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Assessing clinical reasoning in undergraduate medical students during history taking with an empirically derived scale for clinical reasoning indicators.

ABSTRACT: BACKGROUND:The clinical reasoning process, which requires biomedical knowledge, knowledge about problem-solving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians' daily practice but difficult to assess. The aim of this study was to empirically develop a Clinical Reasoning Indicators-History Taking-Scale (CRI-HT-S) and to assess the clinical reasoning ability of advanced medical students during a simulation involving history taking. METHODS:The Clinical Reasoning Indictors-History Taking-Scale (CRI-HT-S) including a 5-point Likert scale for assessment was designed from clinical reasoning indicators identified in a qualitative study in 2017. To assess indicators of clinical reasoning ability, 65 advanced medical students (semester 10, n =?25 versus final year, n =?40) from three medical schools participated in a 360-degree competence assessment in the role of beginning residents during a simulated first workday in hospital. This assessment included a consultation hour with five simulated patients which was videotaped. Videos of 325 patient consultations were assessed using the CRI-HT-S. A factor analysis was conducted and the students' results were compared according to their advancement in undergraduate medical training. RESULTS:The clinical reasoning indicators of the CRI-HT-S loaded on three factors relevant for clinical reasoning: 1) focusing questions, 2) creating context, and 3) securing information. Students reached significantly different scores (p

SUBMITTER: Furstenberg S

PROVIDER: S-EPMC7574202 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Assessing clinical reasoning in undergraduate medical students during history taking with an empirically derived scale for clinical reasoning indicators.

Fürstenberg Sophie S Helm Tillmann T Prediger Sarah S Kadmon Martina M Berberat Pascal O PO Harendza Sigrid S

BMC medical education 20201019 1

<h4>Background</h4>The clinical reasoning process, which requires biomedical knowledge, knowledge about problem-solving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians' daily practice but difficult to assess. The aim of this study was to empirically develop a Clinical Reasoning Indicators-History Taking-Scale (CRI-HT-S) and to assess the clinical reasoning ability of advanced medical students during a simulation involving history taking.<h4>Metho ...[more]

PMID: 33076879

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Project description:BackgroundThe illness script method employs a theoretical outline (e.g., epidemiology, pathophysiology, signs and symptoms, diagnostic tests, interventions) to clarify how clinicians organized medical knowledge for clinical reasoning in the diagnosis domain. We hypothesized that an educational intervention based on the illness script method would improve medical students' clinical reasoning skills in the diagnosis domain.MethodsThis study is a randomized controlled trial involving 100 fourth-year medical students in Shiraz Medical School, Iran. Fifty students were randomized to the intervention group, who were taught clinical reasoning skills based on the illness script method for three diseases during one clinical scenario. Another 50 students were randomized to the control group, who were taught the clinical presentation based on signs and symptoms of the same three diseases as the intervention group. The outcomes of interest were learner satisfaction with the intervention and posttest scores on both an internally developed knowledge test and a Script Concordance Test (SCT).ResultsOf the hundred participating fourth-year medical students, 47 (47%) were male, and 53 (53%) were female. On the knowledge test, there was no difference in pretest scores between the intervention and control group, which suggested a similar baseline knowledge in both groups; however, posttest scores in the intervention group were (15.74 ± 2.47 out of 20) statistically significantly higher than the control group (14.38 ± 2.59 out of 20, P = 0.009). On the SCT, the mean score for the intervention group (6.12 ± 1.95 out of 10) was significantly higher than the control group (4.54 ± 1.56 out of 10; P = 0.0001). Learner satisfaction data indicated that the intervention was well-received by students.ConclusionTeaching with the illness script method was an effective way to improve students' clinical reasoning skills in the diagnosis domain suggested by posttest and SCT scores for specific clinical scenarios. Whether this approach translates to improved generalized clinical reasoning skills in real clinical settings merits further study.

Project description:Background: Clinical reasoning refers to a thinking process including medical problem solving and medical decision making skills. Several studies have shown that the clinical reasoning process can be influenced by a number of factors, e.g. context or personality traits, and the results of this thinking process are expressed in case presentation. The aim of this study was to identify factors, which predict the quality of case summary statements as an indicator of clinical reasoning of undergraduate medical students in an assessment simulating the first day of residency. Methods: To investigate factors predicting aspects of clinical reasoning 67 advanced undergraduate medical students participated in the role of a beginning resident in our competence-based assessment, which included a consultation hour, a patient management phase, and a handover. Participants filled out a Post Encounter Form (PEF) to document their case summary statements and other aspects of clinical reasoning. After each phase, they filled out the Strain Perception Questionnaire (STRAIPER) to measure their situation dependent mental strain. To assess medical knowledge the participants completed a 100 questions multiple choice test. To measure stress resistance, adherence to procedures, and teamwork students took part in the Group Assessment of Performance (GAP) test for flight school applicants. These factors were included in a multiple linear regression analysis. Results: Medical knowledge and teamwork predicted the quality of case summary statements as an indicator of clinical reasoning of undergraduate medical students and explained approximately 20.3% of the variance. Neither age, gender, undergraduate curriculum, academic advancement nor high school grade point average of the medical students of our sample had an effect on their clinical reasoning skills. Conclusion: The quality of case summary statements as an indicator of clinical reasoning can be predicted in undergraduate medical students by their medical knowledge and teamwork. Students should be supported in developing abilities to work in a team and to acquire long term knowledge for good case summary statements as an important aspect of clinical reasoning.

