Teaching Clinical Reasoning – A student’s perspective

Hello! I’m Ada, a junior doctor from Cracow, Poland. I would like to describe how teaching clinical reasoning looks like from a student’s perspective – I just graduated university in June, so my memories are still fresh. Let’s get on with it!

At Jagiellonian University in Cracow, clinical reasoining (CR) teaching started at the second year, with the course Introduction to the Clinical Sciences and Laboratory Training in Clinical Skills.

The first course lasted a whole year. We were divided into 9-person groups, each supervised by a teacher and served with patient’s cases. The aim was for each group to manage a case to the best of their abilities – gather information, outline which lab and imaging tests would be needed, and finally how to treat the patient. We were allowed to use any books and websites we deemed necessary as this was only the second year of our studies, and all we knew were basic sciences – anatomy, physiology, biochemistry etc. The teacher was more a moderator of our discussion, trying not to impose his views and solutions on us. At the end of each class, we summarized the most important issues about each case, and where we lacked knowledge the most. At the next class, volunteers gathered necessary information about the issues and delivered a short presentation to the rest of the group. I remember this course as a nice brainstorming experience, where every idea was valid and counted.

The second course lasted four years – till the end of our studies. We were learning how to gather information from patients, be it adult, pediatric or a “poor historian”. We also were taught how to examine a patient and how to suture wounds and even the basics of laparoscopy. There was a particular emphasis placed on an ability to communicate with a patient effectively, for example how to make sure they understand us and how to deliver difficult news. During this course we also had to solve virtual patients’ cases in the CASUS system. We were evaluated by OSCE on the third and last year of our studies.

At 4th, 5th and 6th years high fidelity simulations took place. This meant we were divided into 5-person teams, with one leader, and had to take care of a simulated patient or a mannequin. We mostly dealt with emergency cases there, and the ability to see how our actions affected, for example, the patient’s blood pressure or consciousness was irreplaceable. It once more evaluated our efficacy of gathering information, but for the first time we were able to test our ability to act promptly. On the 6th year we also had an occasion to work with a nurse as a part of our team, which bettered our interdisciplinary communication. After each case we analysed our steps with the supervising teacher – what was done right and what could be done better next time.

Above all, since the 3rd year we had clinical rotations, and while the aforementioned courses really added to my knowledge, the rotations really varied in quality. Of course, there were talented teachers, and going to their classes was an enlightening experience – but there were also teachers who acted as if they lacked ideas about how to make a student an active participant in classes or at least be heard. I don’t doubt their knowledge was vast – it’s just that sometimes it was hard for them to describe their reasoning process or they didn’t feel the need to do so to us – “it’s just done like that” or “it’s in the guidelines”; not to mention that many of them didn’t even know that clinical reasoning is something that can be actively taught. This way I feel that many opportunities to learn clinical reasoning in rotations were lost.

This is why I joined the DID-ACT project – I experienced from the first-person perspective on how much could be done to better the quality of teaching at medical universities. I’m also keen on teaching myself – and when I’ll become a teacher, I want to do it the best way possible. I’ve experienced classes where the topic didn’t seem too interesting, but the teacher transformed it into something fascinating and inspiring.

With all the professionals involved and great ideas created in the DID-ACT project, I think that it’s the best place to begin a change in teaching clinical reasoning.

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How to teach synchronously in a virtual setting

  • You need a reliable camera, microphone, and virtual platform and be familiar with its features, such as whiteboard, chat, polling, breakout rooms, etc.
  • At the beginning establish communication rules, e.g. whether participants should raise their (virtual) hand, use the chat, and/or just speak. Also, we recommend asking participants to turn on their camera
  • For small group work break out rooms work very well, just be clear about the tasks the groups should work on prior to dividing them into the groups.
  • For collaboration the use of integrated virtual whiteboards or other platforms such as Padlet are very useful. Just make sure prior to the session that you have everything setup and the links at hand, e.g. to post them in the chat.
  • Allow a bit more time for starting the session and the group works as there might be participants who are not familiar with the platform or technical problems might occur.

How to motivate unprepared participants

  • Make clear that the asynchronous assignments are a core part of the course and that its content will not be repeated. Even if it is difficult, stick to that when starting the synchronous teaching session.
  • If you expect unprepared participants, you can start the session with a student-centered group exercise mixing prepared and unprepared students to increase peer-pressure and make them realize that being unprepared does not feel good.  
  • Use the introductory or closing quizzes / tests so that participants can self- assess whether they have the required knowledge and you as a facilitator can see the level of knowledge and preparation of your participants.

Further recommended reading:

How to involve participants with different levels of experience

  • To account for such different levels, we recommend making use of the asynchronous preparatory phases which also include introductory quizzes in which participants can self-assess their prior knowledge and you as a facilitator can assess the differences within your group. Participants with less prior experience can also be guided to additional preparatory resources.
  • Encourage participants to work in pairs or small groups when preparing so that they can help and learn from each other. You could even facilitate this by dividing them into groups with different levels of experience.
  • Similarly, during the synchronous phases, we recommend forming groups with participants different levels of experience and emphasize the peer support aspects of such group activities.
  • We also recommend starting with rather smaller groups and allow more time than stated in the course outlines, if you expect a heterogenous level of experience. This way you can better manage this challenge.
  • Encourage your participants to ask questions, emphasizing that nobody knows everything and that it is important for learning to ask questions.  
  • Especially in the train-the-trainer course you might have to deal with over-confident participants, who especially in an interprofessional setting can dominate the group. This is a complex cultural challenge, but you could try to establish (and follow) communication rules at the beginning of a session.  

How to address potential overlaps or redundancies

  • Identify what is already included and what is missing in your curriculum related to clinical reasoning outcomes and compare it to the DID-ACT blueprint. Prioritize learning outcomes that are not yet covered but regarded as important.
  • Identify activities, resources, or teaching sessions with similar learning outcomes that might be in need for change anyway because of low evaluation results, teachers or students struggle with it. These could be suitable for adding or replacing parts with DID-ACT activities.
  • Ask teachers and students about overlaps and gaps they see in their teaching / learning of clinical reasoning and where they struggle. This could also be done by a reflection round after related teaching activities in the curriculum
  • Although ideally a longitudinal integration is aimed at, we recommend to starting small with a pilot implementation to gain experience and develop a show case.

How to teach in an interprofessional setting

  • Allow for enough time prior to the teaching for the organization and motivation / encouragement of stakeholders and participants
  • Allow for enough time and guidance during the course so that the participants from the different professions can get to know each other and their professions and discuss their different perspectives. This might mean that you need to calculate some extra time in addition to the suggested duration of the learning unit.
  • There may be a different understanding of clinical reasoning in the different health professions, so we recommend making participants aware of this. You could for example use and adapt activities from the learning units on the health profession roles to facilitate this.
  • Courses in an interprofessional setting should not come too early in the curriculum (not before professions have formed their own professional identity - however, this also depends on the aim of the course). 
  • Make sure you have enough participants from different professions. If possible, the facilitator could divide the participants in smaller groups with an equal distribution of professions. 
  • Similarly, you need an equal distribution of facilitators / facilitators from different professions.
  • Develop customized learning materials considering the different professions. If needed you can adapt the material and activities provided in the DID-ACT curriculum.

Further recommended reading:

van Diggele, C., Roberts, C., Burgess, A. et al. Interprofessional education: tips for design and implementation. BMC Med Educ 20, 455 (2020). (Link)

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