Learning Clinical Reasoning Research Articles

Hybrid PBL and Pure PBL: Which one is more effective in developing clinical reasoning skills for general medicine clerkship?-A mixed-method study.

This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students' perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students' perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient's chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one's own errors and selecting appropriate keywords from the whole aspect of the patient.

Developing and Integrating Asynchronous Web-Based Cases for Discussing and Learning Clinical Reasoning: Repeated Cross-sectional Study.

Trainees rely on clinical experience to learn clinical reasoning in pediatric emergency medicine (PEM). Outside of clinical experience, graduate medical education provides a handful of explicit activities focused on developing skills in clinical reasoning. In this paper, we describe the development, use, and changing perceptions of a web-based asynchronous tool to facilitate clinical reasoning discussion for PEM providers. We created a case-based web-based discussion tool for PEM clinicians and fellows to post and discuss cases. We examined website analytics for site use and collected user survey data over a 3-year period to assess the use and acceptability of the tool. The learning tool had more than 30,000 site visits and 172 case comments for the 55 published cases over 3 years. Self-reported engagement with the learning tool varied inversely with clinical experience in PEM. The tool was relevant to clinical practice and useful for learning PEM for most respondents. The most experienced clinicians were more likely than fellows to report posting commentary, although absolute rate of commentary was low. An asynchronous method of case presentation and web-based commentary may present an acceptable way to supplement clinical experience and traditional education methods for sharing clinical reasoning.

In-Person or Online? The Effect of Delivery Mode on Team-Based Learning of Clinical Reasoning in a Family Medicine Clerkship.

In health professions education, team-based learning (TBL) has been used to help learners develop clinical reasoning and decision-making skills. The COVID-19 pandemic has challenged institutions to move curriculum delivery from largely in-person to online. With the anticipated return to in-person instruction and arguments made in favor of online instruction in certain circumstances, evidence is needed to support decision making in curriculum planning. The purpose of this study was to examine the effect of delivery mode (in-person vs. online) on student learning of clinical reasoning and clinical decision-making (CR/CDM) in the family medicine clerkship. Data from three cohorts of third-year medical students were included in the study: 2018/2019 cohort, in-person; 2019/2020 cohort, half of the cohort in-person, half of the cohort online; 2020/2021 cohort, online. Students’ performance data—individual readiness assurance test (IRAT) and group readiness assurance test (GRAT) scores—were used. The Generalized Estimating Equations (GEE) analysis was performed. As expected, students scored higher in GRAT than IRAT across the three cohorts. No significant IRAT-GRAT differences were observed between in-person and online delivery of TBL sessions. Student learning of CR/CDM in TBL is comparable between the two modes of delivery in the family medicine clerkship. Future research in other clerkships, years of medical education, and professional programs is needed to inform decision making regarding the TBL delivery mode.

Implementation of the Blended Learning Method to Enhance Clinical Reasoning among Nursing Students

Clinical reasoning has an important role in nursing care. Therefore, an appropriate learning model is needed to produce great clinical reasoning among nursing students. The blended learning method is a flexible and technology-based learning model that has the potential to improve nursing students’ clinical psychomotor skills and overall performance. This study aims to determine the effect of the blended learning method on the clinical reasoning ability of nursing students. This was a quasi-experimental study that used a pretest-posttest design and a control group. The number of samples was 35 respondents in each group. The samples were recruited using a simple random sampling method. The intervention was conducted for 14 weeks in the intervention group. Clinical reasoning was measured using the Clinical Reasoning Assessment Tools (CRAT). Data were then analyzed using the Mann-Whitney test. There were differences in the clinical reasoning ability between the experimental group (p <0.001) and the control group (p = 0.128). A positive effect was found between the blended learning method and clinical reasoning ability among nursing students. Thus, a flexible learning process can provide repetition and continuity of the learning process and improve the students' critical thinking processes.

