Abstract
BackgroundThe clinical reasoning process, which requires biomedical knowledge, knowledge about problem-solving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians’ daily practice but difficult to assess. The aim of this study was to empirically develop a Clinical Reasoning Indicators-History Taking-Scale (CRI-HT-S) and to assess the clinical reasoning ability of advanced medical students during a simulation involving history taking.MethodsThe Clinical Reasoning Indictors-History Taking-Scale (CRI-HT-S) including a 5-point Likert scale for assessment was designed from clinical reasoning indicators identified in a qualitative study in 2017. To assess indicators of clinical reasoning ability, 65 advanced medical students (semester 10, n = 25 versus final year, n = 40) from three medical schools participated in a 360-degree competence assessment in the role of beginning residents during a simulated first workday in hospital. This assessment included a consultation hour with five simulated patients which was videotaped. Videos of 325 patient consultations were assessed using the CRI-HT-S. A factor analysis was conducted and the students’ results were compared according to their advancement in undergraduate medical training.ResultsThe clinical reasoning indicators of the CRI-HT-S loaded on three factors relevant for clinical reasoning: 1) focusing questions, 2) creating context, and 3) securing information. Students reached significantly different scores (p < .001) for the three factors (factor 1: 4.07 ± .47, factor 2: 3.72 ± .43, factor 3: 2.79 ± .83). Students in semester 10 reached significantly lower scores for factor 3 than students in their final year (p < .05).ConclusionsThe newly developed CRI-HT-S worked well for quantitative assessment of clinical reasoning indicators during history taking. Its three-factored structure helped to explore different aspects of clinical reasoning. Whether the CRI-HT-S has the potential to be used as a scale in objective structured clinical examinations (OCSEs) or in workplace-based assessments of clinical reasoning has to be investigated in further studies with larger student cohorts.
Highlights
The clinical reasoning process, which requires biomedical knowledge, knowledge about problemsolving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians’ daily practice but difficult to assess
To assess indicators of clinical reasoning ability advanced medical students participated in a 360-degree competence assessment in the role of beginning residents during a simulated first workday of residency [15]
The assessment consisted of three phases: 1) a consultation hour with five simulated patients, 2) a management phase (2.5 h) to organize these patients’ diagnostic steps and to interact with other health care personnel, and 3) a handover of the patients to a resident (30 min)
Summary
The clinical reasoning process, which requires biomedical knowledge, knowledge about problemsolving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians’ daily practice but difficult to assess. Clinical reasoning is a core element of medical practice. The thinking during a patient contact happens with the most likely diagnostic hypothesis being formed within the first minutes [1]. This hypothesis is confirmed, refined or ruled out as a result of further information through specific target-oriented questions [1]. The teacher often asks medical students only for a possible diagnosis and diagnostic tests leading to this diagnosis without considering the reasoning process itself [8]
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