No Clinical Reasoning Without Me – It’s Time to Put the Client’s Perspective in the Forefront

Generally, clinical reasoning refers to a health professional’s thinking and decision-making process. It guides practical actions, implying a process limited to the cognitive activities of health professionals. In more elaborated definitions of clinical reasoning, we may also find concepts such as collaboration and context. These imply a broader view of the reasoning process where the client and situational factors also come into play. The number of definitions of clinical reasoning are innumerable. Variations within and between different professional disciplines are equally as many. There is no established singular definition of the nature, relevant components or boundaries of a health professional’s clinical reasoning. The co-existence of multiple definitions leads to a plethora of variation in clinicians’ view(s) of clinical reasoning. These variations in turn influence their consistent and uniform application of reasoning in practice.

My name is Maria Elvén, I’m a lecturer and researcher in physiotherapy. In my PhD-work, focusing on clinical reasoning in physiotherapy, clinical reasoning was studied from a biopsychosocial and person-centred perspective. As such, clinical reasoning in relation to health and illness are dependent on biomedical, psychological and social aspects. Accordingly, to be in ‘good health’ represents different realities for different individuals. This variation emphasizes the need to grasp the persons’ individual perceptions. We must understand their own definitions of health and life situation in tandem, with their mental and bodily status from a health care perspective in the clinical reasoning process. Person-centredness, e.g., that the clinician considers the unique needs and specific health concerns of the person, and treats the individual as competent to make decisions about their own care, is a way to empower clients to take an active part in the clinical reasoning process.

Let’s pause here and reflect! Based on your view/definition of clinical reasoning, what is the goal of the clinical reasoning process? A correct diagnostic decision? A well-performed analytical thought process? A well-founded treatment decision? A satisfied clinician? A satisfied client? 

If I ask myself these questions, the ultimate goal of effective clinical reasoning is that the client achieves their own goal(s) related to their current health problem. To be able to reach this goal, the clinical reasoning process cannot be confined to the mind of the clinician, the process needs to be articulated and shared with the client. To make full use of the client as an active partner in the clinical process, shared treatment decisions are not sufficient. The client needs to be aided in supporting their role as an important  contributor to the analysis of the problem as well. This process also involves selecting and prioritizing among various treatments and management strategies that fit their actual life situation, as well as continuously evaluate their effectiveness.

We have covered a lot of ground surrounding the clinician’s inner process. The next step is to look beyond the cognitive processes of the clinician and to further elaborate on what meaningful client participation and involvement implies in the reasoning process. As suggested in my definition of clinical reasoning in physiotherapy, clinical reasoning is a process performed in partnership between the client and the clinician; ultimately stressing their shared responsibilities and equal values (Elvén, 2019). Performance of such reasoning may need training and competence development for clinicians to be able to support clients in their role as clinical reasoning partners.  

That brings us to where we are today and what I am hoping to bring into the DID-ACT project. In the DID-ACT project, the client perspective in clinical reasoning is clearly in focus. This is done by the inclusion of learning objectives related to client participation and shared decision-making. These learning objectives will influence learning activities and assessments in the forthcoming clinical reasoning curriculum development. The aim is that the client-perspective will play an increasingly important role in the learning and teaching of clinical reasoning in this project. 

I’m looking forward to contributing to a strengthened role for the client or patient in general health care, and, more specifically, clinical reasoning and I hope you’ll join me!

Elvén, M. (2019) Clinical reasoning focused on clients’ behaviour change in physiotherapy: Development and evaluation of the Reasoning 4 Change instrument. Doctoral dissertation. Mälardalen University. Västerås.

Curricular Framework for DID-ACT

We published our most recent deliverable this week: Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators.

Team meeting to discuss the framework and work in virtual small groups

The goal of this deliverable was to provide our curricular framework with teaching/ assessment methods for the student curriculum and the train-the-trainer course.

Having already established our initial needs assessment and definition of goals and objectives (Deliverable 2.1), we have reached the exciting point of providing educational strategies in terms of a curriculum framework for clinical reasoning. We followed the constructive alignment theory to ensure an optimal alignment of learning objectives, teaching, and assessment. We have employed a theme-based approach. We plan to continue using a blended-learning format to help ensure flexibility for our learners while also utilizing an optimal match of teaching and assessment. 

Blended learning combines online activities, such as virtual patients and interactive videos, with face-to-face methods such as bedside teaching. We aim for our courses to have the learner at the centre, meaning that the student is actively engaged in their learning. In this set up, the teacher is more to support and facilitate learning. 

Some of our biggest wins in this work package have been:

  • Defining 35 general learning objectives in D2.1 and aligned them in 14 themes/ categories to describe the DID-ACT student curriculum and the train-the-trainer course.
  • We have defined four different learner levels: Novice, Intermediate, Advanced, and Teacher. 
  • Our list of suitable learning and assessment methods that align with our previously defined categories.
  • A breakdown of our teaching and learning assessment strategies for clinical reasoning clearly defined. 
  • Overarching curricular outline for the categories, theories, errors, and aspects of patient participation related to the clinical reasoning process. These outlines include the specific learning objectives, teaching and learning activities, as well as assessments, both summative and formative, for our courses. 

