Tag Archives: Clinical reasoning

Biomedical knowledge, clinical cognition and diagnostic justification: a structural equation model

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Anna T Cianciolo, Reed G Williams, Debra L Klamen and Nicole K Roberts

Context  The process whereby medical students employ integrated analytic and non-analytic diagnostic strategies is not fully understood. Analysing academic performance data could provide a perspective complementary to that of laboratory experiments when investigating the nature of diagnostic strategy. This study examined the performance data of medical students in an integrated curriculum to determine the relative contributions of biomedical knowledge and clinical pattern recognition to diagnostic strategy.

Methods  Structural equation modelling was used to examine the relationship between biomedical knowledge and clinical cognition (clinical information gathering and interpretation) assessed in Years 1 and 2 of medical school and their relative contributions to diagnostic justification assessed at the beginning of Year 4. Modelling was applied to the academic performance data of 133 medical students who received their md degrees in 2011 and 2012.

Results  The model satisfactorily fit the data. The correlation between biomedical knowledge and clinical cognition was low–moderate (0.26). The paths between these two constructs and diagnostic justification were moderate and slightly favoured biomedical knowledge (0.47 and 0.40 for biomedical knowledge and clinical cognition, respectively).

Conclusions  The findings suggest that within the first 2 years of medical school, students possessed separate, but complementary, cognitive tools, comprising biomedical knowledge and clinical pattern recognition, which contributed to an integrated diagnostic strategy at the beginning of Year 4. Assessing diagnostic justification, which requires students to make their thinking explicit, may promote the integration of analytic and non-analytic processing into diagnostic strategy.

Rethinking clinical reasoning: time for a dialogical turn

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Stephen Loftus

Medical Education 2012: 46: 1174–1178

Context  Clinical reasoning lies at the heart of medical practice and has been the subject of scholarly inquiry and research for some decades. However, despite this, it is still poorly understood. This is largely because current theoretical models are limited in their explanatory power because they are based on particular assumptions of what constitutes clinical reasoning.

Discussion  A variety of ways of articulating and conceptualising clinical reasoning can provide us with richer means of understanding what is involved in clinical encounters. A dialogical approach to clinical reasoning is proposed. Dialogism provides a vocabulary that encourages us to integrate insights from different frameworks in ways that combine the strengths of each. Dialogism also puts a focus on the complex ways in which we use language in clinical reasoning to generate meaning. The complexity of language includes narrative, rhetoric and metaphor.

Conclusions  A dialogical approach does not require us to discard the findings of earlier theories about clinical reasoning, but provides us with a means of integrating what we know in ways that are more useful in the reality of clinical practice.

How to construct and implement script concordance tests: insights from a systematic review

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Valérie Dory, Robert Gagnon, Dominique Vanpee and Bernard Charlin

Medical Education 2012: 46: 552–563

Context  Programmes of assessment should measure the various components of clinical competence. Clinical reasoning has been traditionally assessed using written tests and performance-based tests. The script concordance test (SCT) was developed to assess clinical data interpretation skills. A recent review of the literature examined the validity argument concerning the SCT. Our aim was to provide potential users with evidence-based recommendations on how to construct and implement an SCT.

Methods  A systematic review of relevant databases (MEDLINE, ERIC [Education Resources Information Centre], PsycINFO, the Research and Development Resource Base [RDRB, University of Toronto]) and Google Scholar, medical education journals and conference proceedings was conducted for references in English or French. It was supplemented by ancestry searching and by additional references provided by experts.

Results  The search yielded 848 references, of which 80 were analysed. Studies suggest that tests with around 100 items (25–30 cases), of which 25% are discarded after item analysis, should provide reliable scores. Panels with 10–20 members are needed to reach adequate precision in terms of estimated reliability. Panellists’ responses can be analysed by checking for moderate variability among responses. Studies of alternative scoring methods are inconclusive, but the traditional scoring method is satisfactory. There is little evidence on how best to determine a pass/fail threshold for high-stakes examinations.

Conclusions  Our literature search was broad and included references from medical education journals not indexed in the usual databases, conference abstracts and dissertations. There is good evidence on how to construct and implement an SCT for formative purposes or medium-stakes course evaluations. Further avenues for research include examining the impact of various aspects of SCT construction and implementation on issues such as educational impact, correlations with other assessments, and validity of pass/fail decisions, particularly for high-stakes examinations.

The influence of medical students’ self-explanations on diagnostic performance

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Chamberland M, St-Onge C, Setrakian J, Lanthier L, Bergeron L, Bourget A, Mamede S, Schmidt H, Rikers R.The influence of medical students’ self-explanations on diagnostic performance. Medical Education; Volume 45, Issue 7, July 2011, Pages: 688–695