Clinical Diagnostic Reasoning Research Articles

Effectiveness of SNAPPS for improving clinical reasoning in postgraduates: randomized controlled trial

BackgroundIn-patient postgraduate teaching suffers with issues like long and unstructured presentations inclusive of a lot of historical information and time constraints due to increasing workload. A six-step pneumonic SNAPPS a learner-centered model modifies the learning encounter by condensing the reporting of facts while encouraging clinical reasoning. This study was planned with the aim to evaluate the effectiveness of SNAPPS as compared to traditional case presentation for facilitating clinical reasoning in inpatient setting. We also wanted to understand perceptions of postgraduates and teachers about this new method of case presentation.MethodsThis open labeled randomized controlled trial was carried amongst the 18 residents of department of Medicine, MGIMS. The teachers and residents in the SNAPPS were sensitized to SNAPPS technique by using videos, role plays and handouts over 2 sessions of 30 min each. Twenty-seven case presentations (3/resident) were carried out in each group (total 54 case presentations). Data was recorded into validated data recording sheet after each presentation and feedback was taken from the teacher as well as residents regarding their perception.ResultsThe SNAPPS model heralds a change in the preceptor training, pairing faulty development and learner development as companions in education. Guided by the SNAPPS technique, students summarized patient findings concisely (7 vs. 2.7 vs. 5.22vs. 2.33, p = 0.0057) while maintaining the same degree of thoroughness as in traditional case presentations. The students in the SNAPPS group were clearer about their diagnostic hypothesis and compared and contrasted their different diagnosis well (2.56 vs. 1.74, p value =0.002). The students in the SNAPPS group initiated patient management discussion almost 20% more times as compared to the control group.ConclusionWe conclude that SNAPPS a learner centered technique for case presentations facilitated the expression of clinical diagnostic reasoning and case based uncertainties in the inpatient setting without extending the unusual length of the student case presentations. It also paved way for enhanced self-directed learning.

Factors Determining Pakistani Medical Students' Career Preference for General Practice Residency Training.

BackgroundFew studies have explored factors affecting preference of medical students towards general practice as a career choice. We conducted a survey in Karachi across various public and private sector medical colleges to examine factors associated with students’ general practice career aspirations in Karachi, Pakistan.MethodsFrom January to March 2018, we distributed a 21-item questionnaire to final year medical students in eight medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item.ResultsA total of 1400 responses were obtained. The top five specialty fields chosen by students with their numbers were: internal medicine, 898 (64.2%); general practice, 337 (24.1%); pediatrics, 449 (32.1%); surgery, 380 (27.2%); and emergency medicine, 243 (17.4%). The “intent to inherit existing practice” and “other academic or professional experiences prior to medical school” had a positive association with choosing general practice while “having a physician parent’’ had a negative association among the medical students demographics after adjusting for other covariates in the multivariable logistic regression. Medical students who ranked “clinical diagnostic reasoning”, “community-oriented practice”, “involvement in preventive medicine”, and “frequent patient communication” as highly important were more likely to choose general practice, whereas, “access to advanced medical fields”, “mastering advanced procedures”, and “depth rather than breadth of practice” were less likely to be associated with general practice aspiration.ConclusionThe study’s results depicted limited interest of family medicine as a career option in graduating students, and pointed out the factors that likely influence the choice of general practice as a career are clinical diagnostic reasoning, community-oriented practice and preventive medicine.

What determines medical students\u2019 career preference for general practice residency training?: a multicenter survey in Japan