Our most recent deliverable is a big step as it establishes the framework for the next steps in our curriculum development process. Our team is both multi-professional international; thereby reflecting the needs of the different health profession curricula and curricular formats of the partner schools. Due to the current COVID-19 pandemic, we could not organize as originally planned in a face-to-face meeting to discuss the framework. However, we were able to organize the work in small groups across professions and contexts who worked asynchronously and met online according to their needs. In addition, we held a series of online meetings to discuss specific aspects and make decisions in consensus. 

Read more about the deliverable in detail here.

What’s next? Coming later in December 2020 will be our “Collection of available Open Educational Resources (OER)”, “Publication of recommendations for learning objectives of a clinical reasoning curriculum”, and our “Set of evaluation and analysis tools”

You can keep track of what is upcoming in the project on our Results page, or by clicking here. 

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.

DID-ACT at AMEE 2020

The Association for Medical Education in Europe (AMEE) is one of the biggest organisations focused on excellence and research in health professions education. It has been organising annual conferences for scholars engaged in this topic for close to 50 years.  The interest in these meetings is rising and has reached the level of around 4000 participants last year. The DID-ACT consortium decided to disseminate its outcomes at AMEE by submitting an abstract informing about the results of the project’s needs analysis.

This year’s conference was originally planned to be held in Glasgow, United Kingdom, however, changes had to be made due to the ongoing COVID-19 pandemic; AMEE’s traditionally face-to-face format was adapted to be a virtual conference that  rose to the challenge and exceeded expectations. Rather than following suit to mainstream reliance on primarily traditional audio-video teleconferencing tools, AMEE took on the challenge to host the conference in a virtual world. The virtual venue encompassed a group of interconnected locations with different purposes. A palm tree grown lobby with information booths led to several lecture theatres, exhibition halls, networking areas and poster rooms. The participants, prior to joining the conference, designed their own avatar and then navigated it through the locations meeting on the way avatars of other participants. The meetings enabled interactions either by typing in a chat window or an audio conversation. Participation in the events held in parallel conference communications could be interactive as well, enabling the audience to applaud, raise hands, and talk to the next-sited neighbour.

The DID-ACT submission was accepted for AMEE 2020 as a virtual poster. This presentation format involves constructing a digital “stack” of multimedia resources which could be presented either in a smartphone app or in a web browser. The content is organised in nested sections depicted as rectangular tiles, each containing resources as text entries, images, web links. Each conference presenter was encouraged to incorporate in the poster a short video showing a voice-over PowerPoint presentation giving an overview of the most important content. In addition it was required to prepare a one page digital print-out of the poster including a QR-code for easy access by smartphones from the real world. The DID-ACT poster was prepared by Andrzej Kononowicz, Małgorzata Sudacka, Felicitas L. Wagner,  Samuel Edelbring, Inga Hege and Sören Huwendiek on behalf of the consortium. In the image below we present the poster print-out. The content is available via this link https://api.ltb.io/show/BWPMF.

The virtual conference was held from 7th until 9th September. Several DID-ACT members participated in the conference events and networked with fellow researchers. In particular there were several conference presentations around the topic of clinical reasoning. By the end of conference the participants form DID-ACT project decided to gather virtually in one of the exhibition hall for a virtual group selfie:

Standing from the left are: Desiree Wiegleb Edstöm, Živa Ledinek, Małgorzata Sudacka, Maria Elvén, Andrzej Kononowicz and Inga Hege

The conference contributions presented at the virtual AMEE conference will be available at least throughout the next year and by that enable playback of the presentations and sustainable project dissemination. Participation in the conference was a memorable event, impressive by its innovation and showing how far virtualisation of education and research can nowadays go. Despite the many benefits of the virtual conference, and thankful it was possible to be held in these troubled pandemic times, we hope we will be able to meet up at the face-to-face conference next year at AMEE 2021 in real world Glasgow to present the community more news around the DID-ACT project.

Covid-19 Summer Term 2020

Summer term 2020 was special. Most universities start their summer term in April and thus, with the onset of the Corona outbreak in March, their preparation time given the circumstances was reduced drastically. One of the major challenges was that face-to-face lectures had to be planned online. In a very short amount of time, new online conference systems were established, and the necessary technical support was partially organized with the help of student tutors. Even though people who work on international projects are already used to video conferencing solutions, the amount of potential technical difficulties is still high and bandwidth issues can destroy all previous efforts.

Instruct, as an e-learning provider, observed a strong increase in online lectures and virtual patient usage in our system. Even institutions that already use our system CASUS and offer numerous online courses outperformed their previous numbers (Graphic 1).

Graphic 1: Comparison of completed virtual patient cases by students from one exemplary university from April to July 2019 and April to July 2020.

The peak in July is the result of exam preparation. We also registered slightly more support requests, however, these were still easily manageable.

In the media, both researchers and newspapers made online learning one of their central themes, especially regarding possibilities on how the current circumstances will impact e-learning in the future. Their findings are not necessarily novel, as can be seen in an article from the New York Times (https://www.nytimes.com/2020/06/13/health/school-learning-online-education.html?smid=em-share), “[…] students tend to learn less efficiently than usual in online courses […]. But if they have a facilitator or mentor on hand, someone to help with the technology and focus their attention — an approach sometimes called blended learning — they perform about as well in many virtual classes, and sometimes better.”

