the Assessment of Clinical Reasoning

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.

Clinical reasoning is a topic that has received significant attention over the last decade, within both the academic and clinical communities. The numerous and varied publications in the Journal of Physical Therapy Education (JOPTE) reflect the profession's interest in studying clinical reasoning in physical therapy education and practice.In this issue, 4 papers address the topic of clinical reasoning. Drs Huhn and Parrott present a research report exploring the use of the Health Sciences Reasoning Test (HSRT) and academic measures (GPA and GRE scores) at the time of admission to predict physical therapist (PT) student success on the NPTE.1 This paper builds on Dr Huhn's prior work examining the utility of the HSRT in demonstrating development of critical thinking skills across PT education programs.2 Drs Venskus and Craig have developed and validated a tool to measure the degree of self-efficacy with respect to the development of clinical reasoning skills reported by PT students. This paper adds to the growing body of literature about the development of clinical reasoning, specifically addressing the student's capability to reason.3The other 2 papers in this issue are research reports that explore the development of clinical reasoning abilities. Dr. Gilliland has applied qualitative research methods to explore the development of diagnostic reasoning in PT students. She employed think aloud processes using a musculoskeletal paper case at 2 points in the students entry-level PT education to identify evolution of diagnostic reasoning.4 Drs Trommelen, Karpinski, and Chauvin studied the effectiveness of a novel instructional activity to promote reflection in a case-based delivery model for neuromuscular physical therapy.5 Like Drs Huhn and Parrott, these authors used standardized measures (the Diagnostic Thinking inventory and the Self-Assessment of Clinical Reasoning Tool) to demonstrate improvement in the student's clinical reasoning and reflective abilities. One of the challenges in conducting and applying this research is the varied methods and assessment tools that are used in studying clinical reasoning.Study of clinical reasoning in PT students has demonstrated that clinical reasoning abilities develop over time within PT curricula.6,7 Research on expertise has demonstrated the continued development of these clinical reasoning abilities beyond formal entry-level education. For example, a study of promising novices over a 2-year period as they entered practice indicated ongoing development and subsequent expansion and refinement of formal and informal learning, clinical skills, and collaboration.8 Findings such as these indicate the importance of creating opportunities to develop clinical reasoning skills as a student and novice practitioner.Another area of study in clinical reasoning has been the development of rubrics to assess clinical reasoning during practical assessment of student's clinical knowledge and skill performance. Two such assessment tools have been reported in JOPTE. The Think Aloud Standardized Patient Examination (TASPE)9 was developed to assess clinical reasoning competency in novice physical therapy students during standardized musculoskeletal patient encounters. Using the TASPE, students are assessed on their ability to synthesize data to inform think-aloud sessions across the hypothetico-deductive reasoning process: hypothesis generation, hypothesis evaluation, and intervention. A second tool, the Clinical Reasoning Grading Rubric, 10 has 2 intended purposes: (1) assess the clinical reasoning skills of PT students, and (2) evaluate readiness to progress to full-time clinical education. This tool incorporates assessment across cognitive, psychomotor, and affective domains with criteria from low to high performance of knowledge, skills, and attitudes.Another category of study is the development of skills that are components of clinical reasoning. Several studies exploring the development of critical thinking have been published in JOPTE over that past few years. …

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.

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.

Introduction This study aimed to investigate dental students' clinical reasoning and diagnostic thinking ability by key feature test and “diagnostic thinking inventory” questionnaire. Methods The present study was a descriptive cross-sectional study. The participants consisted of 61 senior dental students. Clinical reasoning and diagnostic thinking were assessed by key feature tests and the “diagnostic thinking inventory” “DTI” questionnaire, respectively. The “diagnostic thinking inventory” was developed by Bordage et al. in France and consisted of 41 questions on a 6-point Likert scale. The satisfaction of students was assessed through a 10-item questionnaire. Data were analyzed using SPSS 19 with descriptive tests (mean, SD, and percentage), student independent T-test, and Pearson correlation. The significance level was determined at p < 0.05. Results The mean scores of the key feature test were 56.55 ± 7.80. Diagnostic thinking scores of learners were reported in diagnostic thinking 136.47 ± 16.45, flexibility in thinking 72.22 ± 11.15, and structure of memory 64.24 ± 7.84. The difference in students' scores in flexibility in thinking was significantly higher among male students than female students. (p-value = 0.04). The students' satisfaction scores were 3.53 ± 0.52, which showed relative satisfaction. Conclusion The participants' clinical reasoning and diagnostic thinking skills were reported at a low level. This issue emphasizes the need for training to enhance diagnostic thinking and clinical reasoning in dental education. Formative evaluation and reform of the educational programs of this course should be considered.

