What does research on clinical reasoning have to say to clinical teachers?
Clinical reasoning is a crucial determinant of physicians’ performance. It is key to arrive at a correct diagnosis, which substantially increases the chance of appropriate therapeutic decisions. Clinical teachers face the daily challenge of helping their students to develop clinical reasoning. To select appropriate teaching strategies, it may be useful to become acquainted with the results of the research on clinical reasoning that has been conducted over the last decades. This article synthesizes the findings of this research that help in particular to understand the cognitive processes involved in clinical reasoning, the trajectory that leads the student from novice to expert, and instructional approaches that have been shown to be useful to facilitating this trajectory. The focus of the article is the diagnostic process, because it is about it that most research has been conducted. This research indicates that there is not a particular reasoning strategy that is specific to expert physicians and could be taught to students. It is the availability of a large knowledge base organized in memory in illness scripts of different formats that explains the expert’s better performance. The more, the richer, and the more well-structured are the illness scripts a physician has stored in memory, the more he/she would be able to make accurate diagnoses. These scripts are formed gradually over the years of education. To help develop them, students should be exposed to a wide variety of clinical problems, with which they must interact actively. Instructional approaches that require students to systematically reflect on problems, analyzing differences and similarities between them, explaining underlying mechanisms, comparing and contrasting alternative diagnoses, have proved useful to help refine disease scripts. These approaches are valuable tools for teachers concerned with the development of their students clinical reasoning.
Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39(4):418-27. https://doi.org/10.1111/j.1365-2929.2005.02127.x.
Elstein AS. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, MA/London, U.K.: Harvard University Press; 1978.
Neufeld VR, Norman GR, Feightner JW, et al. Clinical problem-solving by medical students: a cross-sectional and longitudinal analysis. Med Educ. 1981;15(5):315-22. https://doi.org/10.1111/j.1365-2923.1981.tb02495.x.
Barrows HS, Norman GR, Neufeld VR, et al. The clinical reasoning of randomly selected physicians in general medical practice. Clin Invest Med. 1982;5(1):49-55.
Eva KW. On the generality of specificity. Med Educ. 2003;37(7):587-8. https://doi.org/10.1046/j.1365-2923.2003.01563.x.
Eva KW, Neville AJ, Norman GR. Exploring the etiology of content specificity: factors influencing analogic transfer and problem solving. Acad Med. 1998;73(10 Suppl):S1-5. https://doi.org/10.1097/00001888-199810000-00028.
Custers EJ, Regehr G, Norman GR. Mental representations of medical diagnostic knowledge: a review. Acad Med. 1996;71(10 Suppl):S55-61. https://doi.org/10.1097/00001888-199610000-00044.
Evans JSBT. Dual-processing accounts of reasoning, judgment, and social cognition. Annu Rev Psychol. 2008;59:255-78. https://doi.org/10.1146/annurev.psych.59.103006.093629.
Evans JST. The heuristic-analytic theory of reasoning: Extension and evaluation. Psychon B Rev. 2006;13(3):378-95. https://doi.org/10.3758/BF03193858.
Kahneman D. A Perspective on Judgment and Choice: Mapping Bounded Rationality. Am Psychol. 2003;58(9):697-720. https://doi.org/10.1037/0003-066X.58.9.697.
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-80. https://doi.org/10.1097/00001888-200308000-00003.
Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41(1):110-20. https://doi.org/10.1067/mem.2003.22.
Norman G. Dual processing and diagnostic errors. Adv Health Sci Educ Theory Pract. 2009;14 Suppl 1:37-49. https://doi.org/10.1007/s10459-009-9179-x.
Lambe KA, O’Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016. https://doi.org/10.1136/bmjqs-2015-004417.
Norman GR, Monteiro SD, Sherbino J, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017;92(1):23-30. https://doi.org/10.1097/ACM.0000000000001421.
Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005;39(1):98-106. https://doi.org/10.1111/j.1365-2929.2004.01972.x.
Schmidt HG, Rikers RM. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Educ. 2007;41(12):1133-9.
Schmidt HG, Norman GR, Boshuizen HPA. A Cognitive Perspective on Medical Expertise - Theory and Implications. Acad Med. 1990;65(10):611-21. https://doi.org/10.1097/00001888-199010000-00001.
Schmidt HG, Boshuizen HPA. On the Origin of Intermediate Effects in Clinical Case Recall. Mem Cognit. 1993;21(3):338-51. https://doi.org/10.3758/BF03208266.
Rikers RMJP, Schmidt HG, Boshuizen HPA. Knowledge encapsulation and the intermediate effect. Contemp Educ Psychol. 2000;25(2):150-66. https://doi.org/10.1006/ceps.1998.1000.
Charlin B, Boshuizen HPA, Custers EJ, et al. Scripts and clinical reasoning. Med Educ. 2007;41(12):1178-84. https://doi.org/10.1111/j.1365-2923.2007.02924.x.
Schmidt HG, Boshuizen HPA. On Acquiring Expertise in Medicine. Educ Psychol Rev. 1993;5(3):205-21. https://doi.org/10.1007/BF01323044.
Hobus PPM, Schmidt HG, Boshuizen HPA, et al. Contextual Factors in the Activation of 1st Diagnostic Hypotheses - Expert Novice Differences. Med Educ. 1987;21(6):471-6. https://doi.org/10.1111/j.1365-2923.1987.tb01405.x.