In an article from the German newspaper, Sueddeutsche Zeitung, called „Schluss mit dem Digitalgejammer!“ (“Stop complaining about Digitalization!”) (https://www.sueddeutsche.de/bildung/hochschulen-und-corona-schluss-mit-dem-digitalgejammer-1.4985116 ), the author highlights the discrepancy between educators moaning about a lack of personal interaction, exchange and dialogue in e-learning, while in reality seminars and lectures are quite often overcrowded permitting no interactivity whatsoever, not to mention dialogues and conversations are rarely feasible. The author states that students might miss pre-Corona campus life, but educators believe and hope that various other reasons also play into this.

It’s exciting to see how this transformation will shape the future, and it seems as though we have a special winter term in store for us, too – this time we will have slightly longer to prepare. One thing is for sure: it’s time for more and better blended learning solutions.

A look back on an eventful first half year

The first phase of the DID-ACT project (January – June 2020) was a very intense and insightful time. The main goal of the first project phase was to conduct a needs assessment among different stakeholder groups regarding a longitudinal clinical reasoning curriculum for students and a train-the-trainer course for teachers. Also, barriers for the implementation for such a curriculum and course as well as potential solutions were investigated.

At the first meeting of the project-team in Augsburg in January, the foundations were laid for the following work. In the next months, we carried out surveys and interviews. The data collection unfortunately collided with the onset of the Corona crisis, which made it a challenging task to recruit participants in the health sector. Nevertheless, we were able to conduct a considerable number of interviews and almost 200 people took part in the survey. During these difficult times, our bi-weekly online-meetings were especially valuable to keep the project on track, coordinate and support each other with the ongoing tasks.

DID-ACT team meeting in zoom

The analysis of the needs for the student curriculum showed that cases and simulations are seen as especially important in the teaching of clinical reasoning while oral and written exams are seen as most useful to assess clinical reasoning. For the train-the-trainer course, a blended-learning approach is favored. Results on barriers are described in our blog entry “Barriers for a clinical reasoning curriculum“. More detailed results can be found in the D1.1a report and the D1.1b report.

After finishing the data analysis regarding needs and barriers for the planned longitudinal clinical reasoning curriculum and the train-the-trainer course, solutions to overcome the identified barriers were sought. We analyzed the answers from our interview partners and conducted an online ideation workshop with the team members to develop further solutions (described in our blog entry “Online ideation workshop”). More details on solutions are described in the D1.2 report.

After this exciting first phase of the project, we are now looking forward to the next months where a curricular framework with learning goals and educational methods for the student curriculum and the train-the-trainer course will be developed.

Barriers for a clinical reasoning curriculum

As part of the DID-ACT project we conducted over 40 interviews with educators, students and clinical reasoning experts asking them among other questions, what barriers they see for developing a clinical reasoning curriculum for students and a train-the-trainer course for teachers. Interestingly, one of the most important barriers mentioned by the interviewees were cultural barriers. This includes aspects such as a lack of collaboration among educators, no culture of reflection, no culture of dealing with errors, and a resistance to change. A second category of barriers was related to the teaching process. Interviewees identified obstacles such as a lack of awareness that clinical reasoning can be taught, a lack of qualified educators to teach students, and also a lack of guidance and standards on how to teach clinical reasoning.

The results of the interviews can be found in the D1.1b report.

As already started in our ideation workshop we are now discussing solutions to overcoming these barriers – the results will be published by the end of June!

Online ideation workshop

In our specific needs analysis we have identified a wide range of barriers and needs for the implementation of a clinical reasoning curriculum in a survey and semi-structured interviews. As a next step we had planned a face-to-face design thinking workshop on May 5th in Krakow, Poland, to develop solutions to overcoming these barriers and addressing the needs. Due to the travel restrictions we decided to try something new and do the workshop in a synchronous online meeting after an asynchronous individual preparation phase.

For the preparation phase we setp up a course in our learning management system and the team members had time to familiarize themselves with the identified barriers and needs. They were asked to submit at least five (better ten) ideas on how these needs and barriers could be addressed including at least one crazy/absurd idea.

In our online meeting on May 5th we divided the 18 participants into four small groups (using the zoom break out rooms) in which they had to present their ideas and clarify any questions. After 20 minutes we met in the plenary in which each group presented their ideas and we documented and clustered those (using the integrated whiteboard). Finally, each particpant was asked to identify three solutions that are easy to do / hard to do / have a high impact.

Overall, the online workshop worked very well, only the simultaneous presentation of ideas and clustering on the whiteboard was tough, and could be better done in two phases with first collecting the ideas and then clustering them.

During the next weeks we will continue the discussion and refinement of the solutions and publish a final version as D1.2 report by the end of June.

