Clinical reasoning education in the clerkship years: A cross-disciplinary national needs assessment

Abstract

Background Improving clinical reasoning education has been identified as an important strategy to reduce diagnostic error—an important cause of adverse patient outcomes. Clinical reasoning is fundamental to each specialty, yet the extent to which explicit instruction in clinical reasoning occurs across specialties in the clerkship years remains unclear. Method The Alliance for Clinical Education (ACE) Clinical Reasoning Workgroup and the Directors of Clinical Skills Courses (DOCS) Clinical Reasoning Workgroup collaborated to develop a clinical reasoning needs assessment survey. The survey questionnaire covered seven common clinical reasoning topics including illness scripts, semantic qualifiers, cognitive biases and dual process theory. Questionnaires were delivered electronically through ACE member organizations, which are primarily composed of clerkship leaders across multiple specialties. Data was collected between March of 2019 and May of 2020. Results Questionnaires were completed by 305 respondents across the six organizations. For each of the seven clinical reasoning topics, the majority of clerkship leaders (range 77.4% to 96.8%) rated them as either moderately important or extremely important to cover during the clerkship curriculum. Despite this perceived importance, these topics were not consistently covered in respondents’ clerkships (range 29.4% to 76.4%) and sometimes not covered anywhere in the clinical curriculum (range 5.1% to 22.9%). Conclusions Clerkship educators across a range of clinical specialties view clinical reasoning instruction as important, however little curricular time is allocated to formally teach the various strategies. Faculty development and restructuring of curricular time may help address this potential gap.

Current status and ongoing needs for the teaching and assessment of clinical reasoning – an international mixed-methods study from the students` and teachers` perspective

“…Overall, our results on the contents of a CR curriculum suggest that all content is important and should be included in a CR curriculum, starting with basic theoretical knowledge and data gathering to more advanced aspects such as errors in CR and collaboration. Two other recent surveys conducted in the United States among pre-clerkship clinical skills course directors [ 12 ] and members of clerkship organizations [ 13 ] came to similar conclusions regarding the inclusion of clinical reasoning content at various stages of medical curricula. How to fit the content into already dense study programs, however, can still be a challenge [ 16 ].…”

“…To the best of our knowledge, in addition to the work by Kononowicz et al [ 10 ], no research exists yet that addresses the needs of teachers for such a course, and Kononowicz et al [ 10 ] did not investigate their needs beyond course content. Recently, Gupta et al [ 12 ] and Gold et al [ 13 ] conducted needs analyses regarding clinical reasoning instruction from the perspective of course directors at United States medical schools, yet a European perspective is missing. Thus, our research questions were the following: What aspects of clinical reasoning are currently taught and how important are they in a clinical reasoning curriculum according to teachers and students?…”

Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition

“…This overall response rate for the clerkship leaders survey was 19% (305/1859) and ranged from 3% to 30% across specialties. Approximately 72% (220/305) percent of ACE respondents were clerkship leaders [ 16 ].…”

“…The authors previously reported separately on cross-sectional surveys of pre-clerkship clinical skills course directors serving as institutional representatives to the DOCS organization, and clerkship leaders (clerkship directors and co-directors, associate clerkship directors, and clerkship clinical site directors) from organizations that comprise ACE [ 15 , 16 ]. This report represents the analysis comparing the results from these two surveys.…”

“…This led to a collaboration between the Directors of Clinical Skills Education (DOCS), a consortium of educators who direct clinical skills education in the pre-clerkship curriculum, and the Alliance for Clinical Education (ACE), an organization encompassing members from clerkship specialty organizations. Both surveyed their members to characterize the current state of clinical reasoning education in their respective UME phase [ 15 , 16 ]. This study examined these data through the lens of the first UME transition.…”