BackgroundFew studies have systematically explored factors affecting medical students’ general practice career choice. We conducted a nationwide multicenter survey (Japan MEdical Career of Students: JMECS) to examine factors associated with students’ general practice career aspirations in Japan, where it has been decided that general practice will be officially acknowledged as a new discipline.MethodsFrom April to December 2015, we distributed a 21-item questionnaire to final year medical students in 17 medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item.ResultsA total of 1264 responses were included in the analyses. The top three specialty choice were internal medicine: 833 (65.9%), general practice: 408 (32.3%), and pediatrics: 372 (29.4%). Among demographic factors, “plan to inherit other’s practice” positively associated with choosing general practice, whereas “having physician parent” had negative correlation. After controlling for potential confounders, students who ranked the following items as highly important were more likely to choose general practice: “clinical diagnostic reasoning (adjusted odds ratio (aOR): 1.65, 95% CI 1.40–1.94)”, “community-oriented practice (aOR: 1.33, 95% CI 1.13–1.57)”, and” involvement in preventive medicine (aOR: 1.18, 95% CI 1.01–1.38)”. On the contrary, “acute care rather than chronic care”, “mastering advanced procedures”, and “depth rather than breadth of practice” were less likely to be associated with general practice aspiration.ConclusionsOur nationwide multicenter survey found several features associated with general practice career aspirations: clinical diagnostic reasoning; community-oriented practice; and preventive medicine. These results can be fundamental to future research and the development of recruitment strategies.

Clinicopathological diagnostic discrepancies: An analysis of 1703 surgical pathology specimens

Background: Evaluation of error occurrence is a vital component of laboratory-quality assurance. One method of the measuring errors is by an assessment of discrepancies in clinical and pathology diagnosis. This study was carried out to determine the occurrence of such differences in our institution and to find out if any association exists between clinical diagnostic reasoning and the nature of the lesion. Materials and Methods: A 3-year retrospective analysis of surgical pathology specimen records was performed for report contents, clinical diagnosis, clinical suspicion, or diagnostic questions. Discrepancy index (Di) was calculated as the number of incompatible cases/total number of cases ×100. Results: An analysis of 1703 cases showed complete agreement between the clinical and pathology diagnosis in majority of the cases (1514, 89.9%) while discordance occurred in 189 (11.1%). There was more discrepancy in benign cases (12.3%, n = 1144) than malignant conditions (8.6%, n = 559). Using Chi-square test of independence, there was association between the nature of the lesion (benign or malignant) and diagnostic concordance (χ2 = 5.24, P = 0.02207) at 0.01 level of significance. There was more discordance in diagnosis of soft tissue lesions (Di = 23.8, n = 1587). Conclusion: This study suggests that greater discrepancies are likely to occur in the diagnoses of benign conditions than malignant diseases.

Writing Case Reports: Teaching and Tuition Techniques, and the Improvement of Clinical Diagnostic Reasoning

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Structured Didactic Education Program for Writing Case Reports Can Motivate Medical Students

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Teaching clinical diagnostic reasoning and research‐mindedness in obstetric and gynaecologic sonography online using Research Skills Development Framework

AbstractThe Australian Qualifications Framework (AQF) requires that graduates of postgraduate degrees have ‘specialised knowledge and skills for research, and/or professional practice and/or further learning’. Australian Sonographer Accreditation Registry (ASAR) accreditation standards now emphasise that medical sonography graduates need to graduate with research capacity in addition to clinical skills and align with AQF framework. To meet these requirements, University of South Australia medical sonography programs, which are delivered externally and online, underwent a major curriculum redesign and changes implemented in 2015. Research Skills Development Framework (RSDF) was embedded across the program to develop sonography‐specific research‐minded thinking for clinical reasoning. RSDF is a conceptual model utilising six facets of enquiry which are ‘embark and clarify’, ‘find and generate’, ‘critically evaluate’, ‘organise’, ‘synthesise and analyse’ and ‘communicate’. This paper reports the experience with RSDF in the online environment to develop problem solving skills, critical thinking and clinical reasoning in one clinical course within the programs, that is, the obstetric and gynaecologic sonography course. This process can be easily translated to the face to face clinical environment and may assist clinical supervisors in clinical supervision and training.