Virtual Patients (VPs)

The virtual patients integrated into the DID-ACT learning units are partly taken from the EU-funded project iCoViP and form the collection for deliberate practice. The virtual patients are freely accessible via the CASUS system at https://crt.casus.net and a description of available VPs with key symptoms and final diagnoses is available in this blueprint. Thus, you can choose VPs suitable for your students and also offer them the whole collection for longitudinal and deliberate practice.

Participants: Medical educators

Learning units: Person-centered approach and the role of patients
Level: Teacher

Description: Offered as part of the faculty development to faculty educators.
Mode: Part to the faculty development program with emphasize on the educational potential of clinical reasoning teaching techniques

Technical Integration: Access to the DID-ACT Moodle, synchronous sessions were held via the virtual platform NewRow.

Tips & Tricks:

Participants: Multi-professional educators (nurses, physicians, paramedics)

Learning units: What is Clinical Reasoning and Models
Level: Teacher

Description: Offered as additional faculty development opportunity to staff members of the Medical Education Department.
Mode: Option / additional part to the faculty development program with emphasize on the educational potential of clinical reasoning teaching techniques

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: Give participants time to familiarize themselves with the learning material between the sessions. Do not put too much in one day - better to meet twice for shorter sessions. Face-to-face sessions lead to more productive discussions than Zoom meetings. Focus on discussion with the audience and on examples from practical teaching to illustrate the learning objectives.

Participants: Multi-professional educators

Learning units: Differences and similarities in clinical reasoning among health professions
Level: Teacher

Description: Offered as part of the faculty development program, it was held as a blended learning course with the synchronous phase online.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via Zoom.

Tips & Tricks: Give good practical information how Moodle works and how the participants can find and work with the different assigments of the learning unit. Emphasize the importance to the participants to work with the different individual tasks, as the discussions will be more interesting and fruitful. Also important that all the participants from different occupations feel comfortable to meet and that they all are a part of the discussion. This is an important and maybe the primary task for the facilitator!

Participants: Multi-professional and international educators

Learning units: Clinical Reasoning teaching and assessment & What is Clinical Reasoning and Models
Level: Teacher

Description: Offered as optional learning unit for participants of the Master of Medical Education (MME) program in Bern/Switzerland.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: To foster a valuable learning experience it is indispensible to provide good case examples that are tailored to the needs and experiences of the participants, so that they can relate to their prior knowledge. Thus, the provided examples in this learning units might need some adaptations for your target group of educators.

Participants: Multi-professional educators across German-speaking coutries

Learning units: Differences and similarities in clinical reasoning among health professions
Level: Teacher

Description: Offered as part of the faculty development program at the University of Augsburg, but open to participants from Germany, Austria, and Switzerland. It was held as a blended learning course with the synchronous phase online. Participants were eager to exchange their experience and disucss their views across institutions and professions.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via Zoom.

Tips & Tricks: To foster a valuable interprofessional experience the participants should represent a balanced mix of professions and also ideally the facilitators should at least represent two different professions. This allows a good discussion and also guarantees that the small groups can work interprofessionally. Our experience with a less-balanced group composition was that the over-represented profession dominates the discussions and it was quite difficult to counter-balance this.

Target group: Medical students in year 2

Learning units: Person-centered approach to clinical reasoning
Level: Novice

Description:The Learning Unit was run as an extra-curricular session as a virtual class. The facilitators were trained on this topic by attending the Train-the-trainer learning unit on "Person-centered approach and the role of patients".
Mode: Extracurricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via NewRow.

Tips & Tricks: Learning objective cross-referencing with the existing curriculum helps identify the level of integration. Encouraging and helping students to get familiar with Moodle before the session facilitates a smooth integration of the asynchronous phases.

Target group: Medical students in year 4 and 5

Learning units: Generating differential diagnoses and deciding about final diagnoses
Level: Novice

Description: The learning unit was integrated into a pediatric emergency department clerkship with a relation to virtual patients already used in this clerkship. Facilitators were trained by attending the train-the-trainer unit on "Information gathering, Generating differential diagnoses, Decision making, and Treatment planning".
Mode: Part of a regular curricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: Integration into clerkships works well, especially with a relation to already used content.

Target group: Medical students in year 1-6

Learning units: All 25 learning units of the DID-ACT curriculum
Level: Novice - Advanced

Description:
Longitudinal integration of the DID-ACT learning units into a clinical skills & communication course with the following suggested distribution across years:
Year 1: What is Clinical Reasoning, Person-centered approach to clinical reasoning, Health profession roles in clinical reasoning, and Biomedical Knowledge & Clinical Reasoning. (Required time in curriculum ca. 5 hours / semester)
Year 2: Dual Process Theory, Illness scripts, Collect and prioritize key clinical findings/problems, and What is clinical reasoning and How can theories be put into practice (Intermediate). (Required time in curriculum: ca. 4 1/2 hours/semester)
Year 3: Generating differential diagnoses and deciding about final diagnosis, Biases and cognitive errors - an Introduction, Analyzing and avoiding errors. (Required time in curriculum: ca. 4 1/2 hours/semester)
Year 4: Using the Outcome Present State Test Model, Developing a treatment plan, Metacognition, reflection and models for reflection, Collaboration of health professions in Clinical Reasoning (Intermediate). (Required time in curriculum: ca. 6 hours/semester)
Year 5: All remaining intermediate learning units: Shared Decision Making in Clinical Reasoning, Decision Support Systems, Ethical aspects - patient management and treatment, Uncertainty. (Required time in curriculum: ca. 5 hours/semester)
Year 6: All 6 advanced learning units: Collaborate with others in clinical reasoning, Decision Support Systems, Biases and cognitive errors, Uncertainty, Metacognition, reflection and models for reflection, Analyzing and avoiding errors.
(Required time: ca. 6 hours / semester. Final year students often have a day/week off from clinical work so these days could be used for DID-ACT learning units and optional participation in the train-the-trainer units)
Years 1-5: Virtual Patients (VPs) as additional deliberate practice activities in increasing number and complexity (e.g. starting with 5 VPs (=ca. 1.5 hours)/semester) in Year 1 and increasing to 10 VPs/semester) in Year 3-5.
Mode: Integrated into a clinical longitudinal course that runs from year 1 to 6 resulting in a total of 2.4 ECTS.

