Work Package 2 Summary: What eating elephants and teaching clinical reasoning have in common

At the end of December 2020, the DID-ACT project consortium welcomed two things: the holidays and the successful completion of Work Package 2. This post aims to provide an update on what that entailed, what we completed, as well as provide a short overview of what we are going to be developing in Work Package 3. To begin, we will provide a brief overview of what we learned using the age-old rhetorical question: “How do you eat an elephant?” To which the answer is, “not in one bite”. 

This rhetorical question is often used to illustrate how overcoming large and complex challenges is done by dividing them into smaller chunks. That when broken down into bite size pieces, these challenges are easier to manage. In the case of the DID-ACT project and beyond, every clinician, educator or researcher who has tried to describe the nature of teaching clinical reasoning, has realized this challenge. As a team, we most definitely learned this throughout work package 2 as we represent a collection of diverse professionals with the same ultimate goal, but with different ideas on how to get there.

When broken down further, we explored and learned how teaching clinical reasoning is a challenge that is inherently multifaceted. One facet, for example, is the complexity of a clinical situation, a second, is the need to grasp the nature of the varied competencies required to address the situation at hand, and third is how to support the learning of these competencies effectively.

Developing a clinical reasoning framework

Last fall the DID-ACT consortium developed a clinical reasoning curriculum framework that included clinical reasoning quality criteria. In addition to the above challenges, we emphasized having an interprofessional clinical reasoning curriculum. Our interprofessional framework was conceived with the input from different nations and educational cultures, all conducted online due to the current pandemic. So – similar to a complex clinical situation, we faced a plethora of challenges when producing and describing a clinical reasoning framework. This work led us to the development of two curricula: one directed to health professions students and one for teachers.

What makes a good clinical reasoning curriculum?

When we zoomed out to get a clear idea of the big picture, we noted a few crucial pedagogical aspects: a strong focus on student-centeredness; a perspective in which the student takes responsibility for their own learning process; as well as a strong connection to relevant clinical situations which means that knowledge and competencies were applied to context. We also noted that the philosophy of “constructive alignment” will be used when designing our clinical reasoning learning units. In practice, this means that the intended learning outcome should direct choices when designing learning activities; thereby creating a harmony between the clinical reasoning learning activities and how they are assessed. This means that the intended learning outcomes hold a central position when designing your clinical reasoning learning activities, assessments, and learning units overall. That is why we structured our interprofessional clinical reasoning framework according to ~ 50 learning objectives in an interdisciplinary consensus process.

Categories for the DID-ACT student curriculum and the train-the-trainer course

DID-ACT’s Health Professions Education Framework

Did we eat the metaphorical elephant in this project phase? Yes! 

By using our various knowledge and skills collectively, then by dividing the bigger task into parts and iteratively working in small and greater teams, we put parts back together to form a much clearer picture. Building from Work Package 1, we had a framework that is grounded in an interdisciplinary needs analysis directed towards a breadth of European health professions schools to launch from. When taking our learning into WP2, our work entailed bringing forward and evaluating a large amount of open learning resources for clinical reasoning based on our desired learning outcomes. It was essential that these learning resources were accessible and of a strong quality for our online clinical reasoning curriculum. When we tied our learning objectives, outcomes, assessment ideas, and open resources together, we created a well-rounded, interprofessional framework and the beginnings of an actual online clinical reasoning course.

At this point, you are most welcome to look at our identified learning objectives, the framework and our recommendations to current national curricular descriptions on our reports page. Hopefully you and your school can benefit from them in order to support explicit learning of clinical reasoning. There is also a collection of existing open educational resources to support you, your students or colleagues that support 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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