Collaborative clinical reasoning learning using an integrated care pathway in undergraduate interprofessional education: An explorative study

ABSTRACT Collaborative clinical reasoning (CCR) is part of interprofessional collaborative practice and aims to negotiate and manage patient problems. An integrated care pathway (ICP) can be used as a framework for developing comprehensive patient care, typically in a clinical setting. This study aims to explore the CCR process in undergraduate interprofessional teams and the use of ICP as guidance in discussing a patient’s problem and its comprehensive management. This is a qualitative study following phenomenology and was performed in an interprofessional education (IPE) program held by Health Science Cluster Universitas Indonesia. A total of four observations involving 40 students and four focus-group discussions involving 18 students from different health professions backgrounds were conducted to explore the CCR process using the ICP framework. In-depth interviews with four tutors from different health professions backgrounds and document analysis were also conducted as triangulation processes. This study shows that CCR was held in two stages – individual and group. The ICP framework could be used as a guiding tool in the CCR process to discuss the patient’s management and discharge plan. This study also demonstrates that there are several challenges in this learning process, including the clinical case used in the discussion, the need for prior knowledge and previous exposure to IPE and the ICP framework, and health professions’ dominance during the discussion. This study provides evidence on learning of CCR using the ICP framework as a guiding tool in a pre-licensure IPE program. This approach is useful for preparing students to develop an interprofessional, comprehensive, and holistic health care plan and to help them understand the roles of each profession.

Affect and Cognitive Closure in Students—A Step to Personalised Education of Clinical Assessment in Psychology with the Use of Simulated and Virtual Patients

Introduction: Since there was no general model of competencies to determine a successful clinical assessment, we based our study on the many skills that are needed to perform one. We analysed students’ learning performance based on inner determinants, such as affect and cognitive closure, with the use of two teaching methods (i.e., simulated patient (SP) or virtual patient (VP)). Methods: The sample comprised 56 fifth-year clinical psychology students. The need for closure (NFC) and efficacy in fulfilling the need for closure (EFNC) were measured using standardised questionnaires. The authors’ VP and SP tools were used to teach and measure the effectiveness of learning psychological interview techniques and clinical reasoning. Clinical interview skills included building contact with the patient, gathering important information and making mistakes. Clinical reasoning skills were divided into eight dimensions for the assessment of mental health. Results: Affect and cognitive closure are important psychological variables in anticipating and developing interview and clinical reasoning skills for psychology students. The simulated patient was more effective for interview skills, while the virtual patient was a beneficial teaching tool for most clinical reasoning skills. Virtual patient training was a useful teaching method for students with a low EFNC, probably because it provided a stable and strong structure. Simulated patient training was effective for people with a high EFNC, presumably because it allowed them to build on their advanced structuring skills. Conclusions: Affect and cognitive closure can be used to identify students’ learning abilities to provide a more personalised education. The results of the present study may be useful for evaluating different teaching methods, monitoring their effectiveness and enhancing students’ performance.

Clinical Reasoning Learning Sessions in COVID 19 Pandemic

Clinical reasoning teaching is an approach educational method based on learning and contextualized and synthesis education. The aim of this study was to determine the value of clinical reasoning teaching sessions, from the perspective of third year medical students using a self-administered questionnaire. One group of ten students participated in this study. They had clinical case sessions during three weeks. An anonymous evaluation self-administered questionnaire was submitted to the students at the end of the period. The average scores given by students for the items “quality of education”, “atmosphere”, “interest in teaching sessions” and “acquisition of new clinical knowledge” were greater than 7/10. All students opted for clinical reasoning teaching as the preferred teaching method for optimal memorization and have found a real contribution of reasoning teaching in the management of relationship with the patient. Clinical reasoning teaching session appears to be widely desired by medical students.

