Development Of Clinical Reasoning Research Articles

Immediate vs Delayed Feedback in a Progressive Musculoskeletal E-module Case for Clinical Reasoning Development

Immediate vs Delayed Feedback in a Progressive Musculoskeletal E-module Case for Clinical Reasoning Development

Evaluating Clinical Reasoning in Undergraduate Medical Education: The Value of a Virtual Oral Assessment.

Oral assessments are essential components of board certification in numerous fields, as they provide insight into problem-solving capacity and clinical reasoning. The development of clinical reasoning often begins in undergraduate medical education and remains a challenge to assess. We developed a pilot oral assessment to evaluate medical student oral presentations and systematically assess clinical reasoning. This was incorporated into a previously existing cumulative assessment at the conclusion of the third year of medical school, with the intent to demonstrate feasibility and future reliability of this exam format. This pilot oral assessment was developed using content taught during third year clerkships. A modified Assessment of Reasoning Tool (ART) was used as the evaluation metric. It was conducted virtually to include faculty members from multiple disciplines and accommodate schedules and space limitations. A total of 152 third year medical students completed the exam, with a total of 15 faculty examiners. 89% of medical students scored as complete in hypothesis directed history, 93% in problem representation, 86% in prioritized differential diagnoses, and 67% in effectively directing management. Most examiners felt an oral assessment is effective to determine a medical student's clinical reasoning ability. Virtual oral assessments of clinical reasoning can be incorporated in undergraduate medical education to identify students struggling with components of clinical reasoning, while also allowing maximum flexibility for the clinician educator workforce as examiners. Longitudinal use of these exams would be valuable to track the development of clinical reasoning across the medical school curriculum.

Learning clinical reasoning skills during the transition from a medical graduate to a junior doctor

Introduction: The literature confirms the challenges of learning clinical reasoning experienced by junior doctors during their transition into the workplace. This study was conducted to explore junior doctors' experiences of clinical reasoning development and recognise the necessary adjustments required to improve the development of clinical reasoning skills. Methods: A hermeneutic phenomenological study was conducted using multiple methods of data collection, including semi-structured and narrative interviews (n=18) and post-consultation discussions (n=48). All interviews and post-consultation discussions were analysed to generate themes and identify patterns and associations to explain the dataset. Results: During the transition, junior doctors’ approach to clinical reasoning changed from a ‘disease-oriented’ to a ‘practice-oriented’ approach, giving rise to the ‘Practice-oriented clinical skills development framework’ helpful in developing clinical reasoning skills. The freedom to reason within a supportive work environment, the trainees’ emotional commitment to patient care, and their early integration into the healthcare team were identified as particularly supportive. The service-oriented nature of the internship, the interrupted supervisory relationships, and early exposure to acute care settings posed challenges for learning clinical reasoning. These findings highlighted the clinical teachers' role, possible teaching strategies, and the specific changes required at the system level to develop clinical reasoning skills among junior doctors. Conclusion: The ‘Practice-oriented clinical skills development framework’ is a valuable reference point for clinical teachers to facilitate the development of clinical reasoning skills among junior doctors. In addition, this research has provided insights into the responsibilities of clinical teachers, teaching strategies, and the system-related changes that may be necessary to facilitate this process. Keywords: Clinical Reasoning, Medical Decision Making, Medical Graduates, Junior Doctor Transition, Hermeneutic Phenomenology, Qualitative Research

High-fidelity simulation versus case-based discussion for training undergraduate medical students in pediatric emergencies: a quasi-experimental study

ObjectiveTo evaluate the effect of high-fidelity simulation of pediatric emergencies compared to case-based discussion on the development of self-confidence, theoretical knowledge, clinical reasoning, communication, attitude, and leadership in undergraduate medical students. Methods33 medical students were allocated to two teaching methods: high-fidelity simulation (HFS, n = 18) or case-based discussion (CBD, n = 15). Self-confidence and knowledge tests were applied before and after the interventions and the effect of HFS on both outcomes was estimated with mixed-effect models. An Objective Structured Clinical Examination activity was conducted after the interventions, while two independent raters used specific simulation checklists to assess clinical reasoning, communication, attitude, and leadership. The effect of HFS on these outcomes was estimated with linear and logistic regressions. The effect size was estimated with the Hedge's g. ResultsBoth groups had an increase in self-confidence (HFS 59.1 × 93.6, p < 0.001; CDB 50.5 × 88.2, p < 0.001) and knowledge scores over time (HFS 45.1 × 63.2, p = 0.001; CDB 43.5 × 56.7, p-value < 0.01), but no difference was observed between groups (group*time effect in the mixed effect models adjusted for the student ranking) for both tests (p = 0.6565 and p = 0.3331, respectively). The simulation checklist scores of the HFS group were higher than those of the CBD group, with large effect sizes in all domains (Hedges g 1.15 to 2.20). ConclusionHFS performed better than CBD in developing clinical reasoning, communication, attitude, and leadership in undergraduate medical students in pediatric emergency care, but no significant difference was observed in self-confidence and theoretical knowledge.

