Clinical Reasoning and Case-Based Decision Making: The Fundamental Challenge to Veterinary Educators

Stephen A May

doi:10.3138/jvme.0113-008r

Abstract

Confusion about the nature of human reasoning and its appropriate application to patients has hampered veterinary students' development of these skills. Expertise is associated with greater ability to deploy pattern recognition (type 1 reasoning), which is aided by progressive development of data-driven, forward reasoning (in contrast to scientific, backward reasoning), analytical approaches that lead to schema acquisition. The associative nature of type 1 reasoning makes it prone to bias, particularly in the face of "cognitive miserliness," when clues that indicate the need for triangulation with an analytical approach are ignored. However, combined reasoning approaches, from the earliest stages, are more successful than one approach alone, so it is important that those involved in curricular design and delivery promote student understanding of reasoning generally, and the situations in which reasoning goes awry, and develop students' ability to reason safely and accurately whether presented with a familiar case or with a case that they have never seen before.

Highlights

In an ideal world, every patient would display unambiguous signs of disease conforming to classical text-book descriptions, and the clinician’s pharmacy would be an assembly of rational and efficacious therapeutic agents which would collectively address all the diseases of the animal kingdom! the ideal world is not the real world, and a series of limitations relating to all aspects of diagnosis and therapy make veterinary medicine “a science of uncertainty”
As modernising curricula introduce both formal learning and assessment of clinical reasoning, students in one school have complained that they are being told in the clinics that they should not engage in "pattern recognition" but that the assessment is pushing them to think in that way[4]
The intention of this paper is to explore the elements involved in clinical reasoning and case-based decision-making, expose some of the myths that have arisen over what students should and should not do, and demonstrate how sound pedagogical principles can guide those involved in curriculum design and delivery in this fundamental area of student learning

Summary

Introduction

The main advantages of PBL in medical education appear to be greater engagement of students in their own learning, leading to superior interpersonal skills and retention of knowledge compared to the assessment-driven tendency to a "learn and forget" strategy seen with traditional programmes[40] This supports the view that, in all types explicit attention to data-driven, forward reasoning, and how it contrasts with the hypothetico-deductive scientific method, is appropriate from the earliest stages. As already indicated, the key focus for students needs to be data-driven, forward reasoning, involving analytical approaches that lead progressively to schema acquisition and expertise, rather than hypothesis-driven strategies that frequently lead to poorer quality problem solving[42] This means that the area in the diagnostic process where students need to work hard is at the level of the clinical signs, and the systems affected in their patients, and not, in the first instance, the level of lists of diagnoses (Table 4). The matrix approach can help students resolve issues they themselves may have in relation to legal requirements and the economics of animal care and practice

Conclusions

Scientific Method

Findings

Conclusion only reached if sustainable