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: 3.47). 07/2010; 85(7):1118-24. DOI: 10.1097/ACM.0b013e3181d5dd0d
Source: PubMed

ABSTRACT 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.

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Available from: Jerome Kassirer, Aug 16, 2015
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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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    ABSTRACT: The Clinical Problem Identification of causes and immediate adjustment to treatment of acute thrombocytopenia occurring in patients in the intensive care unit is required to avoid imminent complications. Hence it is important to train awareness and clinical decision making of students in the medical curriculum. Therefore, real-life cases were transferred into an interactive eLearning platform comprising the steps of patient assessment and therapeutic decisions. Heparin-induced platelet count decrease is an immune-mediated prothrombotic disorder, resulting from an adverse drug reaction (Kelton and Warkentin, 2008). After cardiac surgery antibodies against circulating heparin—platelet factor (PF) four complexes develop in up to 50%. Patients experience a risk of 1–5% to acquire clinical symptoms of heparin-induced thrombocytopenia (HIT) (Warkentin et al., 2000; Linkins et al., 2012). Due to complications, mortality rates are high and amount to 5–10% (Kelton and Warkentin, 2008; Kelton et al., 2013). As clinical teaching case a 59-year-old male patient is presented, who was admitted to the intensive care unit (ICU) of the General Hospital of Vienna on extracorporeal life support (ECMO). The man underwent bypass surgery six days ago in a peripheral hospital and is concomitantly suffering from an active infection. On the fourth day at ICU a platelet count decrease has been noticed.
    Frontiers in Psychology 05/2015; 6. DOI:10.3389/fpsyg.2015.00473 · 2.80 Impact Factor
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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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    ABSTRACT: Abstract Clinical reasoning is a critical core competency in medical education. Strategies to support the development of clinical reasoning skills have focused on methodologies used in traditional settings, including lectures, small groups, activities within Simulation Centers and the clinical arena. However, the evolving role and growing utilization of virtual patients (VPs) in undergraduate medical education; as well as an increased emphasis on blended learning, multi-modal models that include VPs in core curricula; suggest a growing requirement for strategies or guidelines that directly focus on VPs. The authors have developed 12 practical tips that can be used in VP cases to support the development of clinical reasoning. These are based on teaching strategies and principles of instructional design and pedagogy, already used to teach and assess clinical reasoning in other settings. Their application within VPs will support educators who author or use VP cases that promote the development of clinical reasoning.
    Medical Teacher 12/2014; DOI:10.3109/0142159X.2014.993951 · 2.05 Impact Factor
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    • "During their professional journey from novice to expert, clinicians should develop their skills of criticality and their ability to reflect on, and analyse their practice experiences in and on action. This metacognitive competence can be developed by ensuring that PBL activities provide students with opportunities for a retrospective analysis of their performance immediately after the discussion of a case (Kassirer, 2010). Kassirer argued that in this retrospective analysis, students should, in collaboration with their tutors, discuss all kinds of diagnostic and cognitive errors, if there were any. "
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    ABSTRACT: Clinical decision making in osteopathy is heavily reliant on palpatory diagnostic findings. Although there is evidence that osteopathy is effective in the management of musculoskeletal conditions; the reliability of palpation as a diagnostic tool remains controversial. Research examining the reproducibility of diagnostic palpation consistently demonstrates that it lacks clinically acceptable levels of reliability. These findings might be explained by how individual perceptual judgments regarding the nature of the lesion or dysfunction are made and by the clinician’s level of professional expertise. Preliminary results from our research indicate that the development of expertise in diagnostic palpation is associated with changes in cognitive processing. Whereas the experts’ diagnostic judgments are heavily influenced by top-down, non-analytical processing; students rely primarily on bottom-up sensory processing from vision and haptics. Ongoing training and clinical practice are, arguably, likely to lead to changes in the osteopath’s neurocognitive architecture. This paper proposes a neurocognitive model of expertise in diagnostic palpation that has implications for osteopathic education and clinical practice. We argue that students and clinicians should be encouraged to appraise the reliability of different sensory cues in the context of clinical examination, combine sensory data from different channels, and consider using both analytical and non-analytical reasoning in their decision making. Importantly, they should develop their skills of criticality and their ability to reflect on, and analyse their practice experiences in and on action.
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