Analysis of Patient Information and Differential Diagnosis with Clinical Reasoning in Pre-Clinical Medical Students

Background: The development of clinical reasoning (CR) abilities in Thai medical students during their pre-clinical years lacked well-designed establishment. Methods: This study utilized a pre-test and post-test design without a control group and was conducted at Walailak University, Thailand, in May 2022. We collected participant baseline characteristics and compared scores evaluated by the instructor and participants before and after the intervention. Additionally, we conducted a post-intervention survey on workshop satisfaction, perspectives on CR, and its learning impact. Results: Nineteen third-year medical students were included in the analysis, and twelve (63.2%) were women. The mean age was 20.6 years (standard deviation, SD: 0.5). The total score evaluated by the instructor after the intervention (8.95; SD, 1.81) was significantly higher than that before the intervention (1.68; SD, 0.67), p &lt; 0.001. The total score evaluated by the participants after the intervention (8.22; SD = 1.44) was significantly higher than that before the intervention (2.34; SD, 2.06), p &lt; 0.001. Overall, satisfaction was high. Conclusions: A short interactive workshop effectively taught CR principles and practice to Thai third-year medical students. These findings support the possibility of implementing this in pre-clinical curricula to prepare them for clinical practice.

Comparative study of outcome of the Teaching methods for Early Clinical Exposure in 1st Professional MBBS students: Ward side patient demonstration method Vs Video &amp; Dummy patient demonstration method

Background: Early Clinical Exposure (ECE) is a newer concept of teaching learning methodology which provides clinical perspective and relevance to learning of basic sciences. ECE also orients towards actual clinical scenarios and helps the medical students to correlate their theoretical knowledge with real life situations right from the first year of medical college. Aims and Objectives: This study aimed to compare the outcome of teaching methods for Early Clinical Exposure in 1st Professional MBBS students and to assess the effect and efficiency in their performance. Materials and Methods: This prospective comparative study was carried with a sample population of 50 students of MBBS 1st prof. 2021 batch who were selected by random allocation method and divided into two groups of 25 students each, one acting as Bedside ECE group and other as Virtual ECE group. Pre training evaluation was performed at the beginning of study and Post training evaluation was performed after three months. The student’s feedback was taken regarding advantages, disadvantages and suggestions for further improvement. Results: A statistically significant difference was observed between the Bedside ECE and Virtual ECE group at post training in theory (t=15.682, p&lt;0.001), practical (t=12.671, p&lt;0.001) and total (t=17.460, p&lt;0.001) marks of the students after 3 months training. The mean scores of participants were significantly improved more in the Bedside ECE group (39.92±3.23) as compared to Virtual ECE group (23.04±3.60). Analysis of students’ feedback revealed that Bedside ECE was found to be more interesting method of teaching as compared to virtual methods and helped to develop empathy towards the patients as well as motivated them to read more about the topic and helped in retention. Conclusion: Direct contact with patient has been seen to play a crucial role in development of clinical reasoning, communication skills and professional attitudes. The concept of Bedside Early Clinical Exposure goes longway in helping young minds in grasping clinical and theoretical concepts better by involving all domains of learning. KEY WORDS: Competency Based Medical Education, Early Clinical Exposure, Empathy, Reflection, Bedside ECE, Virtual ECE

