Anat Cell Biol.  2020 Jun;53(2):151-161. 10.5115/acb.19.199.

Infusing the axioms of clinical reasoning while designing clinical anatomy case vignettes teaching for novice medical students: a randomised cross over study

• V DK
• R R
• Priyadharshini N
• Murugan M
• Devi R

• KMID: 2503445
• DOI: http://doi.org/10.5115/acb.19.199

Abstract

The clinical reasoning skills is often gained when the biomedical knowledge is broadened and deepened alongside exposure to patients. The ‘ideal’ blend of axioms of clinical reasoning and case based learning would establish the pedagogical bridges right from the first year of medical education. So this study aimed to investigate the perceived importance and efficacy of teaching clinical reasoning skills among first year medical students, as this has not previously been described. As a priori, two clinical reasoning skill sessions were conducted using clinico-anatomical case vignettes designed according to the literature regarding clinical reasoning (‘serial cue’ approach and hypothetico-deduction). Students were divided into intervention and control group and crossed over in subsequent sessions. Analysis was done by mixed method approach including measuring proof of benefit using post-test comparison, quantitative survey and qualitative analysis by nominal group discussion. Post test scores were compared using student’s t-test. Feedbacks were analysed using descriptive statistics. The results showed that post test scores were significantly higher in intervention group than the control group in both sessions (P<0.001, 0.016). A total of 66% students felt, diagnostic skills and lateral thinking abilities were improved and It helped in developing problem-solving abilities for 67% students. clinico-anatomical case vignettes helped in understanding anatomical basis of clinical conditions for 61% students. To conclude, introducing clinical reasoning has considerable effect in improving the decision making ability of the students and if incorporated right from the first year, would better prepare the students in successful transition to clinical learning environment.

Keyword

Clinical reasoning; Problem-based learning; Case vignette; Novice learner; Mixed methods

Figure

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  Fig. 1 Concept map of clinical reasoning principles used in the vignettes.

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  Fig. 2 Outline of segments and the reasoning principles used in the process of clinical anatomy case vignettes.

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  Fig. 3 Comparison of mean post test scores between intervention and control groups.

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  Fig. 4 Perceptions of students on the effectiveness of clinical reasoning sessions.

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  Fig. 5 Students reflection on usefulness of clinical reasoning sessions in improving problem solving abilities.

Reference

1. Norman G. 2005; Research in clinical reasoning: past history and current trends. Med Educ. 39:418–27. DOI: 10.1111/j.1365-2929.2005.02127.x. PMID: 15813765.

2. Kassirer JP. 2010; Teaching clinical reasoning: case-based and coached. Acad Med. 85:1118–24. DOI: 10.1097/ACM.0b013e3181d5dd0d. PMID: 20603909.

3. van Gog T, Ericsson KA, Rikers RMJP, Paas F. 2005; Instructional design for advanced learners: establishing connections between the theoretical frameworks of cognitive load and deliberate practice. Educ Technol Res Dev. 53:73–81. DOI: 10.1007/BF02504799.

4. van Merriënboer JJG, Sweller J. 2005; Cognitive load theory and complex learning: recent developments and future directions. Educ Psychol Rev. 17:147–77. DOI: 10.1007/s10648-005-3951-0.

5. Allchin D. 2013; Problem- and case-based learning in science: an introduction to distinctions, values, and outcomes. CBE Life Sci Educ. 12:364–72. DOI: 10.1187/cbe.12-11-0190. PMID: 24006385. PMCID: PMC3763004.

6. Dammers J, Spencer J, Thomas M. 2001; Using real patients in problem-based learning: students' comments on the value of using real, as opposed to paper cases, in a problem-based learning module in general practice. Med Educ. 35:27–34. DOI: 10.1046/j.1365-2923.2001.00841.x. PMID: 11123592.

7. Waechter D. 2015. Liaison Committee on Medical Education glossary of terms for LCME accreditation standards and elements 2015-2016. LCME;Washington, DC: p. 10.

8. Dalton L, Gee T, Levett-Jones T. 2015; Using clinical reasoning and simulation-based education to 'flip' the Enrolled Nurse curriculum. Aust J Adv Nurs. 33:29–35.

9. Kong LN, Qin B, Zhou YQ, Mou SY, Gao HM. 2014; The effectiveness of problem-based learning on development of nursing students' critical thinking: a systematic review and meta-analysis. Int J Nurs Stud. 51:458–69. DOI: 10.1016/j.ijnurstu.2013.06.009. PMID: 23850065.

10. Bowen JL. 2006; Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 355:2217–25. DOI: 10.1056/NEJMra054782. PMID: 17124019.

11. Hall KH. 2002; Reviewing intuitive decision-making and uncertainty: the implications for medical education. Med Educ. 36:216–24. DOI: 10.1046/j.1365-2923.2002.01140.x. PMID: 11879511.

12. Dawson NV. 1993; Physician judgment in clinical settings: methodological influences and cognitive performance. Clin Chem. 39:1468–78. discussion 1478–80. DOI: 10.1093/clinchem/39.7.1468. PMID: 8330409.

13. Fischhoff B. 2003; Hindsight not equal to foresight: the effect of outcome knowledge on judgment under uncertainty. Qual Saf Health Care. 12:304–11. discussion 311–2. DOI: 10.1136/qhc.12.4.304. PMID: 12897366. PMCID: PMC1743746.