Mediating Effects of Cognitive Load on the Relationship Between Learning Flow and Clinical Reasoning Skills in Virtual Simulation Learning

BackgroundAlthough the demand for virtual simulation learning is increasing to substitute clinical practicum, there are a lack of studies that identify the relationships among learning flow, cognitive load, and clinical reasoning skills in virtual simulation learning. MethodsThis study was a cross-sectional survey with 148 nursing students who completed virtual simulation learning as a substitution for clinical practicum during the COVID-19 pandemic. Participants completed a web-based self-administered questionnaire. Data were analyzed using multiple regression analysis to identify the mediating effects of cognitive load on the relationship between learning flow and clinical reasoning skills. ResultsLearning flow and cognitive load were significant predictors of clinical reasoning skills. Cognitive load mediated the relationship between learning flow and clinical reasoning skills. ConclusionSimulation educators should apply best-practice standards by enhancing learning flow and cognitive load to achieve clinical reasoning skills in virtual simulation learning.

Learning clinical reasoning in the workplace: a student perspective

IntroductionClinical reasoning is a core competency for every physician, as well as one of the most complex skills to learn. This study aims to provide insight into the perspective of learners by asking students about their own experiences with learning clinical reasoning throughout the medical Master’s curriculum.MethodsWe adopted a constructivist approach to organise three semi-structured focus groups within the Master’s curriculum at the medical school of the Radboud University Medical Center in Nijmegen (Netherlands) between August and December 2019. Analysis was performed through template analysis.ResultsThe study included 18 participants who (1) defined and interpreted clinical reasoning, (2) assessed the teaching methods and (3) discussed how they used their context in order to learn and perform clinical reasoning during their clinical rotations. They referred to a variety of contexts, including the clinical environment and various actors within it (e.g. supervisors, peers and patients).ConclusionWith regard to the process by which medical students learn clinical reasoning in practice, this study stresses the importance of integrating context into the clinical reasoning process and the manner in which it is learnt. The full incorporation of the benefits of dialogue with the practice of clinical reasoning will require additional attention to educational interventions that empower students to (1) start conversations with their supervisors; (2) increase their engagement in peer and patient learning; (3) recognise bias and copy patterns in their learning process; and (4) embrace and propagate their role as boundary crossers.

THE EVALUATION OF THE LEARNING BY CLINICAL REASONING AMONG STUDENTS OF 3RD YEAR OF MEDICINE- FACULTY OF MEDICINE AND PHARMACY OF MARRAKESH

Clinical reasoning learning (CRA) is a teaching method based on interactive teaching. Its objective is to lead the student to acquire a diagnostic approach by developing a clinical reasoning. In order to evaluate this method of active teaching from the point of view of the medical student, we carried out a cross-sectional descriptive study among students of the 3rd year of medicine of the faculty of medicine and pharmacy of Marrakesh, having held out-patient clinics at the Mohamed VI university hospital in Marrakesh or at Ibn Sina Military Hospital and attended at least two CRA sessions during their day school curriculum. Data were collected during the last week of July 2016, via a quiz. One hundred and forty-two quiz were operated with a participation rate of 95%. Students reported that CRA sessions are interesting but insufficient. The CRA sessions had a very important place in medical education for 84% of our students and they had brought medical knowledge to the majority. The clinical reasoning learning made it possible to apply the theoretical knowledge acquired during the medical studies for 62% students and allowed to acquire medical skills for 95%. It turns out that the CRA is a teaching method which is appreciated by students and which is an interesting complement to the traditional forms of teaching.

Clinical Reasoning Needs to Be Explicitly Addressed in Health Professions Curricula: Recommendations from a European Consortium.