The Effects of Pediatric Experiential Learning During a 1-Week Intensive

Background and Purpose. Growing evidence supporting the effectiveness of pediatric experiential learning (EL) in physical therapist education programs suggests that EL can aid in the development of students' clinical reasoning (CR) and self-efficacy (SE). Previous studies indicate that pediatric EL provides students with structured learning opportunities that may lead to meaningful gains in psychomotor skills, self-confidence, communication, and CR. Whether gains can be achieved during a pediatric intensive course rather than a semester-long course is unknown. The purpose of this research was to evaluate the change in perceived CR and SE experienced by physical therapist students who completed a high-dose (at least 15 hours) EL pediatric-intensive (1 week). Case Description. Second-year physical therapist students (n = 18) enrolled in the Advanced Pediatric Elective Intensive completed the Self-Assessment of Clinical Reflection and Reasoning (SACRR) and the Physical Therapy Self-Efficacy Scale (PTSE) on the first and last day of the course. Outcomes. A paired-samples t test revealed a statistically significant increase in SACRR scores from pre-test (M = 91.29, SD = 8.04) to post-test (M = 102.88, SD = 7.06), t (16) = 7.30, P &lt; .001, as well as PTSE scores from pre-test (M = 13.44, SD = 2.64) to post-test (M = 19.00, SD = 2.06), t (17) = 9.70, P &lt; .001. The results of this research suggest that active teaching methods, such as EL, may contribute to improvements in physical therapist students' perceived CR and SE. Discussion and Conclusion. Educators could consider a week-long EL intensive as a feasible and effective option to increase physical therapist students' perceived CR and SE related to pediatric physical therapy practice.

An Online Learning Experience Simulating Video Telehealth with Older Adults: Student Perceptions.

Older adults are an underserved population with a broad-spectrum of care needs due to multi-morbidity, including increasing rates of mental health conditions. Though a prime target for tele-behavioral health due to access barriers, older adults face a persistent digital divide that necessitates clinician training and education to ensure interprofessional tele-behavioral health is tailored to their needs. This paper presents findings from a simulation learning program designed to teach students about the role of video telehealth with populations with diverse needs. Occupational therapy (OT) students enrolled in a Master's program between 2017 and 2018 conducted a simulated video telehealth session geared for an older adult. Sessions were recorded and annotated by students, who then provided feedback on their experience of the simulation via reflective essays (N = 27). Essays were analyzed using conventional content analysis with themes revealing the benefits of simulation in providing students with an opportunity to experience the often unpredictable nature of video telehealth. Themes also revealed perceived limitations of video and the negative impact of age-related conditions and age itself on older adults' ability to engage in video, reflecting ageist stereotyping and bias as potential barriers to novice practitioners' integration of video telehealth with older adults. Simulation provides students an opportunity to engage in active learning and problem-solving in the moment, fostering students' development of clinical reasoning while promoting reflective practice. Findings reveal the importance of supporting students' recognition of biased attitudes to ensure equitable application of tele-behavioral health care, especially to populations with complex needs.

Neurocognitive Correlates of Clinical Decision Making: A Pilot Study Using Electroencephalography.

The development of sound clinical reasoning, while essential for optimal patient care, can be quite an elusive process. Researchers typically rely on a self-report or observational measures to study decision making, but clinicians' reasoning processes may not be apparent to themselves or outside observers. This study explored electroencephalography (EEG) to examine neurocognitive correlates of clinical decision making during a simulated American Board of Anesthesiology-style standardized oral exam. Eight novice anesthesiology residents and eight fellows who had recently passed their board exams were included in the study. Measures included EEG recordings from each participant, demographic information, self-reported cognitive load, and observed performance. To examine neurocognitive correlates of clinical decision making, power spectral density (PSD) and functional connectivity between pairs of EEG channels were analyzed. Although both groups reported similar cognitive load (p = 0.840), fellows outperformed novices based on performance scores (p < 0.001). PSD showed no significant differences between the groups. Several coherence features showed significant differences between fellows and residents, mostly related to the channels within the frontal, between the frontal and parietal, and between the frontal and temporal areas. The functional connectivity patterns found in this study could provide some clues for future hypothesis-driven studies in examining the underlying cognitive processes that lead to better clinical reasoning.

Enhancing clinical reasoning with Chat Generative Pre-trained Transformer: a practical guide.