Project description:Clinical reasoning for acute dyspnoea: Comparison of final-year medical students from discipline- and competency-based undergraduate programmes. BACKGROUND:The global shift to competency-based medical education aims to improve the performance of its trainees, including in the key competency domain of clinical reasoning. However, research on whether such education actually improves clinical reasoning is sparse. The purpose of this study is to compare assessed clinical reasoning performance in digitally presented cases of acute dyspnoea between final-year medical students from a traditional, discipline-based and those from an integrated, competency-based undergraduate programme. METHODS:A total of 60 medical students in their final-year clerkships participated in the study; 30 were from a discipline-based programme, and 30 were from a competency-based programme of the same faculty. The students completed a knowledge test consisting of 22 single choice items and a computer-based test of clinical reasoning with six video-based case scenarios with different underlying diseases leading to dyspnoea. The operationalized measures of clinical reasoning were the number and relevance of the diagnostic tests chosen, time to diagnosis and diagnostic accuracy. RESULTS:The two groups did not differ in their knowledge of the acute dyspnoea content domain. With regard to clinical reasoning, the selection of relevant tests, time required to make a diagnosis and accuracy of the diagnosis varied across the six case scenarios in both groups. However, the results from the measures of the clinical reasoning process did not differ between the students from the two types of undergraduate medical programmes. No significant differences were found with regard to the selection of relevant diagnostic tests (M?=?63.8% vs. M?=?62.8%), the time to a diagnosis (M?= 128.7?s vs. M?= 136.4?s) or the accuracy of diagnosis (M?=?82.2% vs. M?=?77.0%). CONCLUSIONS:Key indicators of the clinical reasoning process, when assessed with objectively measured parameters, did not differ between final-year medical students from a traditional, discipline-based and those from an integrated, competency-based undergraduate programme in the domain of acute dyspnoea. The results substantiate and expand those of previous studies based on subjective assessor ratings that showed limited change in the clinical reasoning performance of medical students with competency-based undergraduate education.

Project description:BACKGROUND:Over-testing of patients is a significant problem in clinical medicine that can be tackled by education. Clinical reasoning learning (CRL) is a potentially relevant method for teaching test ordering and interpretation. The feasibility might be improved by using an interactive whiteboard (IWB) during the CRL sessions to enhance student perceptions and behaviours around diagnostic tests. Overall, IWB/CRL could improve their skills. METHODS:Third-year undergraduate medical students enrolled in a vertically integrated curriculum were randomized into two groups before clinical placement in either a respiratory disease or respiratory physiology unit: IWB-based CRL plus clinical mentoring (IWB/CRL + CM: n = 40) or clinical mentoring only (CM-only: n = 40). Feasibility and learning outcomes were assessed. In addition, feedback via questionnaire of the IWB students and their classmates (n = 233) was compared. RESULTS:Analyses of the IWB/CRL sessions (n = 40, 27 paperboards) revealed that they met validated learning objectives. Students perceived IWB as useful and easy to use. After the IWB/CRL + CM sessions, students mentioned more hypothesis-based indications in a test ordering file (p < 0.001) and looked for more nonclinical signs directly on raw data tests (p < 0.01) compared with students in the CM-only group. Last, among students who attended pre- and post-assessments (n = 23), the number of diagnostic tests ordered did not change in the IWB/CRL + CM group (+ 7%; p = N.S), whereas it increased among CM-only students (+ 30%; p < 0.001). Test interpretability increased significantly in the IWB/CRL + CM group (from 4.7 to 37.2%; p < 0.01) but not significantly in the CM-only group (from 2.4 to 9.8%; p = 0.36). CONCLUSIONS:Integrating IWB into CRL sessions is feasible to teach test ordering and interpretation to undergraduate students. Moreover, student feedback and prospective assessment suggested a positive impact of IWB/CRL sessions on students' learning.