Clinical reasoning entails the application of knowledge and skills to collect and integrate information, typically with the goal of arriving at a diagnosis and management plan based on the patient’s unique circumstances and preferences. Evidence-informed, structured, and explicit teaching and assessment of clinical reasoning in educational programs of medical and other health professions remain unmet needs. We herein summarize recommendations for clinical reasoning learning objectives (LOs), as derived from a consensus approach among European and US researchers and health professions educators. A four-step consensus approach was followed: (1) identification of a convenience sample of the most relevant and applied national LO catalogues for health professions educational programs (N = 9) from European and US countries, (2) extraction of LOs related to clinical reasoning and translation into English, (3) mapping of LOs into predefined categories developed within the Erasmus+ Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators (DID-ACT) consortium, and (4) synthesis of analysis findings into recommendations for how LOs related to clinical reasoning could be presented and incorporated in LO catalogues, upon consensus. Three distinct recommendations were formulated: (1) make clinical reasoning explicit, (2) emphasize interprofessional and collaboration aspects of clinical reasoning, and (3) include aspects of teaching and assessment of clinical reasoning. In addition, the consortium understood that implementation of bilingual catalogues with English as a common language might contribute to lower heterogeneity regarding amount, structure, and level of granularity of clinical reasoning LOs across countries. These recommendations will hopefully motivate and guide initiatives towards the implementation of LOs related to clinical reasoning in existing and future LO catalogues.

The perceived relationship between reflective learning conversation and clinical reasoning skills amongst critical care and trauma nurses: A cross sectional parallel mixed method

BackgroundTo enhance clinical reasoning skills and reflective practices, Hamad Medical Corporation implemented a new educational initiative known as the reflective learning conversations method. The educational method was designed to discuss reflectively post real patient experiences. The reflective conversations aim to improve nurses' practices and ensure patient safety in the critical care and trauma units. ObjectivesThis study investigates the perceived relationship between reflective learning conversations method and clinical reasoning skills amongst critical care and trauma nurses, and explores how clinical reasoning skills can be developed through learning conversation activities. DesignA cross sectional parallel mixed methods study was conducted in Hamad Medical Corporation critical care and trauma units. Anonymous self-reported questionnaires were collected from 236 critical care and trauma nurses who attended the reflective learning conversation activities. Focus group interviews were concurrently conducted alongside the questionnaire survey. ResultsAttending reflective learning conversations educational activities has a significantly positive impact on critical care and trauma nurses' clinical reasoning skills. Reflective practice can be promoted and enhanced through the use of reflective learning conversations method. However, attending group reflection and the fear of feeling threatened are perceived barriers to reflective learning conversations. ConclusionsReflective learning conversations are perceived as an effective clinical education method to enhance the clinical reasoning skills of critical care and trauma nurses. There are barriers to effective learning conversation methods which need further in depth investigations considering gender and seniority factors.

Towards a New Platform Based on Web 2.0 Technologies Supporting Collaborative Clinical Reasoning Behavior Skills

Clinical Reasoning (CR) is a complex skill that must be learned by students during their training. However, it is difficult to learn and it is not immediately apparent how training should be organized to develop and improve students' clinical reasoning behavior. The use of Web 2.0 technologies in e-learning and e-health provides opportunities to consider effective teaching and learning methods, with an emphasis on collaboration. The importance of collaboration in medical education and practice is growing, and by working together professionals can build a better future. When a shared information need becomes a collaborative site, it is called Collaborative Information Behavior (CIB). To date, there is no system that fully supports CIB in clinical reasoning learning. This paper focuses on studies conducted in the field of CIB. In addition, research related to the clinical reasoning learning in medical pedagogy is also considered. A model dedicated to the design of a collaborative clinical reasoning behavioral environment in synchronous mode is proposed. The proposed model was concretized by a collaborative environment supporting behavioral competencies in collaborative clinical reasoning based on Web 2.0 technologies (MEDcollab), which aims to make student learning visible and accessible to educators.

