When less is more for the struggling clinical reasoner

Abstract

Busy clinician-educators are often tasked with remediating medical students who have deficits in clinical reasoning. In this essay, we share our early experience with providing less feedback and more practice to these trainees. We suggest that front line teachers can streamline their feedback to struggling reasoners by focusing solely on the problem representation and prioritized differential diagnosis of the main problem in their oral presentations and then engaging in repeated loops of feedback until the student achieves competency in real time. By receiving feedback targeted to the assessment alone and employing deliberate practice, struggling students have the opportunity to make concrete improvement during short-term clinical assignments. This remediation approach is feasible for busy clinician-educators and warrants formal study.

Insights about instructional design features of an interprofessional education initiative involving clinical reasoning with physiotherapy and medicine students

“…Requests for more time spent "participating in case-focused discussions" and "observing clinical reasoning modelled by clinicians" reflect design features of the workshop that were valued and could be enhanced. These two requests are in alignment with findings from studies involving medicine students learning clinical reasoning (Audétat et al, 2017;Connor & Dhaliwal, 2015;Croskerry, 2009b;Trowbridge et al, 2015) and were also considered applicable to physiotherapy students.…”

“…As also reported by Burgess et al (2020), both medicine and physiotherapy students appreciated the opportunity to work together and gain another professional perspective on patient cases. The interprofessional context of the workshop created opportunities to broaden student and educator perspectives of clinical reasoning, consistent with descriptions of clinical reasoning as a thinking process and an encultured practice influenced by professional occupations (Connor & Dhaliwal, 2015;Croskerry, 2009b;Higgs, 2018;Trowbridge et al, 2015;Wijbenga et al, 2019). Findings from this workshop could be enriched with further data collection from students and by including staff perspectives; however, the workshop has not been repeated to date due to timetabling impasses and resource costs for nine staff to facilitate a session with 110 students despite having multi-level support that is vital for interprofessional education initiatives to succeed (de Vries-Erich et al, 2017).…”

“…When considered from an instructional design perspective, requests for more opportunities to practise presenting cases can be viewed as reflecting the priorities of the medicine programme and an emphasis on developing diagnostic reasoning skills. In the context of learning clinical reasoning, presenting a case is analogous to problem representation and is recognised as a valuable focus of attention in learning diagnostic reasoning (Audétat et al, 2017;Connor & Dhaliwal, 2015;Croskerry, 2009b;Trowbridge et al, 2015). Future workshops could include more opportunities to present cases for both groups of students by varying the format to include other contexts such as a ward-based face-to-face handover, a note written to a general practitioner or physiotherapist, or a conversation with a patient about their management plan.…”

“…Recommended instructional design features for interprofessional education initiatives vary depending on the theoretical perspective underpinning the recommendations. When clinical reasoning is viewed primarily as a thinking process, recommendations include providing students with explicit opportunities to practise deliberately and reflect upon their use of intuitive and analytical thinking process because the former is context-dependent, whereas, the latter can be learned in more theoretical or abstract situations (Connor & Dhaliwal, 2015;Croskerry, 2009b;Trowbridge et al, 2015). When clinical reasoning is viewed as a process of enculturation into professional practice, then recommendations emphasise providing students with opportunities to develop problem-solving capabilities that involve tasks, situations, and interactions with others that increase in complexity, ambiguity, and authenticity over time (Higgs 2018;Wijbenga et al, 2019).…”

‘Remediation of pre-clerkship clinical skill performance using a hybrid coaching model’

“…DP promotes performance improvement with a focused approach on recognizing areas of difficulty utilizing a teacher/coach and a standards-based practice of those skills to improve performance [4]. While DP has been used by athletes and musicians to enhance performance, it has also been applied in medical education for teaching and remediating clinical reasoning, including successful remediation of students' skills performance [2,5]. Previously we utilized DP to remediate students after a poor exam performance.…”