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions face-to-face or online.

Tips & Tricks:
Alining a longitudinal curriculum with curricula of other health professions remains a challenge and requires careful and early planning, but the asynchronous phases might be a good starting point for interprofessional teaching sessions. The VPs can be quite easily aligned with other curricular courses e.g., based on key symptoms.

Target group: Medical students in year 3

Learning units: Person-centered approach to clinical reasoning
Level: Novice

Description: The learning unit was integrated into the Laboratory Training of Clinical Skills. This course consists of six face-to-face meetings for groups of around 10 students. Within the meetings the students discuss various topics related to communication skills and person-centered approach. The fifth of the six meetings of the course was replaced by the DID-ACT learning unit. Students could then refer back to this learning unit during final session of the course.
Mode: Part of a regular curricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face. If possible, a uniform technology to provide access to the online resources in the class (using university tablets in our case) and support of the technical staff on-site was helpful to lower the technical barrier.

Tips & Tricks: Changing of the standard format of classes is interesting and motivating for the students. Virtual patients are a tool to present authentic clinical scenarios which are appreciated by the students. A blend of role-play and virtual patients allows students to take advantages of the two methods to reach the learning objectives.

Target group: Medical students in year 2 and nursing students in year 3 across Europe

Learning units: Collaboration of Health Professions in Clinical Reasoning
Level: Intermediate

Description:
This learning unit was implemented with , aside from clinical reasoning, tow additional objectives: 1) providing internationalization experience for students without traveling. 2) Deepening the knowledge of one's own professional roles and responsibilities and knowledge of another profession .
Mode: Extra-curricular interprofessional learning session with international participants

Technical Integration: Self-registration on DID-ACT Moodle, synchronous sessions via zoom.

Tips & Tricks: Facilitators running this course and supporting the discussions should be careful about supporting and encouraging all the participating professions' perspectives.

Target group: Medical students in year 1 and 2 (preclinical) across Europe

Learning units: Introduction into Clinical Reasoning & Health profession roles in clinical reasoning
Level: Novice

Description: The course was offered as a blended learning module to students from different medical schools in Europe as an international elective. Synchronous phases were held online via Zoom. The international aspect was very motivating for students and they learnt a lot from each other by exchanging their perspectives and how they are taught clinical reasoning vaspects. This teaching mode could also be implemented as an activity to welcome or prepare new Erasmus students. Facilitairs were trained by attending the train-the-trainer learning unit on "Differences and similarities in clinical reasoning among health professions".
Mode: Elective course

Technical Integration: Self-registration on DID-ACT Moodle, synchronous sessions via zoom and use of Padlet for interactivities.

Tips & Tricks: The organization with the registration of students was a bit complex, so, we suggest just setting dates and let students book. Allow enough (more time) for discussion and introduction rounds as participants do not know each other and are eager to hear and learn from peers at other schools and countries. Ideally, this session could also be held interprofessionally, however, it makes the finding of suitable dates even more complex.

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)

Theoretical / Background Knowledge

These resources and activities summarize all topics from the student learning units to introduce educators to these concepts. These resources are part of the train-the-trainer courses and marked as "optional" . Thus, they can be used optionally by course facilitators if participants are not yet familiar with basic concepts.

Theme(s): All basic concepts of clinical reasoning
Level: Educators
Format: Additional resources and material provided for each train-the-trainer learning unit that can be integrated if needed, e.g. if participants are quite new to the topic. These resources cover the basic concepts of a topic without going into the teaching aspects, so they can be used as preparatory steps.

Metacognition, reflection and models for reflection

Similar to the novice learning unit learners are asked to complete a reflective diary for five days. However, in this learning unit they should focus on critical or difficult situations in the clinical context.

Theme(s): Errors & biases
Level: Advanced
Format: Asynchronous online preparatory phase (ca. 60 min) with a synchronous follow-up meeting (ca. 60 min)
Recommended ECTS: 0.07
Links: Student course - Facilitator resources

Ethical aspects - patient management and treatment

his learning unit provides an introduction into bioethical principles, consent, capacity, and ethical clinical reasoning.