14. Dawson NV, Arkes HR, Siciliano C, Blinkhorn R, Lakshmanan M, Petrelli M. 1988; Hindsight bias: an impediment to accurate probability estimation in clinicopathologic conferences. Med Decis Making. 8:259–64. DOI: 10.1177/0272989X8800800406. PMID: 3185178.

15. Hassan S. 2006; About clinicopathological conference and its' practice in the School of Medical Sciences, USM. Malays J Med Sci. 13:7–10.

16. Christensen N, Black L, Furze J, Huhn K, Vendrely A, Wainwright S. 2017; Clinical reasoning: survey of teaching methods, integration, and assessment in entry-level physical therapist academic education. Phys Ther. 97:175–86. DOI: 10.2522/ptj.20150320. PMID: 27609900.

17. Boshuizen HPA, Schmidt HG. 1992; On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cogn Sci. 16:153–84. DOI: 10.1207/s15516709cog1602_1.

18. Linsen A, Elshout G, Pols D, Zwaan L, Mamede S. 2018; Education in clinical reasoning: an experimental study on strategies to foster novice medical students' engagement in learning activities. Health Prof Educ. 4:86–96. DOI: 10.1016/j.hpe.2017.03.003.

19. Mamede S, Figueiredo-Soares T, Elói Santos SM, de Faria RMD, Schmidt HG, van Gog T. 2019; Fostering novice students' diagnostic ability: the value of guiding deliberate reflection. Med Educ. 53:628–37. DOI: 10.1111/medu.13829. PMID: 30917406. PMCID: PMC6594026.

20. Mamede S, Schmidt HG, Penaforte JC. 2008; Effects of reflective practice on the accuracy of medical diagnoses. Med Educ. 42:468–75. DOI: 10.1111/j.1365-2923.2008.03030.x. PMID: 18412886.

21. Kreiter CD, Bergus G. 2009; The validity of performance-based measures of clinical reasoning and alternative approaches. Med Educ. 43:320–5. DOI: 10.1111/j.1365-2923.2008.03281.x. PMID: 19335573.

22. Kumar D, Rajprasath R, Murugan M. 2019; Integrating clinical reasoning principles in case-based learning sessions for first-year medical students: lessons learned. Res Dev Med Educ. 8:20–3. DOI: 10.15171/rdme.2019.004.

23. Elstein AS, Shulman LS, Sprafka SA. 1978. Medical problem solving: an analysis of clinical reasoning. Harvard University Press;Cambridge, MA:

24. Ten Cate O. 2014; Trusting graduates to enter residency: what does it take? J Grad Med Educ. 6:7–10. DOI: 10.4300/JGME-D-13-00436.1. PMID: 24701302. PMCID: PMC3963798.

25. Wolpaw T, Papp KK, Bordage G. 2009; Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Acad Med. 84:517–24. DOI: 10.1097/ACM.0b013e31819a8cbf. PMID: 19318792.

26. Mylopoulos M, Woods N. 2014; Preparing medical students for future learning using basic science instruction. Med Educ. 48:667–73. DOI: 10.1111/medu.12426. PMID: 24909528.

27. van Gessel E, Nendaz MR, Vermeulen B, Junod A, Vu NV. 2003; Development of clinical reasoning from the basic sciences to the clerkships: a longitudinal assessment of medical students' needs and self-perception after a transitional learning unit. Med Educ. 37:966–74. DOI: 10.1046/j.1365-2923.2003.01672.x. PMID: 14629409.

28. Barfield LC, Taylor BR, Santen SA. 2007; Learning physical diagnosis: a new paradigm. Med Educ. 41:1097. DOI: 10.1111/j.1365-2923.2007.02875.x. PMID: 17973775.

29. Atherley AE, Hambleton IR, Unwin N, George C, Lashley PM, Taylor CG Jr. 2016; Exploring the transition of undergraduate medical students into a clinical clerkship using organizational socialization theory. Perspect Med Educ. 5:78–87. DOI: 10.1007/s40037-015-0241-5. PMID: 26951164. PMCID: PMC4839013.

30. Schworm S, Renkl A. 2007; Learning argumentation skills through the use of prompts for self-explaining examples. J Educ Psychol. 99:285–96. DOI: 10.1037/0022-0663.99.2.285.

31. Nokes TJ, Hausmann RGM, Vanlehn K, Gershman S. 2011; Testing the instructional fit hypothesis: the case of self-explanation prompts. Instr Sci. 39:645–66. DOI: 10.1007/s11251-010-9151-4.

32. Mamede S, van Gog T, Sampaio AM, de Faria RM, Maria JP, Schmidt HG. 2014; 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. 89:121–7. DOI: 10.1097/ACM.0000000000000076. PMID: 24280855.

33. Nishigori H, Masuda K, Kikukawa M, Kawashima A, Yudkowsky R, Bordage G, Otaki J. 2011; A model teaching session for the hypothesis-driven physical examination. Med Teach. 33:410–7. DOI: 10.3109/0142159X.2010.540269. PMID: 21355686.

34. Jain V, Rao S, Jinadani M. 2019; Effectiveness of SNAPPS for improving clinical reasoning in postgraduates: randomized controlled trial. BMC Med Educ. 19:224. DOI: 10.1186/s12909-019-1670-3. PMID: 31226996. PMCID: PMC6588865.

35. Schmidt HG, Boshuizen HPA. 1993; On acquiring expertise in medicine. Educ Psychol Rev. 5:205–21. DOI: 10.1007/BF01323044.