The effectiveness of the iLearning application on chest tube care education in nursing students

BackgroundTube dislodgment has been ranked as the top three medical accidents for five years consecutively in Taiwan. Chest tube care accidents affect patient's health and life significantly. Typically, education on chest tube care focuses on the knowledge transmission with limited guiding nursing students in learning clinical reasoning. The Generation Z students prefer mobile devices. It is crucial to incorporate mobile applications to learning. PurposeThe purpose of this study was to evaluate effectiveness of the teaching intervention program (“iLearning app for chest tube care”) in improving nursing students' clinical reasoning ability and self-directed learning. MethodA quasi-experimental study with a cluster sample was used. A total of 107 nursing students were recruited with the intervention group (n = 53) using the “iLearning app” to learn chest tube care, and the comparison group (n = 54) using the “traditional teaching”. Data were collected before the intervention, one week and one month after the intervention. ResultThe result showed that there was no difference in clinical reasoning and self-directed learning between groups before the intervention. However, the intervention group showed significantly higher clinical reasoning and self-directed learning scores than the comparison group (p < .05) one week and one month after the intervention. It indicated that the students' clinical reasoning abilities and self-directed learning improved with implementation of the intervention. ConclusionThe results indicated that the “iLearning app” intervention improved the clinical reasoning and self-directed learning in nursing students. This intervention used situated learning with concept mapping to guide student learning and demonstrated effectiveness in improving their clinical reasoning ability. Immediate feedback of the course instructor might trigger deeper learning and self-correction of clinical reasoning. The “iLearning app” could be used as a tool to improve students' clinical reasoning and self-directed learning, and thus enhance lifelong learning.

The Effect of Case Presentation on Student Physical Therapists' Clinical Reasoning Hypotheses

Purpose: Clinical reasoning is an essential skill for Physical Therapists to develop for making sound decisions regarding patient care. Case-method teaching is an instructional strategy commonly implemented in physical therapy professional education programs for facilitating clinical reasoning skill acquisition. One advantage of case-method teaching is the various ways cases can be portrayed. The purpose of this study was to identify how a case is portrayed effects student thinking and their subsequent clinical decision making. Method: Third-year student physical therapists (n = 14) working in dyads clinically reasoned through a hypothetical musculoskeletal case presented via written case study or simulated patient experience. Talk aloud methodology via concurrent reports was implemented for data collection. Mann-Whitney U-tests followed by manual calculations of effect sizes were conducted for comparing hypothesis category generation between groups. Results: A total of 14 hypothesis categories were generated by the student dyads during the problem-solving sessions. Specifically, students generated more ideas regarding health condition, and contextual factors when thinking through a written case study whereas significantly more thoughts regarding symptom characteristics, client perspectives, and minimizing reasoning errors were generated during simulated patient experiences. Conclusion: When implementing case-method teaching, physical therapy academic educators need to be aware that the manner a case is portrayed affects the clinical judgements students generate and their learning of clinical reasoning. Future research should continue to investigate these effects and how they ultimately impact clinical practice.

Re-visioning clinical reasoning, or stepping out from the skull

The problem Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts. A solution Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, ‘extended’ cognition is configured as an outside-in process of ‘sensemaking’ or ‘adaptive expertise’. The future Current ‘predictive processing’ cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an ‘ecological perception’ or ‘externalistic’ model provides a counter to the current dominant paradigm of ‘ego-logical’ cognitive reasoning – the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.

Clinical reasoning: exploring its characteristics and enhancing its learning.

Clinical reasoning is an extensive and intricate field, dealing with the process of thinking and decision making in practice. Its study can be quite challenging because it is context and task dependent. Educational frameworks such as the conscious competence model and the dual process reasoning model have been developed to help its understanding. To enhance the learning of clinical reasoning, there are significant areas that can be targeted through learning processes. These include knowledge adequacy; ability to gather appropriate patient data; use of proper reasoning strategies to address specific clinical questions; and the ability to reflect and evaluate on decisions taken, together with the role of the wider practice community and the activity of professional socialisation. This article explores the characteristics of clinical reasoning and delves deeper into the various strategies that prove useful for learning.