This study aimed to elucidate effective methodologies for utilizing the generative artificial intelligence (AI) system, namely the Chat Generative Pre-trained Transformer (ChatGPT), in improving clinical reasoning abilities among clinicians. We conducted a comprehensive exploration of the capabilities of ChatGPT, emphasizing two main areas: (1)efficient utilization of ChatGPT, with a focus on application and language selection, input methodology, and output verification; and (2) specific strategies to bolster clinical reasoning using ChatGPT, including self-learning via simulated clinical case creation and engagement with published case reports. Effective AI-based clinical reasoning development requires a clear delineation of both system roles and user needs. All outputs from the system necessitate rigorous verification against credible medical resources. When used in self-learning scenarios, capabilities of ChatGPT in clinical case creation notably enhanced disease comprehension. The efficient use of generative AIs, as exemplified by ChatGPT, can impressively enhance clinical reasoning among medical professionals. Adopting these cutting-edge tools promises a bright future for continuous advancements in clinicians' diagnostic skills, heralding a transformative era in digital healthcare.

Teaching Clinical Reasoning inthe Preclinical Period.

Developing the clinical reasoning skills necessary to becoming an astute diagnostician is essential for medical students. While some medical schools offer longitudinal opportunities for students to practice clinical reasoning during the preclinical curriculum, there remains a paucity of literature fully describing what that curriculum looks like. As a result, medical educators struggle to know what an effective clinical reasoning curriculum should look like, how it should be delivered, how it should be assessed, or what faculty development is necessary to be successful. We present our Introduction to Clinical Reasoning course that is offered throughout the preclinical curriculum of the Uniformed Services University of the Health Sciences. The course introduces clinical reasoning through interactive lectures and 28 case-based small group activities over 15 months.The curriculum is grounded in script theory with a focus on diagnostic reasoning. Specific emphasis is placed on building the student's semantic competence, constructing problem lists, comparing and contrasting similar diagnoses, constructing a summary statement, and formulating a prioritized differential diagnosis the student can defend. Several complementary methods of assessment are utilized across the curriculum. These include assessments of participation, knowledge, and application. The course leverages clinical faculty, graduate medical education trainees, and senior medical students as small group facilitators. Feedback from students and faculty consistently identifies the course as a highly effective and engaging way to teach clinical reasoning. Our Introduction to Clinical Reasoning course offers students repeated exposure to well-selected cases to promote their development of clinical reasoning. The course is an example of how clinical reasoning can be taught across the preclinical curriculum without extensive faculty training in medical education or clinical reasoning theory. The course can be adapted into different instructional formats to cover a variety of topics to provide the early learner with sequential exposure and practice in diagnostic reasoning.

COMPARISON OF TRADITIONAL- AND CASE-BASED METHOD FOR LEARNING PHYSIOLOGY AMONG 1ST YEAR MBBS STUDENTS

Objective: The medical science of physiology is both basic and applied. Traditional physiology instruction is teacher-centered, with little involvement from the students. A self-directed learning strategy focused on training through the use of personal narratives is known as case-based learning (CBL). The present study was conducted to assess the effectiveness of CBL method in teaching physiology among 1st year MBBS students. Methods: This study was conducted among 1st year MBBS students of 2022–2023 batch. The study design included a pre-test, a CBL discussion on a specific topic, and a post-test following the CBL session. MS Excel and SPSS version 23 were used to gather, tabulate, and statistically analyze the data. Results from the pre-and post-tests were compared using the student’s “t” test, and p&lt;0.05 was regarded as statistically significant. The 12 questions that made up the feedback survey were all expressed as percentages. Results: When pre-and post-test results were compared, the post-test score after the CBL session was significantly better than the pre-test score of the session. The majority of students supported CBL activities. In student feedback, more than 95% of the students thought CBL classes helped interaction among them. More than 94% of the students thought CBL classes helped in clearing doubts, helped in increasing interest. More than 91% of the students thought CBL classes improved conceptual thinking. Conclusion: Through active learning, CBL can be utilized as an addition to lectures to augment standard teaching/learning approaches. It encourages the drive to learn and the development of clinical reasoning

The development of clinical reasoning throughout the training and career of psychiatrists in Singapore.

