Design Blended Learning

What every teacher needs to know about clinical reasoning

Print Friendly, PDF & Email
  1. Importance of pedagogical examples or cases. Students should be able to build a database of cases.
  2. Study the basic biomedical sciences together with solving real cases.
  3. See cases relevant to the topic of a course, but sometimes mix the cases of different topics.
  4. Students will not make spontaneous comparisons between cases. You have to stimulate this.
  5. If a student solves a problem correctly, it will not guarantee the student understands the basic mechanism and vice versa

K.W. Eva, Medical Education 2004; 39:98 – 106


In summary, much debate has occurred within the medical education literature on the structure of medical expertise. In the late 1970s, Elstein et al. presented the hypothetico-deductive model of clinical reasoning – namely, that when faced with a new case, doctors generate a set of hypotheses that they later use to test against the data presented. Since then, numerous frameworks of knowledge representation have been developed, but research performed in the last 15 years has questioned whether or not any particular framework will prove correct. More recently, evidence has begun to accumulate suggesting a more comprehensive approach to clinical teaching, an approach that includes recognition of the benefits of both analytic and non-analytic approaches to clinical reasoning and enables students to take advantage of the best of both worlds. Further awareness of the prevalence of context specificity has highlighted the need to provide students with various strategies to position them better to adapt flexibly as the situation demands. The remaining paragraphs of this article will outline some of the implications arising from this present understanding to facilitate reflection on current pedagogical techniques and stimulate the development of new approaches.

First and foremost, this review highlights the importance of teaching around examples. The earlier students accumulate a mental database of cases, the sooner they develop a firm foundation to allow non-analytic processes to contribute. This idea is not new to medical educators – it is a fundamental principle of good pedagogy. What is relatively new, however, is the recognition that a few complex and elaborate examples are likely to be suboptimal as practical teaching tools. Context specificity and the need to build up an adequate database from which to reason by way of analogy demand that many examples be seen, that students be enabled to engage in the problem-solving process actively, and that the examples provide an accurate representation of the range of ways in which specific conditions present. This latter criterion has become increasingly important to consider as the evolution of the health system in many parts of the world has lessened the probability that students will randomly encounter many medical conditions during their clinic-based learning experiences. As a result, clinical teachers and curriculum planners must have greater awareness and creativity to ensure that students receive adequate exposure to pedagogically valuable cases.

Second, clinical teachers should recognise that the traditional 2-stage approach to clinical teaching, dating back at least as far as Flexner, in which students are expected to master the basic biomedical sciences before considering clinical problems, may be inappropriate. Evidence suggests that understanding basic science mechanisms can assist diagnosticians in generating accurate hypotheses and, therefore, should remain part of medical training. It must be recognised, however, that this strategy provides a way of reaching the correct diagnosis, not the way. Similarly, simply working on a ward and interacting with a series of patients without additional focus on the underlying principles of the cases may do students a disservice by weakening one of the avenues by which they might be able to derive solutions to future cases.

Third, practice with cases should proceed in a way that mimics the eventual use of the resulting knowledge. Clinicians rarely encounter a novel case in which the diagnosis is known. Working through textbook cases in which one already knows the diagnosis as a result of the chapter topic (or the topic of the lecture) does not enable the student to determine whether or not they would be able to If the patient presentation and case representation outlined in Fig. 3 are thoroughly entwined with a particular diagnosis, practice with the critical hypothesis testing phase is lost. In support of this statement, many investigators have shown that ‘mixed practice’ in which students see cases of multiple categories mixed (as opposed to blocked practice in which students work through a block of cases from one diagnostic category before proceeding to the next block of cases from a different diagnostic category) is pedagogically optimal. Furthermore, clinical teachers should not rely on students to spontaneously make meaningful comparisons across problems. Students are much more likely to successfully reason by analogy when explicitly instructed to attempt to identify similarities in the underlying concepts of superficially distinct problems. As such, principles inherent in novel examples should be related to those inherent in past examples whenever possible. Adding to the benefit of such an educational strategy is the by-product of providing better information to the clinical teacher regarding where students may be experiencing difficulties. It is well known that experts have difficulty predicting the errors that others make. Providing students with an opportunity to reveal idiosyncratic mistakes enables clinical teachers to focus teaching efforts in a direction most likely to benefit individual students.

Finally, the flexibility inherent in clinical reasoning and the prevalence of context specificity have real implications for clinical teachers’ evaluation of trainees. One should not assume that because a student has provided an accurate diagnosis and management plan, they fully understand the physiological mechanisms underlying the process. Similarly, even if the student can explain the underlying physiological mechanisms, one should not assume they would provide an accurate diagnosis upon encountering the next case. In domains afflicted by context specificity (i.e., all domains), a ‘multiple biopsy’ approach to evaluation is required to assess a student’s performance accurately. While no one would dream of assessing knowledge with a single multiple-choice question, recognising the need to broadly sample when assessing other characteristics of expertise has been less forthcoming. In hindsight, it has become clear that context specificity significantly contributes to the poor psychometric qualities of evaluation exercises like the triple jump, patient management problems and extended essay and oral examinations. The more time required to perform an evaluation task, the less opportunity to have students complete the task multiple times. To ensure the information reliably indicates student ability level is collected, clinical teachers should continue utilising tools such as the objective structured clinical examination, clinical reasoning exercise and multiple-choice tests.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.