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.

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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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    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.
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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.
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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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    Full-text · Article · Dec 2014 · Advances in Health Sciences Education
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