The current study sought to explain how different professional experiences led Singaporean psychiatrists to alter their clinical reasoning processes as their careers evolved from psychiatry residents to senior consultant psychiatrists. The current qualitative study interviewed 26 clinicians at various stages of their psychiatric career, spanning residents to senior psychiatrists. The authors used a constructivist grounded theory approach to structure the collection and analysis of data. Analyses produced a dense theoretical explanation rooted in the experiences of participants. Several differences emerged between the way psychiatry residents and senior psychiatrists explained their reasoning process and the experiences on which they based their preference. Residents preferred using deductive logic-driven frameworks that were diagnosis-centric, because of the pressures they experienced during their training and assessments. Senior psychiatrists emphasized a more holistic and problem-centric approach. Participants attributed the changes that occurred over time to practical experiences, such as their greater clinical responsibility and independence, and individual experiences, such as growing sensitivity to the clinical reasoning process or their growing propensity for professional reflectiveness. These changes manifest as an increase in repertoire and flexibility in deployment of different clinical reasoning strategies. It is important for trainees to be aware of the deductive and inductive modes of clinical reasoning during supervision and to be comfortable with shifting clinical focus from diagnoses to specific individual problems. Training programs should provide and plan adequate longitudinal clinical exposure to develop clinical reasoning abilities in a way that allows consequences of decisions to be explored. Continued faculty development to ease the diversification of clinical reasoning skills should be encouraged, as should reflectivity in the learners during clinical supervision.

Transformative learning in clinical reasoning: a meta-synthesis in undergraduate primary care medical education

ABSTRACT Clinical reasoning is a vital medical education skill, yet its nuances in undergraduate primary care settings remain debated. This systematic review explores clinical reasoning teaching and learning intricacies within primary care. We redefine clinical reasoning as dynamically assimilating and prioritising synthesised patient, significant other, or healthcare professional information for diagnoses or non-diagnoses. This focused meta-synthesis applies transformative learning theory to primary care clinical reasoning education. A comprehensive analysis of 29 selected studies encompassing various designs made insights into clinical reasoning learning dimensions visible. Primary care placements in varying duration and settings foster diverse instructional methods like bedside teaching, clinical consultations, simulated clinics, virtual case libraries, and more. This review highlights the interplay between disease-oriented and patient-centred orientations in clinical reasoning learning. Transformative learning theory provides an innovative lens, revealing stages of initiation, persistence, time and space, and competence and confidence in students’ clinical reasoning evolution. Clinical teachers guide this transformation, adopting roles as fortifiers, connoisseurs, mediators, and monitors. Patient engagement spans passive to active involvement, co-constructing clinical reasoning. The review underscores theoretical underpinnings’ significance in shaping clinical reasoning pedagogy, advocating broader diversity. Intentional student guidance amid primary care complexities is vital. Utilising transformative learning, interventions bridging cognitive boundaries enhance meaningful clinical reasoning learning experiences. This study contributes insights for refining pedagogy, encouraging diverse research, and fostering holistic clinical reasoning development.

Pharmacy students' perceptions of clinical reasoning development through a foundational thinking application framework

Background and purposePharmacy students must learn to integrate the foundational and clinical sciences to make therapeutic decisions. There is a need for a developmental framework and scaffolding tools to bridge foundational knowledge with clinical reasoning among novice learners in pharmacy education. Our purpose is to describe the development and student perceptions of a framework designed to integrate foundational knowledge and clinical reasoning in second-year pharmacy students. Educational activity and settingUsing script theory as a conceptual model, a Foundational Thinking Application Framework (FTAF) was designed around a four-credit Pharmacotherapy of Nervous Systems Disorders course at the beginning of the second year of the doctor of pharmacy curriculum. The framework was implemented as two structured learning guides known as a unit plan and a pharmacologically based therapeutic evaluation. A total of 71 students in the course were asked to complete a 15-question online survey assessing perceptions towards specific components of the FTAF. FindingsOf 39 survey respondents, 37 (95%) described the unit plan as a useful organizer for the course. Thirty-five (80%) students agreed or strongly agreed that the unit plan helped organize instructional material for a given topic. Students (n = 32, 82%) preferred the pharmacologically based therapeutic evaluation format, with text comments highlighting that it provided good practice for clinical experiences and helped to organize critical thinking. SummaryOur study found that students had positive perceptions of FTAF's implementation within a pharmacotherapy course. Pharmacy education can benefit by adapting script-based strategies that have been successful in other health professions.

Reasons for Provider-to-Provider Synchronous Teleconsultations Between Nurses in Primary Care: A Cross-Sectional Study of TelessaúdeRS-UFRGS Service.