Theme(s): Ethical Aspects
Level: Intermediate
Format: Asynchronous online preparatory phase (ca. 60 min) with a synchronous follow-up meeting (ca. 90 min)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Decision Support Systems

The learning unit includes the generation of a decision tree based on a breast cancer data set from radiology department using the RapidMiner software package and an elaboration of the concepts of sensitivity and specificity. Furthermore, we will apply Bayesian reasoning and give an opportunity to discuss the base rate fallacy problem and the use of electronic calculators to judge the risk. The learning unit is finished with a discussion of the barriers/facilitators of using computers/AI in hospitals to support clinical reasoning.

Theme(s): Gathering, interpreting, and synthesizing information, Decision making
Level: Advanced
Format: Synchronous meeting (ca. 90 min) followed by an asynchronous phase (ca. 90 min)
Recommended ECTS: 0.1
Links: Student course - Facilitator resources

Uncertainty

In this learning unit, the approach of practice inquiry will be introduced and applied.

Theme(s): Biases & errors
Level: Advanced
Format: Asynchronous online preparation (ca. 60 min) followed by a synchronous meeting (ca. 60 min)
Recommended ECTS: 0.07
Links: Student course - Facilitator resources

Analyzing and avoiding errors

This learning unit will provide general and specific aspects of a morbidity and mortality conference and apply the knowlege by working through a case report.

Theme(s): Biases & errors
Level: Advanced
Format: Asynchronous online preparation (ca. 60 min) followed by a synchronous meeting (ca. 90 min)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Biases and cognitive errors

This learning unit introduces additional errors and biases and your will have the opportunity to work on virtual patients to identify error-prone situations.

Theme(s): Biases & errors, Ethical aspects, Theories of clinical reasoning
Level: Advanced
Format: Asynchronous online preparataion (ca. 60 min) for a follow-up synchronous meeting (ca. 90 min)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Shared Decision Making in Clinical Reasoning

In this learning unit, learners will be familiarized or re-familiarized with the basic concept of shared decision-making (SDM) in a way that serves as a steping stone for how to implement key concepts and models into practice. A job aid on shared decision-making will be a takeaway from this learning unit.

Theme(s): Patient Perspective, Decision Making
Level: Intermediate
Format: Asynchronous online preparation (ca. 60 min) with a follow-up synchronous meeting (ca. 90 min)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Collaboration of health professions in clinical reasoning

In this learning unit you will be able to apply interprofessional aspects of clinical reasoning and understand similarities and differences between the clinical reasoning of health professions. This facilitates a better communicate across professions in the clinical reasoning process to meet the needs of the patient.

Theme(s): (Interprofessional) Collaboration
Level: Intermediate
Format: Starting with two synchronous meetings (each 60 min or combined) followed by an asynchronous follow-up (ca. 60 min)
Recommended ECTS: 0.1
Links: Student course - Facilitator resources

Decision Support Systems

The aim of this learning unit is to facilitate a discussion about which aspects of clinical reasoning can be supported by artificial intelligence and what the limitations of machines in clinical reasoning are.

Theme(s): Gathering, interpreting, and synthesizing information, Decision making
Level: Intermediate
Format: Synchronous meeting (ca. 90 min) with a follow-up asynchronous phase (ca. 90 min)
Recommended ECTS: 0.1
Links: Student course - Facilitator resources

Evaluation of Clinical Reasoning

This learning unit provides an overview about surveys and questions suitable to evaluate clinical reasoning teaching. It also introduces the relevance of learning analytics.

Theme(s): Teaching clinical reasoning
Level: Educators
Format: Self-guided on-demand course with different material on clinical reasoning evaluation (ca. 60 min)
Recommended ECTS: 0.03
Links: Course

Discussing and teaching about cognitive errors and biases

In this learning unit participating educators and clinicians will have the opportunity to share ideas on how a culture for discussing errors should look like. They will also learn more about most common errors and biases in clinical resoning and (teaching) strategies on how to avoid these. This learning unit supports educators in teaching the student courses on the novice level: Biases and cognitive errors, Uncertainty, and Analyzing & avoiding errors

Theme(s): Teaching clinical reasoning, Errors & biases, Theories of clinical reasoning, Ethical aspects
Level: Educators
Format: Asynchronous preparation (ca. 60 min) followed by a synchronous meeting (ca. 90 min). Optional additional activities are provided for beginners (ca. 80 min).
Recommended ECTS: 0.08 (including optional phase: 0.13)
Links: Participant course - Facilitator resources

Information gathering, Generating differential diagonses, Decision making, and Treatment planning

This learning unit is designed to support educators in implementing the student courses on Collect and prioritize key clinical findings/problems, Generating differential diagnoses and deciding about final diagnosis, Developing a treatment plan, and Biomedical Knowledge and Clinical Reasoning

Theme(s): Teaching clinical reasoning, Gathering, interpreting & synthesizing information, Generating differential diagnoses, Developing a treatment / management plan, Decision making, Ethical aspects
Level: Educators
Format: Asynchronous preparation (ca. 60 min) followed by a synchronous meeting (ca. 60 min). Optional additional activities for beginners are available (ca. 60 min).
Recommended ECTS: 0.07 (including optional phase: 0.1)
Links: Participant course - Facilitator resources

Person-centred approach and the role of patients

This learning unit prepares educators to comprehensively and confidently teach the the learning unit on Person-centred approach to clinical reasoning. This unit will take educators through the learning content provided in the learning unit, as well as supports them in familiarizing themselves with the resources and exercises. Educators will have the opportunity to create their own teaching notes as part of this learning unit.