Learning strategies used by undergraduate nursing students in the context of a digitial educational strategy based on script concordance: A descriptive study

Backgroundthe digital educational strategy based on script concordance is an educational method that has been attracting increasing attention in healthcare education programs to fostering the development of clinical reasoning. It includes a digitized Script Concordance Test with incorporated expert feedback. However, the learning strategies required of students in the context of its use remain unknown. ObjectiveThis study aimed to identify the learning strategies that undergraduate nursing students need to use in the context of the digital educational strategy based on script concordance. MethodA qualitative descriptive design was used to identify student learning strategies. Data was collected using an online questionnaire and semi-directed focus group interviews. Bégin's taxonomy provided the framework for linking the data collected to learning strategies required of students. ResultsForty-four students participated in the study. Results show that when using a digital educational strategy based on script concordance, students are called to rely on their nascent scripts in order to select the data in short ill-defined clinical vignettes, evaluate new information repeatedly, anticipate microjudgments, and thus, gradually increase their knowledge and refine their scripts. Viewing the experts' feedback and consulting the referencing tools helped students self-monitor their knowledge, a key metacognitive strategy to learning clinical reasoning. Completed individually or with peers, the digital educational strategy could be used to learn a particular concept or as an integrative activity before an evaluation. ConclusionThis original study has allowed us to link nursing clinical reasoning teaching conditions to the learning strategies used to develop this competency. Study results inform instructors about digital educational strategy based on script concordance to make it complementary with other educational strategies to better support complex learning of nursing clinical reasoning.

Effects of a Blood Transfusion Course Using a Blended Learning Approach on the Acquisition of Clinical Reasoning Skills among Nursing Students in Morocco

learning clinical reasoning skills in nursing education is a challenge for teachers and students. This study investigated the effects of a blended learning program on the acquisition of clinical reasoning skills via a blood transfusion course. The study employed a two group randomised controlled design with an experimental group (group 1, 16 students) and a control group (group 2, 16 students) recruited from a population of second-year nursing students at the Mohamed VI University of Health Sciences in Casablanca, Morocco, during the 2018–2019 academic year. The experimental group received blended instruction, while the control group received traditional classroom instruction over four sessions. One month after the experiment, a post-test was conducted with both groups using 'key-feature questions' that included four clinical situations and 30 questions. The mean scores of the two groups were compared to assess the degree of acquisition of clinical reasoning skills. The mean post-test score was significantly higher in the experimental group than the control group (the p-value of the Mann-Whitney Test is less than 0.05). Moreover, a statistically significant correlation was detected between students' clinical reasoning scores and their theoretical examination marks. These results suggest that blended learning is useful for enhancing the clinical reasoning skills of nursing students, at least in the short term. Thus, it seems appropriate to develop more blended courses and integrate this approach into nursing education programs.

Barriers to Learning Clinical Reasoning: a Qualitative Study of Medicine Clerkship Students.

Clinical reasoning is crucial to good patient care, but both learning and applying clinical reasoning skills in the context of a complex working environment can be challenging. We sought to understand the perceived barriers to learning clinical reasoning, as experienced by internal medicine clerkship students at our institution. We invited internal medicine clerkship students to participate in focus groups to discuss their experiences with and barriers to learning clinical reasoning. A survey was administered to gather additional responses. Responses were reviewed, coded, and synthesized to identify key themes. Twenty-nine medicine clerkship students (male = 14, female = 15) participated in six 60-minute focus groups, and 121 (61% response rate) students responded to the barriers to clinical reasoning survey from March 2018 to May 2019. We identified three themes (clerkship acclimation, data access, and practice optimization) and ten subthemes as aspects of the clerkship environment that impacted students' ability to develop clinical reasoning skills. Students identified barriers to learning clinical reasoning during the internal medicine clerkship. The themes "clerkship acclimation" and "data access" were identified as prerequisites to clinical reasoning while the theme "practice optimization" described key components of the deliberate practice of clinical reasoning. Educators and health systems may improve the development of clinical reasoning by recognizing and overcoming these barriers within clinical learning environments.