Project description:To successfully learn using open Internet resources, students must be able to critically search, evaluate and select online information, and verify sources. Defined as critical online reasoning (COR), this construct is operationalized on two levels in our study: (1) the student level using the newly developed Critical Online Reasoning Assessment (CORA), and (2) the online information processing level using event log data, including gaze durations and fixations. The written responses of 32 students for one CORA task were scored by three independent raters. The resulting score was operationalized as "task performance," whereas the gaze fixations and durations were defined as indicators of "process performance." Following a person-oriented approach, we conducted a process mining (PM) analysis, as well as a latent class analysis (LCA) to test whether-following the dual-process theory-the undergraduates could be distinguished into two groups based on both their process and task performance. Using PM, the process performance of all 32 students was visualized and compared, indicating two distinct response process patterns. One group of students (11), defined as "strategic information processers," processed online information more comprehensively, as well as more efficiently, which was also reflected in their higher task scores. In contrast, the distributions of the process performance variables for the other group (21), defined as "avoidance information processers," indicated a poorer process performance, which was also reflected in their lower task scores. In the LCA, where two student groups were empirically distinguished by combining the process performance indicators and the task score as a joint discriminant criterion, we confirmed these two COR profiles, which were reflected in high vs. low process and task performances. The estimated parameters indicated that high-performing students were significantly more efficient at conducting strategic information processing, as reflected in their higher process performance. These findings are so far based on quantitative analyses using event log data. To enable a more differentiated analysis of students' visual attention dynamics, more in-depth qualitative research of the identified student profiles in terms of COR will be required.

Project description:BackgroundA clinical diagnostic support system (CDSS) can support medical students and physicians in providing evidence-based care. In this study, we investigate diagnostic accuracy based on the history of present illness between groups of medical students using a CDSS, Google, and neither (control). Further, the degree of diagnostic accuracy of medical students using a CDSS is compared with that of residents using neither a CDSS nor Google.MethodsThis study is a randomized educational trial. The participants comprised 64 medical students and 13 residents who rotated in the Department of General Medicine at Chiba University Hospital from May to December 2020. The medical students were randomly divided into the CDSS group (n = 22), Google group (n = 22), and control group (n = 20). Participants were asked to provide the three most likely diagnoses for 20 cases, mainly a history of a present illness (10 common and 10 emergent diseases). Each correct diagnosis was awarded 1 point (maximum 20 points). The mean scores of the three medical student groups were compared using a one-way analysis of variance. Furthermore, the mean scores of the CDSS, Google, and residents' (without CDSS or Google) groups were compared.ResultsThe mean scores of the CDSS (12.0 ± 1.3) and Google (11.9 ± 1.1) groups were significantly higher than those of the control group (9.5 ± 1.7; p = 0.02 and p = 0.03, respectively). The residents' group's mean score (14.7 ± 1.4) was higher than the mean scores of the CDSS and Google groups (p = 0.01). Regarding common disease cases, the mean scores were 7.4 ± 0.7, 7.1 ± 0.7, and 8.2 ± 0.7 for the CDSS, Google, and residents' groups, respectively. There were no significant differences in mean scores (p = 0.1).ConclusionsMedical students who used the CDSS and Google were able to list differential diagnoses more accurately than those using neither. Furthermore, they could make the same level of differential diagnoses as residents in the context of common diseases.Trial registrationThis study was retrospectively registered with the University Hospital Medical Information Network Clinical Trials Registry on 24/12/2020 (unique trial number: UMIN000042831).

Project description:BackgroundReflective practice (RP) plays a crucial role in encouraging learners to think critically and consciously about their performances. Providing constructive feedback can further enhance RP. But non-Western learners might face different learning barriers compared to learners in the West, where RP originated.MethodsIn this retrospective study, we assessed RP and feedback performances on Thai medical students' patient history-taking skills. We applied RP and peer feedback, along with feedback from the instructors, during the history-taking sessions of the ten-week introduction course for fourth-year medical students. Twelve history-taking sessions were used for the analysis. Two instructors assessed students' reflective performance and categorised them into one of the six stages of Gibbs' reflective cycle; their feedback performances were analysed using Pendleton's model. We investigated the correlations between students' overall grade point average (GPAX) and patient history-taking scores on the Objective Structured Clinical Examination (OSCE). Students' opinions of the RP teaching method were also collected.ResultsAll (n = 48) students participated in our study. The students' mean age was 21.2 ± 0.5 years. The majority of the students were female (64.6%). The data indicated that 33 and 4% of the participants were categorised into the evaluation stage and action plan stage of Gibbs' reflective cycle, respectively. In addition, 22 and 15% of the participants were able to state what their peers did well and suggest how peers could improve their skills, respectively. All students passed the minimum passing level of four history-taking OSCE stations. Participants agreed that RP was a useful tool (mean 9.0, SD 0.1), which enhanced their thought processes (mean 8.4, SD 0.2) and future performances (mean 8.2, SD 0.2). However, there was no correlation between the students' highest Gibbs' reflection levels and their history-taking OSCE scores.ConclusionsRP, together with feedback, proved to be a useful technique to help fourth-year Thai medical students improve their reflection skills, enhance their medical knowledge, and improve patient history-taking skills. Further study with longer monitoring is required to further explore negative and positive influential factors affecting students' achievement of better reflection performances.

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Assessing clinical reasoning in undergraduate medical students during history taking with an empirically derived scale for clinical reasoning indicators.

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Assessing clinical reasoning in undergraduate medical students during history taking with an empirically derived scale for clinical reasoning indicators.

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