Theme(s): Teaching clinical reasoning, Patient perspective
Level: Educators
Format: Asynchronous preparation (ca. 60 min), followed by a synchronous meeting (ca. 90 min). Optional additional activites are available for beginners (ca. 100 min).
Recommended ECTS: 0.08 (including optional phases: 0.14)
Links: Participant course - Facilitator resources

Differences and similarities in clinical reasoning among health professions

This learning unit introduces teaching methods for clinical reasoning in different healthcare professions and prepares educators to teach the learning units on Health profession roles in clinical reasoning

Theme(s): Teaching clinical reasoning, (Interprofessional) collaboration
Level: Educators
Format: Asynchronous preparation (ca. 60 min) followed by a synchronous meeting (ca. 70 min). Optional additional activities provided for beginners (ca. 120 min).
Recommended ECTS: 0.07 (including optional phases: 0.14)
Links: Course,Facilitator resources

What is Clinical Reasoning and Models

This learning unit familiarizes healthcare profession educators on teaching aspects related to the clinical reasoning process and terminology of the different health professions. This includes how to explain the importance of clinical reasoning in the different health professions to students and how to support students in reflecting on clinical reasoning theories. The learning unit prepares you for teaching the novice courses on What is clinical reasoning, Dual Process Theory, Outcome Present State model, and Illness scripts.

Theme(s): Teaching clinical reasoning, Theories of clinical reasoning
Level: Educators
Format: Two synchronous meetings (ca. 60 and 45 min) with asynchronous phase (ca. 45 min) in between. Optional additional phase with ca. 45 min.
Recommended ECTS: 0.08 (including optional phase: 0.11)
Links: Course, Facilitator resources

Clinical Reasoning teaching and assessment

This learning unit provides and overview about teaching and assessment methods for clinical reasoning. It also highlights some general apsects, such as the importance of constructive alignment or how to organize group discussions.

Theme(s): Teaching clinical reasoning
Level: Educators
Format: Self-guided on-demand course with different material on clinical reasoning teaching and assessment.
Recommended ECTS: 0.03
Links: Course

DID-ACT clinical reasoning curriculum

This learning unit provides an overview about the DID-ACT student curriculum including all course outlines and resources neede to implement these learning units. It also introduces a tutorial on how to read the course outlines and use the provided resources.

Theme(s): Teaching clinical reasoning
Level: Educators
Format: Self-guided on-demand course with different material on our DID-ACT curriculum including all course outlines for student learning units and material needed.
Links: Course

Analyzing and avoiding errors

Along a case report this learning unit introduces the root cause analysis (RCA) to analyze errors and start to find ways for preventing / avoiding errors.

Theme(s): Errors & Biases
Level: Novice
Format: Asynchronous preparation (ca. 90 min) followed by a synchronous meeting (ca. 70 min)
Recommended ECTS: 0.09
Links: Student course - Facilitator resources

Metacognition, reflection and models for reflection

In this learning unit reflection models will be introduced and self-reflection will be applied on form of a reflective diary.

Theme(s): Errors & biases
Level: Novice
Format: Synchronous meeting (ca. 60 min), followed by an asynchronous online phase (ca. 80 min) and a concluding synchronous meeting (ca. 80 min)
Recommended ECTS: 0.12
Links: Student course - Facilitator resources

Uncertainty

The aim of this learning unit is to introduce situations of uncertainty and strategies that can be applied in such situations to avoid errors.

Theme(s): Errors & biases
Level: Intermediate
Format: Asynchronous preparation (ca. 60 min) followed by a synchronous session (ca. 90 min)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Biases and cognitive errors - an Introduction

This learning unit provides a basic introduction into the topic of biases and cognitive errors. It introduces a selection of common biases, such as premature closure or confirmation bias with providing the opportunity to elaborate on these biases with case vignettes.

Theme(s): Errors & biases, Theories of clinical reasoning, Ethical aspects
Level: Novice
Format: Asynchronous preparation (ca. 70 min) with a follow-up synchronous meeting (ca. 90 min)
Recommended ECTS: 0.09
Links: Student course - Facilitator resources

Developing a treatment plan

This learning unit provides an introduction into the topics "EBM in the context of clinical reasoning" and "developing a treatment/management plan" for students with no or some prior clinical experience.

Theme(s): Developing a treatment / management plan, Ethical aspects, Patient perspective
Level: Novice
Format: Asynchronous preparation (ca. 45 min) followed by a synchronous meeting (ca. 80 min)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Generating differential diagnoses and deciding about final diagnosis

This learning unit introduces different methods of creating and organizing differential diagnoses. There is also opportunity to practice the finding of differential diagnoses as well as discriminating and confining features on a prototypical case.