Schmidt HG, Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ. 2015;49(10):961-73. https://doi.org/10.1111/medu.12775.
Sherbino J, Dore KL, Wood TJ, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012;87(6):785-91. https://doi.org/10.1097/ACM.0b013e318253acbd.
Sherbino J, Kulasegaram K, Howey E, et al. Ineffectiveness of cognitive forcing strategies to reduce biases in diagnostic reasoning: a controlled trial. CJEM. 2014;16(1):34-40. https://doi.org/10.2310/8000.2013.130860.
Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. ‘Immunising’ physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf. 2020. https://doi.org/10.1136/bmjqs-2019-010079.
Loewenstein J, Thompson L, Gentner D. Analogical Learning in Negotiation Teams: Comparing Cases Promotes Learning and Transfer. Acad Manag Learn Edu. 2003;2(2):119-27. https://doi.org/10.5465/amle.2003.9901663.
Gentner D, Loewenstein J, Thompson L. Learning and transfer: A general role for analogical encoding. J Educ Psychol. 2003;95(2):393-408. https://doi.org/10.1037/0022-0618.104.22.1683.
Ericsson KA. Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert-Performance Approach With Deliberate Practice. Acad Med. 2015;90(11):1471-86. https://doi.org/10.1097/ACM.0000000000000939.
Ericsson KA, Krampe RT, Teschromer C. The Role of Deliberate Practice in the Acquisition of Expert Performance. Psychol Rev. 1993;100(3):363-406. https://doi.org/10.1037/0033-295X.100.3.363.
Woods NN, Brooks LR, Norman GR. It all make sense: biomedical knowledge, causal connections and memory in the novice diagnostician. Adv Health Sci Educ Theory Pract. 2007;12(4):405-15. https://doi.org/10.1007/s10459-006-9055-x.
Ark TK, Brooks LR, Eva KW. The benefits of flexibility: the pedagogical value of instructions to adopt multifaceted diagnostic reasoning strategies. Med Educ. 2007;41(3):281-7. https://doi.org/10.1111/j.1365-2929.2007.02688.x.
Hatala RM, Brooks LR, Norman GR. Practice makes perfect: the critical role of mixed practice in the acquisition of ECG interpretation skills. Adv Health Sci Educ Theory Pract. 2003;8(1):17-26. https://doi.org/10.1023/A:1022687404380.
Chamberland M, Mamede S. Self-Explanation, An Instructional Strategy to Foster Clinical Reasoning in Medical Students. Health Professions Education. 2015;1(1):24-33. https://doi.org/10.1016/j.hpe.2015.11.005.
Chamberland M, Mamede S, St-Onge C, et al. Self-explanation in learning clinical reasoning: the added value of examples and prompts. Med Educ. 2015;49(2):193-202. https://doi.org/10.1111/medu.12623.
Chamberland M, Setrakian J, St-Onge C, et al. Does providing the correct diagnosis as feedback after self-explanation improve medical students diagnostic performance? BMC Med Educ. 2019;19(1):194. https://doi.org/10.1186/s12909-019-1638-3.
Chamberland M, St-Onge C, Setrakian J, et al. The influence of medical students’ self-explanations on diagnostic performance. Med Educ. 2011;45(7):688-95. https://doi.org/10.1111/j.1365-2923.2011.03933.x.
Mamede S, Figueiredo-Soares T, Eloi Santos SM, et al. Fostering novice students’ diagnostic ability: the value of guiding deliberate reflection. Med Educ. 2019;53(6):628-37. https://doi.org/10.1111/medu.13829.
Mamede S, van Gog T, Moura AS, et al. Reflection as a strategy to foster medical students’ acquisition of diagnostic competence. Med Educ. 2012;46(5):464-72. https://doi.org/10.1111/j.1365-2923.2012.04217.x.
Mamede S, van Gog T, Sampaio AM, et al. How can students’ diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases. Acad Med. 2014;89(1):121-7. https://doi.org/10.1097/ACM.0000000000000076.
Rattner SL, Louis DZ, Rabinowitz C, et al. Documenting and comparing medical students’ clinical experiences. JAMA. 2001;286(9):1035-40. https://doi.org/10.1001/jama.286.9.1035.
Wimmers PF, Schmidt HG, Splinter TA. Influence of clerkship experiences on clinical competence. Med Educ. 2006;40(5):450-8. https://doi.org/10.1111/j.1365-2929.2006.02447.x.
de Giovanni D, Roberts T, Norman G. Relative effectiveness of high- versus low-fidelity simulation in learning heart sounds. Med Educ. 2009;43(7):661-8. https://doi.org/10.1111/j.1365-2923.2009.03398.x.
Massoth C, Roder H, Ohlenburg H, et al. High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students. BMC Med Educ. 2019;19(1):29. https://doi.org/10.1186/s12909-019-1464-7.
Copyright (c) 2020 Scientia Medica
This work is licensed under a Creative Commons Attribution 4.0 International License.
The submission of originals to Scientia Medica implies the transfer by the authors of the right for publication. Authors retain copyright and grant the journal right of first publication. If the authors wish to include the same data into another publication, they must cite Scientia Medica as the site of original publication.
Creative Commons License
Except where otherwise specified, material published in this journal is licensed under a Creative Commons Attribution 4.0 International license, which allows unrestricted use, distribution and reproduction in any medium, provided the original publication is correctly cited.