Harvard Macy Community Blog

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Teaching Clinical Reasoning: How early is too early?

Although most medical schools have a pre-clerkship course dedicated to history taking, physical exam, and early patient exposure, clinical reasoning is rarely taught during the first years of medical school. Educators routinely wait until the more clinically focused clerkship to introduce and foster these skills. A recent national survey of clerkship directors found that most students enter clerkship with a “poor to fair” knowledge of clinical reasoning concepts. As a result, early clerkship students are left to merely observe the complex cognitive processes of more experienced clinicians that result in diagnostic and management decisions. Questions such as “How did you get to that?,” “How did you process all of that information so quickly?,” and “How did you know which questions to ask?” are common.

The status quo is not without justification. Some believe that effective clinical reasoning will be acquired on its own, through an osmosis of sorts, as a learner accumulates more knowledge and experience. And unlike medical knowledge, which is routinely examined during medical school to ensure consistent student progression, clinical reasoning is difficult to assess, and students develop on different time frames. Yet, we cannot afford for this debate to occur in a vacuum. Diagnostic error is an epidemic, and some experts estimate that 75% of diagnostic errors can be attributed to clinician diagnostic thinking failure.

Thankfully, there is recent evidence that clinical reasoning can be effectively taught in the pre-clerkship. Rencic et al. suggested that clinical reasoning can be taught early in medical education by making the process explicit to students. Capitalizing on advances in cognitive psychology, Norman et al. found that educational strategies encouraging use of both system 1 non-analytic processes and system 2 analytic processes, together termed dual process theory, as well as strategies focused on the reorganization of knowledge improved diagnostic accuracy. Bowen et al. suggested a comprehensive clinical reasoning framework for teaching using dual process theory, problem representation, and illness scripts. Marcum et al. recently proposed augmenting this model with metacognition in order to reinforce or to alter a learner’s cognitive processes, which, in turn, enhances their ability to reason quickly and accurately in future consultations. Just as metacognition can be a monitoring system for the cognitive processes of a practicing clinician by reinforcing sound clinical reasoning that leads to a correct diagnosis or remedying faulty clinical reasoning that leads to an incorrect diagnosis, a mentor can promote metacognitive skills through immediate and effective feedback. Thus, knowing how clinicians make decisions is important for novice medical students and their faculty mentors.

In addition, the clerkship years may not enhance student development of clinical reasoning skills as expected. At most schools, the clerkship experience of any given student can be quite varied due to inherent institutional limitations and faculty time demands. Yet, as mentioned above, medical schools commonly rely on the clerkship environment to ingrain clinical reasoning skills through repeated patient interaction and consistent exposure to faculty role models. Clinical expertise in a given field does not necessarily constitute expertise in teaching clinical reasoning. Experienced clinicians can find it difficult to explain their deeper, nonlinear reasoning processes to students as they work through a case.

At my institution, we have designed and implemented a clinical reasoning curriculum that begins on day one of medical school. Our approach acknowledges the developmental stage of the medical students, beginning with sessions focused on teaching the foundational concepts (“language”) of clinical reasoning and gradually advancing in difficulty, using clinical cases timed with the teaching of biomedical content to promote application of knowledge. Our approach also relies on a consistent, longitudinal relationship between students and physician coaches with dedicated time and training to teach these concepts. The goal of this curriculum is to be both explicit in our teaching and nurturing of individual students as they develop at their own pace. We have developed exercises to hopefully enhance our student’s self-regulated learning skills, thought to be a predictor of improved clinical reasoning skills, and promote metacognition on behalf of the physician coaches. Although it is too soon to accurately assess the effectiveness of our curriculum, our approach is consistent with recent evidence. We hope that providing students with a standardized cognitive framework for clinical reasoning along with a new language to discuss their reasoning process early in medical school eases the uptake and application of biomedical knowledge and ultimately enhances clinical decision making down the line.

How early do you teach clinical reasoning? What are your experiences with encouraging clinical reasoning among undergraduate medical education learners? Comment below and join the conversation!

 

Did you know that the Harvard Macy Institute Community Blog has had more than 190 posts? Previous blog posts have explored topics including teaching clinical reasoning, identifying the GAP in clinical reasoning, and educating physicians to navigate the complexity and uncertainty of clinical care.

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Thursday, 13 August 2020