Theme(s): Generating differential diagnoses, Decision Making
Level: Novice
Format: Two synchronous meetings (ca. 90 min each) with an asynchronous phase in between (ca. 60 min)
Recommended ECTS: 0.13
Links: Student course - Facilitator resources

Collect and prioritize key clinical findings/problems

This learning unit highlights how to collect and prioritize key clinical findings using case examples.

Theme(s): Gathering, interpreting & synthesizing information
Level: Novice
Format: Asynchronous preparatory phase (ca. 45 min) followed by a synchronous meeting (ca. 60 min)
Recommended ECTS: 0.06
Links: Student course - Facilitator resources

Biomedical Knowledge and Clinical Reasoning - Knowledge Encapsulation

This learning unit explains the interconnection of biomedical knowledge and differential diagnoses formulation and explores different techniques to visualize encapsulated knowledge.

Theme(s): Theories of Clinical Reasoning
Level: Novice
Format: Two synchronous sessions (ca. 60 min each) with an asynchronous learning phase in between (ca. 45 min)
Recommended ECTS: 0.09
Links: Student course - Facilitator resources

Person-centered approach to clinical reasoning

The goal of this learning unit is to define what a 'person perspective' is in the context of healthcare provision and highlight why it is important when providing a quality healthcare experience. Learners will also visit the definitions of biomedical information as well as recite the terminology "diagnostic and analysis" in a way that helps patients and their families understand this stage in healthcare provision. Lastly, learners will combine the above into practical ability using questions that promote support for families and patients using terminology that facilitates mutual understanding.

Theme(s): Patient perspective
Level: Novice
Format: A synchronous meetings (ca. 90 min), with a preparatory and a follow-up asynchronous phase (ca. 90 and 45 min)
Recommended ECTS: 0.13
Links: Student course - Facilitator resources

Collaborate with others in clinical reasoning

This learning unit provides basic knowledge within different healthcare professions or across medical specialisations e.g. surgery, internal medicine and their collaboration with others in clinical reasoning.

Theme(s): (Interprofessional) Collaboration
Level: Advanced
Format: Asynchronous online preparation (ca. 60mins) for a follow-up synchronous meeting (ca. 90 mins)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Health profession roles in clinical reasoning

This learning unit provides an introduction to the various health professions involved in health care on the subject of clinical reasoning. The unit has been developed for beginner and novice learners, and is appropriate for those who have and have not yet had extensive clinical experience due to the team aspect of the assessments. The learning unit will highlight varied professions ranging between physiotherapy, medicine, nursing, and occupational therapy and learners will be able to compare and contrast the definitions of clinical reasoning within said professions, as well as relate how this team-understanding fits into the broader picture of healthcare, with a goal to establish a common understanding and definition of 'clinical reasoning'.

Theme(s): (Interprofessional) Collaboration
Level: Novice
Format: Asynchronous preparatory phase (ca 45 min) followed by a synchronous meeting (ca. 90min)
Recommended ECTS: 0.08
Links: Student course - Facilitator resources

Using the Outcome Present State Test Model

This learning unit provides an introduction into the the Outcome-Presenter-State model for clinical reasoning, which is applied especially in nursing. The learning unit is designed for novices of all health professions who are at the beginning of their education.

Theme(s): Theories of Clinical Reasoning
Level: Novice
Format: Asynchronous preparation phase (ca. 80 min) with a follow-up synchronous meeting (ca. 90 min)
Recommended ECTS: 0.09
Links: Student course - Facilitator resources

Illness Scripts

This learning unit provides an introduction into scripts in general and more specifically into llness scripts for novices who are at the beginning of their education and do not have any prior knowledge or experience with illness scripts.

Theme(s): Theories of Clinical Reasoning
Level: Novice
Format: Two synchronous sessions (ca. 160 min) with an asynchronous learning phase (ca. 60 min) in between
Recommended ECTS: 0.12
Links: Student course - Facilitator resources

Dual Process Theory

This learning unit provides an introduction into the dual processing theory amd highlights the differences between system 1 and system 2 reasoning.

Theme(s): Theories of Clinical Reasoning
Level: Novice
Format: Asynchronous preparation phase (ca. 90 min) followed by a synchronous meeting (ca. 90 min)
Recommended ECTS: 0.1
Links: Student course - Facilitator resources

What is clinical reasoning and how can theories be put into practice

This learning unit covers how clinical reasoning theories can be used/applied during beside teaching, internships or other patient-centered situations and why it is important to know these theories. It deepens the differences and similarities of clinical reasoning in the health professions, terminology used and importance of clinical reasoning.

Theme(s): Theories of Clinical Reasoning
Level: Intermediate
Format: Asynchronous preparation (ca. 45 min) for a follow-up synchronous meeting (ca. 60 min)
Recommended ECTS: 0.07
Links: Student course - Facilitator resources

What is Clinical Reasoning - An Introduction

This learning unit provides an introduction into the topic for novices who are at the beginning of their education and do not have any prior knowledge or experiences with clinical reasoning.

Theme(s): Theories of Clinical Reasoning
Level: Novice
Format: Synchronous meeting (60 min) followed by asynchronous follow-up (60 min)
Recommended ECTS: 0.07
Links: Student course - Facilitator resources

Skip to content