The Hot Zone: An Online Decision-centered Vignette Player for Teaching Clinical Diagnostic Reasoning Skills on the Management and Treatment of Patients with Malaria

The Hot Zone: An Online Decision-centered Vignette Player for Teaching Clinical Diagnostic Reasoning Skills on the Management and Treatment of Patients with Malaria

Education characteristics and inspirations of medical students of American David Geffen School of Medicine

This article describes the choosing and assessing methods during recruiting of medical students, the teaching methods by which basic and clinical curriculum as well as theoretical knowledge and practice of clinical diagnostic reasoning training are closely integrated, the Electronic network teaching plat-form, and the top-level design and management of teaching of David Geffen School of Medicine of the University of California at Los Angeles (UCLA) of the United States. We hope, by learning, to promote the progress and development of China's medical education. Key words: United States; China; Medical education; Teaching methods

Imaging in conjunction with physical therapy in management of a patient with history of thoracic tumour

Background:Physical therapy care for musculoskeletal conditions includes an ongoing process that systematically considers and prioritises diagnostic hypotheses. These diagnostic hypotheses include those that are typical for common musculoskeletal conditions, and must also include more rare conditions that would require care outside the scope of practice of the physical therapist. When additional screening is required, physical therapists collaborate with other providers or directly order the appropriate tests to rule out suspected pathology.Case Description:This article illustrates the use of musculoskeletal imaging ordered by a physical therapist to guide ongoing management of a patient with back pain and a history of cancer.Outcomes:The patient successfully returned to moderate-intensity sport activities after a course of physical therapy.Discussion:This case provides an example of how clinical diagnostic reasoning combined with clinical privileges to order musculoskeletal imaging can facilitate diagnostic accuracy in a timely and cost-efficient manner.

Clinical Diagnostic Reasoning of Tooth Pain

Clinical Diagnostic Reasoning of Tooth Pain

An Educational Model for Undergraduate Psychiatry Students to Promote Clinical Diagnostic Reasoning

In this paper we describe an educational model for undergraduate psychiatry students. In the proposed model, the contents of clinical cases are drawn from patients’ clinical data stored in the electronic medical records of the hospital. Teachers can develop a variety of learning materials and tasks based on real clinical cases, related to a variety of specific mental disorders. The clinical cases are presented to the students in an interactive format, to stimulate and enhance self-regulated learning as well as collaboration among students. The training model aims to develop and improve effective clinical reasoning skills in psychiatry students, through practicing the diagnostic skills and the competences of treatment definition of the principal psychiatric disorders previously studied from a theoretical point of view. To reach this objective, a collaborative training environment has been defined to reproduce each phase of the diagnosis process. During each phase, students are guided in carrying out individual and collaborative tasks, and they receive feedback from teachers about their performance. This work is based on the assumption that case-based learning programs represent an effective learning methodology for medical students.

A balance beam aid for instruction in clinical diagnostic reasoning.

We describe a balance beam aid for instruction in diagnosis (BBAID) and demonstrate its potential use in supplementing the training of medical students to diagnose acute chest pain. We suggest the BBAID helps students understand the process of diagnosis because the impact of tokens (weights and helium balloons) attached to a beam at different distances from the fulcrum is analogous to the impact of evidence to the relative support for 2 diseases. The BBAID presents a list of potential findings and allows students to specify whether each is present, absent, or unknown. It displays the likelihood ratios corresponding to a positive (LR+) or negative (LR-) observation for each symptom, for any pair of diseases. For each specified finding, a token is placed on the beam at a location whose distance from the fulcrum is proportional to the finding's log(LR): a downward force (a weight) if the finding is present and a lifting force (a balloon) if it is absent. Combining the physical torques of multiple tokens is mathematically identical to applying Bayes' theorem to multiple independent findings, so the balance beam is a high-fidelity metaphor. Seven first-year medical students and 3 faculty members consulted the BBAID while diagnosing brief patient case vignettes. Student comments indicated the program is usable, helpful for understanding pertinent positive and negative findings' usefulness in particular situations, and welcome as a reference or self-test. All students attended the effect of the tokens on the beam, although some stated they did not use the numerical statistics. Faculty noted the BBAID might be particularly helpful in reminding students of diseases that should not be missed and identifying pertinent findings to ask for.