Introduction: Nurses have proven to be fundamental for the expansion and consolidation of primary health care (PHC), as well as the development of digital health strategies. We explored the results of a synchronous telephone teleconsultations service between professionals for nurses in Brazil. Methods: This is a cross-sectional study. We retrieved data from teleconsultations registry. All teleconsultations answered by the team of nurses between September 2018 and July 2021 were analyzed regarding the reasons (according to International Classification of Primary Care, 2nd edition-ICPC-2) and decisions of the teleconsultation. Results: There were 9,273 phone teleconsultations registered in the period, requested by 3,125 nurses from all states throughout the country, of which 56.9% called once and 15.9% used the teleconsultations at least 4 times. We found 362 different reasons for solicitations, which were classified according to the ICPC-2 chapters. The most frequent codes were respiratory (25.9%), general and unspecified (21.2%), and skin (21.2%), which corresponded to 68% of the total sample. Most teleconsultations (66.9%) had as outcome the maintenance of the case at PHC. Conclusion: Teleconsultations are widely used and address a broad number of situations. This service may improve the quality of Brazilian PHC and promote the development of clinical reasoning and critical thinking by nurses.

Characteristics and processes of registered nurses' clinical reasoning and factors relating to the use of clinical reasoning in practice: a scoping review.

The objective of this review was to examine the characteristics and processes of clinical reasoning used by registered nurses in clinical practice, and to identify factors reported to relate to the use of clinical reasoning by registered nurses in clinical practice. Significant variability in the clinical reasoning of graduate registered nurses has been identified in research, with underdeveloped and unsafe clinical reasoning being linked to failure-to-rescue and sentinel events in the clinical setting. The identification of characteristics and processes of clinical reasoning, and factors relating to registered nurses' clinical reasoning when engaged in clinical practice, will increase understanding of the clinical reasoning requirements for undergraduate registered nurses and of potential factors that may affect their clinical reasoning. Studies including registered nurses who met the criteria for registered nurse registration in Australia and who used clinical reasoning to engage with health care consumers in all practice environments were eligible for inclusion. Eight databases were searched, with articles identified through CINAHL, MedNar, PubMed, Science Direct, ERIC, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Database searches were conducted on December 31, 2020, and updated August 20, 2021, with primary qualitative and quantitative research studies in English from 2000 onwards considered for inclusion. Opinion papers, text, and reports were not included. Data were extracted based on the draft charting tool from the scoping review protocol, with results presented in tabular format and in a narrative summary. The 29 qualitative and 5 quantitative research studies included in the scoping review utilized exploratory descriptive, descriptive rationalist, narrative, ethnography, correlational, observational, and grounded theory methodologies in their research designs. Observation, think-aloud sessions, questionnaires, surveys, interviews, and focus groups were used to collect data from the 1099 participants in 9 countries. Multiple concepts related to the characteristics (n=35) and processes (n=30) of clinical reasoning were detected in the research studies, with 5 categories identified: i) situation management, ii) data management, iii) interpreting, iv) implementing and evaluating, and v) professional practice, with an additional processes category identified (decision-making processes). The factors (n=26) reported to relate to clinical reasoning were categorized into environment of care, care requirements, professional practice, experience, knowledge, and decision-making processes. Connections between the various concepts were evident throughout the review. The scoping review identified characteristics and processes of clinical reasoning, as well as factors reported to relate to clinical reasoning in all studies. The concepts that comprise the clinical reasoning of registered nurses in clinical practice must be considered in undergraduate registered nurse education. Registered nurses must complete their baccalaureate program with well-developed clinical reasoning to ensure safe clinical practice. Understanding the characteristics and processes of registered nurses' clinical reasoning in clinical practice, and the factors reported to relate to clinical reasoning, supports the creation of targeted resources for development and assessment of clinical reasoning.

Analysis of Expert Feedback to Determine Intellectual Standards for Student Pharmacist Clinical Reasoning Development