Deciding on a diagnosis and treatment is essential to the practice of medicine. Developing competence in these clinical reasoning processes, commonly referred to as diagnostic and therapeutic reasoning, respectively, is required for physician success. Clinical reasoning has been a topic of research for several decades, and much has been learned. However, there still exists no clear consensus regarding what clinical reasoning entails, let alone how it might best be taught, how it should be assessed, and the research and practice implications therein.In this article, the authors first discuss two contrasting epistemological views of clinical reasoning and related conceptual frameworks. They then outline four different theoretical frameworks held by medical educators that the authors believe guide educators' views on the topic, knowingly or not. Within each theoretical framework, the authors begin with a definition of clinical reasoning (from that viewpoint) and then discuss learning, assessment, and research implications. The authors believe these epistemologies and four theoretical frameworks also apply to other concepts (or "competencies") in medical education.The authors also maintain that clinical reasoning encompasses the mental processes and behaviors that are shared (or evolve) between the patient, physician, and the environment (i.e., practice setting). Clinical reasoning thus incorporates components of all three factors (patient, physician, environment). The authors conclude by outlining practical implications and potential future areas for research.

Aim: We can define clinical reasoning as the ability to think and decide in clinical processes, which is non-reductive, multidimensional and free from prejudices. Clinical reasoning is a basic competence that a physician should have. In this article, theories about clinical reasoning, stages of clinical reasoning, training and evaluation methods, and the relationship between clinical reasoning and medical malpractice are discussed and related evidence is presented.Methods: The article was prepared by the traditional review methodResults: Non-analytical (system 1), analytical (system 2) thinking and dual process theories are accepted among the theories of how clinical reasoning is realized. Non-analytical thinking is an intuitive thinking that takes place fast and does not require much mental effort. Analytical thinking (system 2 thinking) is established by establishing a cause-effect relationship. In clinical reasoning, the stages of gathering information, forming hypothesis and testing hypothesis constitute a general framework. For clinical reasoning education, frameworks / models for this competence should be determined in educational activities, assessment and evaluation from the first years, and their use should be encouraged. Medical errors and inadequate clinical reasoning processes are related. For this reason, it is important to consider the clinical reasoning insufficiency areas in educational approaches. Clinical reasoning assessments should cover all stages of reasoning. Numerous methods and question / inquiry frameworks have been identified in the evaluation of clinical reasoning. In these, the basic principles are to ask questions that require reasoning with guides structured in accordance with the clinical reasoning stages.Conclusions: Clinical reasoning ability is the basic competence that a physician should have in order to ensure patient safety by reducing medical errors, to reduce unnecessary work and procedures in health, to prevent patient physician disputes and therefore violent events. Learning and assessment activities should be planned using models suitable for clinical reasoning terms and stages.

Understanding the process of expert clinical reasoning improves our ability to develop, practice, maintain, teach, and assess clinical diagnostic expertise. The dual process model describes a synergistic interplay of associative thinking and analytical reasoning. These complimentary processes facilitate the efficient abstraction of data from clinical presentations, the identification of key features, and the production of useful problem representations. These are compared unconsciously to prototypical cases stored in memory as illness scripts for a best match. A lack of a satisfactory match may stimulate a conscious, analytic analysis of discordance, ideally reducing bias and error and promoting further script development. An awareness of this process and the use of existing observation and assessment techniques can enable both the teaching and the assessment of clinical reasoning. Learners can also be taught to use these techniques to help develop self-assessment of clinical reasoning performance. Teaching and assessing clinical reasoning in others stimulates clinician teachers to reflect on their own clinical reasoning and practice, serving as an effective form of continuous professional learning.

