Effective clinical reasoning is of interest to educators because of its importance in clinical practice, particularly in the field of medical error. However, few published clinical reasoning curricula exist. Consensus statement on the content of clinical reasoning curricula in undergraduate medical education provides recommendations for schools. The UK Clinical Reasoning in Medical Education group (CReME) discussed a systematic approach consistent with current evidence-based literature. Their conclusion? What is taught, how it is taught, and when it is taught can facilitate clinical reasoning development effectively, through purposeful curriculum design.

Madrid - Feb 11, 2022. While all medical schools teach knowledge, skills and behaviours, there is good evidence that existing training programmes may not provide adequate notions regarding clinical reasoning and patient safety. According to the paper, there is no proof that teaching the general thinking processes involved in clinical decision making by itself results in a better performance.  Representatives from over half of UK medical schools, organized in the CReME group, agreed that medical schools should implement a formal clinical reasoning curriculum that is horizontally and vertically integrated throughout the degree in Medicine.

Cognitive failures contribute to the majority of diagnostic errors. The matter is that accurate approaches to medical conditions require knowledge of epidemiology, basic sciences and clinical and social psychology. Likewise, several components of clinical reasoning require specific information, abilities and understanding that may not be explicitly emphasised in some curricula. CReME’s review identified five domains:  (1) clinical reasoning concepts, (2) history and physical examination, (3) choosing and interpreting diagnostic tests, (4) problem identification and management, and (5) shared decision making. Nedless to say, the detection of singularities and the reinterrogation of signs is especially relevant.

The goal of the CReME group is to provide medical teachers, curriculum planners and policy makers with a practical guideline on the content of clinical reasoning curricula in undergraduate medical education.  To develop these recommendations, they used a three-stage approach. In the first stage, 20 members from 12 medical schools attended a whole-day meeting to identify a list of clinical reasoning-specific teaching that should be delivered by medical schools (what to teach). In the second stage, a literature review was conducted to identify teaching strategies that are successful in improving the clinical reasoning ability of medical students (how to teach). 

Articles that merely described a particular approach to teaching clinical reasoning, with or without student/faculty evaluation, were excluded. These criteria resulted in 27 eligible articles that included empirical findings and described a teaching intervention designed to improve the clinical reasoning ability of medical students. Two studies involved teaching schemas/illness scripts; three involved teaching the principles of clinical decision making; four used strategies that employed thinking aloud, brainstorming or cognitive mapping; seven taught ‘cognitive forcing strategies’; and eleven used practice cases with feedback.

In the final stage, practical recommendations for the content of undergraduate clinical reasoning curricula were made based on these findings in the form of a consensus statement and the text was emailed to all the members of the group for comments. The agreed ideas were grouped into five domains of clinical reasoning mapped against the UK General Medical Council’s ‘Outcomes for Graduates’, and they also included suggestions for when to teach during a 5 year programme. 

Learners should demonstrate an understanding of key theories (e.g. dual process), how clinical reasoning develops, the problem of diagnostic and cognitive errors, the role of clinical reasoning in care, and other factors that may impair the clinical reasoning process or outcome. They should also be able to synthetise data from the history and physical examination to judge the probability of the presence of particular symptoms and signs. That’s to say, many patients do not present with the typical features described in textbooks. For example, medical students are taught that meningitis in adults presents with meningism, but in the UK, only around half have symptoms of photophobia and neck stiffness.

By graduation, trainees should be able to suggest investigations based on knowledge of what question a particular test can answer, and be able to use evidence-based guidelines and decision aids to assist in their clinical decisions regarding appropriate exams. They should be able to construct a prioritised differential diagnosis, including relevant must-not miss diagnoses.This means learners must medical students must learn to manage clinical uncertainty because for any given diagnoses, there may be numerous potential approaches, all which may be appropiate but dependent on a number of factors including patient preferences, comorbidities, resources, cost-effectiveness and local policies.

As they do in Practicum Script, learners should be able to use metacognitive knowledge and critical thinking to improve their performance. Guided reflection has been shown to improve diagnostic performance and foster the learning of clinical knowledge. Medical students need to be aware that management decisions are often co-produced with patients, carers, teams, evidence-based guidelines, technology scores and decision aids. They need to understand that in real world situations, knowledge is not something that is entirely in their head but is distributed throughout the environment in people, computers, books, and other tools or instruments.

Better outcomes for students and patients

Teaching the principles of decision making to medical students did not improve performance. Teaching cognitive forcing strategies designed to reduce error from cognitive biases also did not improve performance. However, teaching illness scripts, using thinking aloud/brainstorming strategies, structured reflection, and practicing cases with feedback did improve performance. There is agreement that formal and experiential knowledge of medicine is central for the development of effective clinical reasoning ability. To date, there is little evidence to demonstrate that teaching about thinking itself (e.g., teaching dual process theory) on its own improves diagnostic performance.

Practice with as many different cases and contexts as possible, including corrective feedback, is critical for expertise. This requires a safe learning environment where the discussion of mistakes is encouraged and where there is recognition of uncertainty and it does not necessarily require any additional teaching time. Instead, a programme of faculty development according to the stage of learning is envisaged. Postgraduates largely learn everything about clinical reasoning implicitly, through apprenticeship. The CReME group proposes to explicitly integrate clinical reasoning into courses throughout each year, adopting a systematic and respectful approach with different local contexts.

Reference

Cooper N, Bartlett M, Gay S, Hammond A, et al; UK Clinical Reasoning in Medical Education (CReME) consensus statement group. Consensus statement on the content of clinical reasoning curricula in undergraduate medical education. Med Teach. 2021 Feb;43(2):152-159.