Objectives. Clinical reasoning (CR) is one of the most important skills for pharmacy learners. Feedback has been proposed as a pedagogy to improve CR skills; however, essential components of CR have yet to be determined within pharmacy education. This study sought to streamline feedback to align with the Pharmacists' Patient Care Process (PPCP).Methods. The investigators used deidentified clinical reasoning "Keep," "Start," or "Stop" (KSS) feedback comments from student-written CR "think-aloud" sessions with pharmacy students in their third professional year. Sections were mapped to the PPCP and were coded by 2 independent investigators according to proposed essential components of CR, using an adapted grounded-theory approach. Investigators could inductively add codes after conferring with the other. Coded feedback was analyzed using a summative content approach. Intercoder reliability was calculated via Holsti index.Results. Five essential components of CR were identified after analysis of 635 KSS comments. The 5 essential components of CR were coded 1178 times. "Accurate," "Concise," "Specific," and "Thorough" were identified a priori, while "Connected" was discovered during feedback comment review. Literature analysis added supporting data to these results through the Paul-Elder Critical Thinking Framework. To maintain consistency in language, these essential components will be referred to as "intellectual standards" moving forward.Conclusion. This novel study successfully identified 5 key intellectual standards of CR. These intellectual standards provide a framework for pharmacy educators to focus feedback to improve student CR. Future research of other intellectual standards pertinent to experiential education is imperative.

An integrated pre-clerkship curriculum to build cognitive medical schema: It's not just about the content.

Both physiology and pathophysiology are essential disciplines in health professional education however, clinicians do not use this knowledge in isolation. Instead, physicians use inter-disciplinary concepts embedded within integrated cognitive schema (illness scripts) established through experience/knowledge that manifest as expert-level thinking. Our goal was to develop a pre-clerkship curriculum devoid of disciplinary boundaries (akin to the physician's illness script) and enhance learners' clerkship and early clinical performance. As well as developing curricular content, the model considered non-content design elements such as learner characteristics and values, faculty and resources and the impact of curricular and pedagogical changes. The goals of the trans-disciplinary integration were to develop deep learning behaviors through, 1) developing of integrated, cognitive schema to support the transition to expert-level thinking, 2) authentic, contextualization to promote knowledge transfer to the clinical realm 3) allowing autonomous, independent learning, and 4) harnessing the benefits of social learning. The final curricular model was a case-based approach with independent learning of basic concepts, differential diagnosis and illness scripting writing, and concept mapping. Small-group classroom sessions were team-taught with basic scientists and physicians facilitating learners' self-reflection and development of clinical reasoning. Specifications grading was used to assess the products (written illness scripts and concept maps) as well as process (group dynamics) while allowing a greater degree of learner autonomy. Although the model we adopted could be transferred to other program settings, we suggest it is critical to consider both content and non-content elements that are specific to the environment and learner.

Initial validation of a script concordance test to measure the development of clinical reasoning among physical therapy residents

Rationale: Clinical reasoning (CR) skills of physical therapy (PT) residents may be limited by a lack of clinical experience, and the complexity of neurologic and elderly patients requires individualized approaches for prescribing walking assistive devices (ADs). Script concordance tests (SCTs), which are case-based assessments that present information that the test taker must examine before answering, can measure the growth in CR. The purpose was to validate a SCT designed to measure CR growth in residents for walking AD prescription. Methods: Using a prospective cohort design, a panel of 20 experienced practicing clinicians reviewed the test content and provided the correct answers. Neurologic and geriatric residencies were identified from the American Board of Physical Therapy Residencies and Fellowships database. Residency directors were informed of the study, and 27 of them provided access to their residents. Residents gave assent in month 1 and were followed through month 6. The SCT and instructions were emailed at both time points. In total, 27 month-1 tests and 20 month-6 tests were returned. Fleiss kappa was used to evaluate the consistency of the clinician panel’s and the residents’ responses at both time periods. Mean scores for the panel and the residents at months 1 and 6 were calculated. Testing for differences between the clinician panel and the residents at months 1 and 6 was assessed using a Mann-Whitney U test, and testing for differences between the residents at the same time points was assessed using a Wilcoxon signed rank test. Results: Demographics of the clinical panel and residents are presented. Internal consistency was moderate, and chance agreement was fair in both groups. Mean test scores were 34.8 (4.3), 34.5 (4.1), and 36.3 (3.9) points for the panel, and residents at months 1 and 6, respectively. Concordance of choices on the SCT between the clinician panel and residents was similar at month 1 and grew more concordant by month 6. Conclusion: The SCT did not differentiate between the practicing clinicians’ and residents’ CR skills to prescribe ADs. Further research comparing the CR of PT residents to PT clinicians in early practice should be undertaken since the residents’ responses were consistent with the practicing clinicians. The unique test construction or the clinician panel, whose members were not required to be board certified, may have introduced error.