Competency 6. Make informed diagnostic and therapeutic decisions that result in optimal clinical judgment

When considering the developmental progression of making informed diagnostic and therapeutic decisions that result in optimal clinical judgment, the role of previous clinical experience cannot be emphasized enough. 1 Schmidt H.G. Boshuizen H.P.A. On acquiring expertise in medicine. Educ Psychol Rev. 1993; 5: 205-221 Crossref Scopus (243) Google Scholar , 2 Patel V.L. Groen G.J. Patel Y.C. Cognitive aspects of clinical performance during patient workup: the role of medical expertise. Adv Heatlh Sci Educ. 1997; 2: 95-114 Crossref PubMed Scopus (30) Google Scholar , 3 Bordage G. Elaborated knowledge: a key to successful diagnostic thinking. Acad Med. 1994; 69: 883-885 Crossref PubMed Scopus (204) Google Scholar , 4 Bowen J.L. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006; 355: 2217-2225 Crossref PubMed Scopus (539) Google Scholar , 5 Schmidt H.G. Rikers R.M.J.P. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Educ. 2007; 41: 1133-1139 PubMed Google Scholar , 6 Schmidt H.G. Norman G.R. Boshuizen H.P.A. A cognitive perspective on medical expertise: theory and implications. Acad Med. 1990; 65: 611-621 Crossref PubMed Scopus (889) Google Scholar , 7 Chang R.W. Bordage G. Connell K.J. The importance of early problem representation during case presentations. Acad Med. 1998; 73: S109-S111 Crossref PubMed Scopus (82) Google Scholar , 8 Bordage G. Prototypes and semantic qualifiers: from past to present. Med Educ. 2007; 41: 1117-1121 Crossref PubMed Scopus (56) Google Scholar , 9 Coderre S. Mandin H. Harasym P.H. Fick G.H. Diagnostic reasoning strategies and diagnostic success. Med Educ. 2003; 37: 695-703 Crossref PubMed Scopus (232) Google Scholar With increasing clinical experience, learners do not simply gain new knowledge in an additive manner. Rather, they reorganize existing knowledge in an elaborated way that allows them to become more efficient and effective in diagnosing and treating new patients who possess features similar to those of previous patients. 1 Schmidt H.G. Boshuizen H.P.A. On acquiring expertise in medicine. Educ Psychol Rev. 1993; 5: 205-221 Crossref Scopus (243) Google Scholar , 2 Patel V.L. Groen G.J. Patel Y.C. Cognitive aspects of clinical performance during patient workup: the role of medical expertise. Adv Heatlh Sci Educ. 1997; 2: 95-114 Crossref PubMed Scopus (30) Google Scholar , 3 Bordage G. Elaborated knowledge: a key to successful diagnostic thinking. Acad Med. 1994; 69: 883-885 Crossref PubMed Scopus (204) Google Scholar , 4 Bowen J.L. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006; 355: 2217-2225 Crossref PubMed Scopus (539) Google Scholar This highly learner-specific knowledge is best gained through individual clinical experience, which is a necessary but not sufficient prerequisite for developmental advancement in making informed diagnostic and therapeutic decisions that result in optimal clinical judgment. As Kolb 10 Kolb D.A. Experiential Learning: Experience as the Source of Learning and Development. Prentice-Hall, Upper Saddle River, NJ1983 Google Scholar suggests in his experiential learning theory, this knowledge is strengthened through reflective observation, active experimentation (eg, in a simulation environment), and abstract conceptualization. In fact, the mental energy that is saved as one becomes more efficient and effective in diagnosing and treating new patients must be reinvested in reflection and new learning if one is ultimately to become an expert clinician and not just an experienced nonexpert. 11 Bereiter C. Scardemalia M. Surpassing Ourselves: An Inquiry Into the Nature and Implications of Expertise. Open Court, Chicago, Ill1993 Google Scholar

Preliminary Factor Analyses Raise Concerns about Script Concordance Test Utility

Purpose Script concordance tests (SCTs) are assessments purported to measure one’s ability to interpret clinical data, a key component of the clinical diagnostic reasoning process. The aim of this research was to directly examine the construct validity/dimensionality of SCTs using factor analysis.

