Teaching Clinical Reasoning: Case-Based and Coached

Tufts University School of Medicine, Boston, Massachusetts, USA. <>
Academic medicine: journal of the Association of American Medical Colleges (Impact Factor: 2.93). 07/2010; 85(7):1118-24. DOI: 10.1097/ACM.0b013e3181d5dd0d
Source: PubMed


Optimal medical care is critically dependent on clinicians' skills to make the right diagnosis and to recommend the most appropriate therapy, and acquiring such reasoning skills is a key requirement at every level of medical education. Teaching clinical reasoning is grounded in several fundamental principles of educational theory. Adult learning theory posits that learning is best accomplished by repeated, deliberate exposure to real cases, that case examples should be selected for their reflection of multiple aspects of clinical reasoning, and that the participation of a coach augments the value of an educational experience. The theory proposes that memory of clinical medicine and clinical reasoning strategies is enhanced when errors in information, judgment, and reasoning are immediately pointed out and discussed. Rather than using cases artificially constructed from memory, real cases are greatly preferred because they often reflect the false leads, the polymorphisms of actual clinical material, and the misleading test results encountered in everyday practice. These concepts foster the teaching and learning of the diagnostic process, the complex trade-offs between the benefits and risks of diagnostic tests and treatments, and cognitive errors in clinical reasoning. The teaching of clinical reasoning need not and should not be delayed until students gain a full understanding of anatomy and pathophysiology. Concepts such as hypothesis generation, pattern recognition, context formulation, diagnostic test interpretation, differential diagnosis, and diagnostic verification provide both the language and the methods of clinical problem solving. Expertise is attainable even though the precise mechanisms of achieving it are not known.


Available from: Jerome Kassirer
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    • "Research on mental processes suggests that disease patterns are stored in " frames, " " clinical scenarios, " " semantic networks/qualifiers, " or " illness scripts. " Repeated presentation and exercising of clinical cases is known to be crucial for an efficient learning process (Norman, 2005; Kassirer, 2010). Implementation of the interactive case-based teaching method into the Medical Curriculum in Vienna was initiated in 2014. "
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    • "Reflection is another component in the development of clinical reasoning skills. This reflective process can include consideration of the issues raised in the case, assessment of the learner's choices, a summary of practice and learning points (Eva 2004; Kassirer 2010) and reminders of practice points (Williams et al. 2011). VP case authors can provide learners with opportunities for debriefing. "
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    • "Authors agree that experts' knowledge base is extensive, includes several types of knowledge, and is organised in a way that makes it usable in daily problem solving (Schmidt and Rikers 2007; Charlin et al. 2007; Bordage 2007). The development of clinical reasoning requires time, is critically dependent on exposure to multiple examples and on the repeated practice of solving clinical cases (Norman 2005; Schmidt and Rikers 2007; Kassirer 2010). Clinical exposure alone is insufficient. "
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