Development of clinical reasoning in an undergraduate medical program at a Brazilian university
Keywords:
Qualitative research, Students, medical, Education, medical, Curriculum, CognitionAbstract
CONTEXT AND OBJECTIVE: The cognitive processes relating to the development of clinical reasoning are only partially understood, which explains the difficulties in teaching this skill in medical courses. This study aimed to understand how clinical reasoning develops among undergraduate medical students. DESIGN AND SETTING: Quantitative and qualitative exploratory descriptive study conducted at the medical school of Universidade Federal de Goiás. METHODS: The focus group technique was used among 40 students who participated in five focus groups, with eight students from each year, from the first to fifth year of the medical school program. The material was subjected to content analysis in categories, and was subsequently quantified and subjected to descriptive statistical analysis and chi-square test for inferential statistics. RESULTS: The content of the students’ statements was divided into two categories: clinical reasoning — in the preclinical phase, clinical reasoning was based on knowledge of basic medical science and in the clinical phase, there was a change to pattern recognition; knowledge of basic medical science — 80.6% of the students recognized its use, but they stated that they only used it in difficult cases. CONCLUSION: In the preclinical phase, in a medical school with a traditional curriculum, clinical reasoning depends on the knowledge acquired from basic medical science, while in the clinical phase, it becomes based on pattern recognition.
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Donnon T, Violato C. Medical students’ clinical reasoning skills as a function of basic science achievement and clinical competency measures: a structural equation model. Acad Med. 2006;81(10 Suppl):S120-3.
Fuks A, Boudreau JD, Cassell EJ. Teaching clinical thinking to first-year medical students. Med Teach. 2009;31(2):105-11.
Charlin B, Lubarsky S, Millette B, et al. Clinical reasoning processes: unravelling complexity through graphical representation. Med Educ. 2012;46(5):454-63.
Loftus S. Rethinking clinical reasoning: time for a dialogical turn. Med Educ. 2012;46(12):1174-8.
Groves M. Understanding clinical reasoning: the next step in working out how it really works. Med Educ. 2012;46(5):444-6.
Graber ML, Tompkins D, Holland JJ. Resources medical students use to derive a differential diagnosis. Med Teach. 2009;31(6):522-7.
Collard A, Gelaes S, Vanbelle S, et al. Reasoning versus knowledge retention and ascertainment throughout a problem-based learning curriculum. Med Educ. 2009;43(9):854-65.
Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39(4):418-27.
Aldekhayel SA, Alselaim NA, Magzoub ME, et al. Constructing a question bank based on script concordance approach as a novel assessment methodology in surgical education. BMC Med Educ. 2012;12:100.
Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: theory and implication. Acad Med. 1990;65(10):611-21.
Sibert L, Charlin B, Corcos J, et al. Stability of clinical reasoning assessment results with the Script Concordance test across two different linguistic, cultural and learning environments. Med Teach. 2002;24(5):522-7.
Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022-8.
Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-90.
Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85(7):1118-24.
Charlin B, Boshuizen HP, Custers EJ, Feltovich PJ. Scripts and clinical reasoning. Med Educ. 2007;41(12):1178-84.
Audétat MC, Laurin S, Sanche G, et al. Clinical reasoning difficulties: a taxonomy for clinical teachers. Med Teach. 2013;35(3):e984-9.
Chamberland M, St-Onge C, Setrakian J, et al. The influence of medical students’ self-explanations on diagnostic performance. Med Educ. 2011;45(7):688-95.
Woolley A, Kostopoulou O. Clinical intuition in family medicine: more than first impressions. Ann Fam Med. 2013;11(1):60-6.
Silva GAR. O processo de tomada de decisão na prática clínica: a medicina como estado da arte [The decision making process in clinical practice: medicine as a state of the art practice]. Rev Soc Bras Clin Med. 2013;11(1):75-9.
Réa-Neto A. Raciocínio clínico − o processo de decisão diagnóstica e terapêutica [Clinical reasoning - the diagnostic and therapeutic decision process]. Rev Assoc Med Bras (1992). 1998;44(4):301-11.
Ahopelto I, Mikkilä-Erdmann M, Olkinuora E, Kääpä P. A follow-up study of medical students’ biomedical understanding and clinical reasoning concerning the cardiovascular system. Adv Health Sci Educ Theory Pract. 2011;16(5):655-68.
Carneiro AV. O raciocínio clínico. Qual a sua natureza? Pode ensinar- se? Revista Portuguesa de Cardiologia. 2003;22(3):433-43. Available from: http://www.spc.pt/dl/rpc/artigos/461.pdf. Accessed in 2015 (Sep 8).
Brailovsky C, Charlin B, Beausoleil S, Coté S, Van der Vleuten C. Measurement of clinical reflective capacity early in training as a predictor of clinical reasoning performance at the end of residency: an experimental study on the script concordance test. Med Educ. 2001;35(5):430-6.
Mamede S, Schmidt HG, Penaforte JC. Effects of reflective practice on the accuracy of medical diagnoses. Med Educ. 2008;42(5):468-75.
Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355(13):1339-44.
Piovezan RD, Custódio O, Cendoroglo MS, Batista NA. Teste de concordância de scripts: uma proposta para a avaliação do raciocínio clínico em contextos de incerteza [Script concordance test: an approach to the evaluation of clinical reasoning in uncertain contexts]. Rev Bras Educ Méd. 2010;34(1):5-12.
Fournier JP, Demeester A, Charlin B. Script concordance tests: guidelines for construction. BMC Med Inform Decis Mak. 2008;8:18.
Dory V, Gagnon R, Vanpee D, Charlin B. How to construct and implement script concordance tests: insights from a systematic review. Med Educ. 2012;46(6):552-63.
Linn A, Khaw C, Kildea H, Tonkin A. Clinical reasoning - a guide to improving teaching and practice. Aust Fam Physician. 2012;41(1- 2):18-20.
Sibert L, Darmoni SJ, Dahamna B, et al. On line clinical reasoning assessment with Script Concordance test in urology: results of a French pilot study. BMC Med Educ. 2006;6:45.
Nouh T, Boutros M, Gagnon R, et al. The script concordance test as a measure of clinical reasoning: a national validation study. Am J Surg. 2012;203(4):530-4.
Bloom BS, Krathwohl DR, Masia BB. Taxonomy of educational objectives: the classification of educational goals: Longman; 1984.
Ferraz APCM, Belhot RV. Taxonomia de Bloom: revisão teórica e apresentação das adequações do instrumento para definição de objetivos instrucionais [Bloom’s taxonomy and its adequacy to define instructional objective in order to obtain excellence in teaching]. Gest Prod. 2010;17(2):421-31.
Boshuizen HPA, Schmidt HG. On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cognitive Science. 1992;16(2):153-84. Available from: http://csjarchive.cogsci.rpi.edu/1992v16/i02/p0153p0184/MAIN.PDF. Accessed in 2015 (Sep 8).