Diagnostic Reasoning: Where We've Been, Where We’re Going

Recently, clinical diagnostic reasoning has been characterized by “dual processing” models, which postulate a fast, unconscious (System 1) component and a slow, logical, analytical (System 2) component. However, there are a number of variants of this basic model, which may lead to conflicting claims. This paper critically reviews current theories and evidence about the nature of clinical diagnostic reasoning. We begin by briefly discussing the history of research in clinical reasoning. We then focus more specifically on the evidence to support dual-processing models. We conclude by identifying knowledge gaps about clinical reasoning and provide suggestions for future research. In contrast to work on analytical and nonanalytical knowledge as a basis for reasoning, these theories focus on the thinking process, not the nature of the knowledge retrieved. Ironically, this appears to be a revival of an outdated concept. Rather than defining diagnostic performance by problem-solving skills, it is now being defined by processing strategy. The version of dual processing that has received most attention in the literature in medical diagnosis might be labeled a “default/interventionist” model,17 which suggests that a default system of cognitive processes (System 1) is responsible for cognitive biases that lead to diagnostic errors and that System 2 intervenes to correct these errors. Consequently, from this model, the best strategy for reducing errors is to make students aware of the biases and to encourage them to rely more on System 2. However, an accumulation of evidence suggests that (a) strategies directed at increasing analytical (System 2) processing, by slowing down, reducing distractions, paying conscious attention, and (b) strategies directed at making students aware of the effect of cognitive biases, have no impact on error rates. Conversely, strategies based on increasing application of relevant knowledge appear to have some success and are consistent with basic research on concept formation.

Conceptualization of category-oriented likelihood ratio: a useful tool for clinical diagnostic reasoning

BackgroundIn the diagnostic reasoning process medical students and novice physicians need to be made aware of the diagnostic values of the clinical findings (including history, signs, and symptoms) to make an appropriate diagnostic decision. Diagnostic reasoning has been understood in light of two paradigms on clinical reasoning: problem solving and decision making. They advocate the reasoning strategies used by expert physicians and the statistical models of reasoning, respectively. Evidence-based medicine (EBM) applies decision theory to the clinical diagnosis, which can be a challenging topic in medical education.This theoretical article tries to compare evidence-based diagnosis with expert-based strategies in clinical diagnosis and also defines a novel concept of category-oriented likelihood ratio (LR) to propose a new model combining both aforementioned methods.DiscussionEvidence-based medicine advocates the use of quantitative evidence to estimate the probability of diseases more accurately and objectively; however, the published evidence for a given diagnosis cannot practically be utilized in primary care, especially if the patient is complaining of a nonspecific problem such as abdominal pain that could have a long list of differential diagnoses. In this case, expert physicians examine the key clinical findings that could differentiate between broader categories of diseases such as organic and non-organic disease categories to shorten the list of differential diagnoses. To approach nonspecific problems, not only do the experts revise the probability estimate of specific diseases, but also they revise the probability estimate of the categories of diseases by using the available clinical findings.SummaryTo make this approach analytical and objective, we need to know how much more likely it is for a key clinical finding to be present in patients with one of the diseases of a specific category versus those with a disease not included in that category. In this paper, we call this value category-oriented LR.

The clinical diagnostic reasoning process determining the use of endoscopy in diagnosing peptic ulcer disease.

To evaluate the clinical diagnostic reasoning process as a tool to decrease the number of unnecessary endoscopies for diagnosing peptic ulcer disease. tudy Cross-sectional KAP study. Shifa College of Medicine, Islamabad, from April to August 2010. Two hundred doctors were assessed with three common clinical scenarios of low, intermediate and high pre-test probability for peptic ulcer disease using a questionnaire. The differences between the reference estimates and the respondents' estimates of pre-test and post test probability were used for assessing the ability of estimating the pretest probability and the post test probability of the disease. Doctors were also enquired about the cost-effectiveness and safety of endoscopy. Consecutive sampling technique was used and the data was analyzed using SPSS version 16. In the low pre-test probability settings, overestimation of the disease probability suggested the doctors' inability to rule out the disease. The post test probabilities were similarly overestimated. In intermediate pre-test probability settings, both over and under estimation of probabilities were noticed. In high pre-test probability setting, there was no significant difference in the reference and the responders' intuitive estimates of post test probability. Doctors were more likely to consider ordering the test as the disease probability increased. Most respondents were of the opinion that endoscopy is not a cost-effective procedure and may be associated with a potential harm. Improvement is needed in doctors' diagnostic ability by more emphasis on clinical decision-making and application of bayesian probabilistic thinking to real clinical situations.