The impact of combining concept-based learning and concept-mapping pedagogies on nursing students' clinical reasoning abilities

PurposeGraduating medical students need broad clinical diagnostic reasoning skills that integrate learning across clinical specialties to deal with undifferentiated patient problems. The opportunity to acquire these skills may be limited during clinical placements on increasingly specialized hospital wards. We developed an intervention of regular general practitioner (GP) facilitated teaching in hospital placements to enable students to develop broad clinical diagnostic reasoning. The intervention was piloted, refined and delivered to a whole cohort of medical students at the start of their third year. This paper examines whether students perceived opportunities to improve their broad diagnostic clinical reasoning through our intervention.MethodsGP-facilitated teaching sessions were delivered weekly in hospital placements to small groups of 6–8 students for 90 mins over 6 weeks. Students practiced clinical reasoning with real patient cases that they encountered on their placements. Evaluation of learning outcomes was conducted through a student questionnaire using Likert scales with free-text boxes for additional explanation. Focus groups were conducted to gain a more in-depth understanding of student perspectives.ResultsAs high as 87% of students agreed that their broad clinical diagnostic reasoning ability had improved. Thematic analysis of the qualitative data revealed four factors supporting this improvement: practicing the hypothetico-deductive method, using real patient cases, composing student groups from different speciality placements and the breadth of the facilitators’ knowledge. Students additionally reported enhanced person-centredness in terms of understanding the patient’s perspective and journey. Students perceived that the added value of general practitioner facilitators lay in their broad knowledge base and knowledge of patient needs in the community.ConclusionOur results suggest that medical students can develop broad clinical diagnostic reasoning skills in hospital settings through regular GP-facilitated teaching. Our approach has the advantage of working within the established curricular format of hospital placements and being deliverable at scale to whole student cohorts.

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). 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. 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. 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.

Clinical reasoning processes involve gathering and interpreting information, creating differential diagnoses and testing hypotheses to inform and guide patient management. Effective clinical reasoning is an essential graduate outcome for medical students to ensure safe and efficient care of patients. In the clinical setting, a large proportion of hospital-related adverse events are attributed to errors in cognitive processes rather than knowledge, including diagnostic reasoning and decision-making. Teaching clinical reasoning is challenging due to its implicit nature, typically relying on internal thinking processes, pattern recognition and the use of prior clinical experiences. Current conventional teaching relies on student-driven application of clinical reasoning during their rotations as part of a hidden curriculum, which can be highly variable, unstructured, non-standardised, with limited oversight from faculty and with few opportunities for feedback. Furthermore, current barriers exist, including difficulties in teaching and assessing clinical reasoning. Due to this, many educators and faculty agree upon the significance of embedding explicit teaching and assessment of clinical reasoning into the curriculum, however the best approach remains poorly characterised. A narrative synthesis was undertaken from the current literature and the authors' collective experience. The synthesis distils this information into ten practical tips to guide design, integration and innovation of clinical reasoning teaching in medical education. Ten tips were identified to support educators' efforts in embedding clinical reasoning into curriculum design and teaching. Together, these ten tips promote explicit, reflective and contextual clinical reasoning learning within the contemporary medical curriculum. Clinical reasoning requires deliberate, longitudinal and student-centred approaches that are integrated within authentic situated learning experiences. The ten tips provide avenues for more evidence-based adoption of effective learning environments that focus on clinical reasoning skills development.

[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.

The cultivation of clinical reasoning ability in nursing students is a hot topic of research among nursing educators worldwide. Only by fully understanding the concept of clinical reasoning, accurately assessing its level, and familiarizing themselves with its influencing factors, can nursing educators develop appropriate measures to cultivate and enhance the clinical reasoning ability of nursing students. Through literature review, this article found that there is no unified and clear concept of clinical reasoning internationally, but experts unanimously agree that the three basic conditions that should be met for conducting clinical reasoning are discipline-specific knowledge, multiple types of thinking, and reasoning skills. There are two main types of evaluation tools for nursing students' clinical reasoning ability: self-evaluation tools and peer evaluation tools. Both have their own advantages and disadvantages. The clinical reasoning ability of nursing students is not only influenced by their own factors such as professional knowledge, experience, and thinking patterns, but also by external factors such as teaching methods and teaching environment.

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.