Education debate: clinical diagnostic reasoning

Whilst it is clear that experienced clinicians adopt a rational approach of diagnosis, the logic of their clinical reasoning has been difficult to define. I outline here an approach based on the four categories of a complete diagnosis: Anatomical diagnosis (system involved); Pathological diagnosis (nature of the condition); Physiological diagnosis (functional consequences) and Aetiological diagnosis (background cause). Each phrase of the history and examination data is assigned to one or other of these categories as the case unfolds, with interpretations and interactions allowing sub-conclusions that gradually build to a final clinical diagnosis overall. The system has the advantage of facilitating a diagnosis individualized to the patient, rather than to some previously learned diagnostic 'checklist'. As such, it should provide an advance over current problem-based approaches to clinical diagnosis.

Virtual patient design and curricular integration evaluation toolkit

Context and setting Virtual patients (VPs) are used increasingly in medical education, especially to teach clinical reasoning. Under the electronic virtual patients (eVIP) Project (http://www.virtualpatients. eu), which is co-funded by the European Union, 320 VPs will be developed and repurposed to different cultures, languages and educational settings. Both the design and the curricular integration of VPs (blended learning) seem to be essential for their success. Why the idea was necessary To date, no standardised instruments to evaluate the design and curricular integration of VPs have been published. Extensive translational research at the practitioner level could add substantially to the limited knowledge we have about the affordances and limitations of VP design and curricular integration with regard to the teaching of clinical reasoning. What was done In order to enable adequate comparisons between the designs and curricular integration of VPs in different institutions, we developed four instruments with a special focus on clinical reasoning: (i) a checklist enabling reviewers such as teachers and authors to characterise the design of a VP in detail; (ii) a questionnaire assessing students’ experiences with VPs for learning clinical reasoning skills; (iii) a checklist enabling reviewers to characterise the curricular integration of VPs in detail, and (iv) a questionnaire assessing students’ experiences with the curricular integration of VPs in relation to clinical reasoning skills. The following sources informed the development of the VP design instruments: (i) literature on strategies to teach clinical reasoning; (ii) literature on the design of teaching cases, and (iii) the results of a focus group study exploring students’ opinions on the ideal design of VPs for learning clinical reasoning skills. The resulting student questionnaire consists of 14 questions clustered into the following five main categories: (i) authenticity of patient encounter and consultation; (ii) professional approach in the consultation; (iii) coaching during consultation; (iv) learning effect; (v) overall judgement. The following sources informed the development of the VP integration instruments: (i) literature on a community of inquiry model; (ii) a blended learning framework; (iii) criteria for categorising didactic scenarios; (iv) results of a focus group study exploring students’ opinions on the ideal curricular integration of VPs for learning clinical reasoning skills, and (v) literature concerning educational strategies to teach clinical diagnostic reasoning. The resulting student VP integration questionnaire consists of 20 questions, clustered in five main categories: (i) teaching presence; (ii) cognitive presence; (iii) social presence; (iv) learning effect, and (v) overall judgement. The comments resulting from the review of the instruments by the eVIP Project partners were used to refine them. The instruments were then tested on the target groups, further refined and again tested and refined. Responses are given on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Each instrument also includes open-ended questions. The multilingual instruments are available via the eVIP website (http://www.virtualpatients.eu/resources/ evaluation-tool-kit/). Evaluation of results and impact The first studies using the above-mentioned instruments indicate that the instruments are suitable for comparing and improving the design and curricular integration of VPs across national borders. We are looking forward to receiving feedback from others who have used the instruments.