Teaching Clinical Reasoning in the Preclinical Period

ABSTRACT

Introduction

Developing the clinical reasoning skills necessary to becoming an astute diagnostician is essential for medical students. While some medical schools offer longitudinal opportunities for students to practice clinical reasoning during the preclinical curriculum, there remains a paucity of literature fully describing what that curriculum looks like. As a result, medical educators struggle to know what an effective clinical reasoning curriculum should look like, how it should be delivered, how it should be assessed, or what faculty development is necessary to be successful. We present our Introduction to Clinical Reasoning course that is offered throughout the preclinical curriculum of the Uniformed Services University of the Health Sciences. The course introduces clinical reasoning through interactive lectures and 28 case-based small group activities over 15 months.

The curriculum is grounded in script theory with a focus on diagnostic reasoning. Specific emphasis is placed on building the student’s semantic competence, constructing problem lists, comparing and contrasting similar diagnoses, constructing a summary statement, and formulating a prioritized differential diagnosis the student can defend. Several complementary methods of assessment are utilized across the curriculum. These include assessments of participation, knowledge, and application. The course leverages clinical faculty, graduate medical education trainees, and senior medical students as small group facilitators. Feedback from students and faculty consistently identifies the course as a highly effective and engaging way to teach clinical reasoning.

Conclusion

Our Introduction to Clinical Reasoning course offers students repeated exposure to well-selected cases to promote their development of clinical reasoning. The course is an example of how clinical reasoning can be taught across the preclinical curriculum without extensive faculty training in medical education or clinical reasoning theory. The course can be adapted into different instructional formats to cover a variety of topics to provide the early learner with sequential exposure and practice in diagnostic reasoning.

INTRODUCTION

Helping medical students develop the clinical reasoning abilities necessary to becoming astute diagnosticians remains a core objective of medical education. We define clinical reasoning as “a skill, process, or outcome wherein clinicians observe, collect, and interpret data to diagnose and treat patients.”¹ Despite this widely accepted educational focus, the acquisition of clinical reasoning abilities has largely been the focus of the clinical rather than the preclinical period of medical school. However, this approach introduces significant limitations for several reasons, including the variability in student supervision and the amount of consistent and quality feedback from faculty.² National reports on diagnostic errors have prompted greater attention to how clinical reasoning is taught in undergraduate medical education.^3,4 While there are various contributing factors to diagnostic error, cognitive factors leading to diagnostic reasoning failures rank among the highest. Any cognitive failure on behalf of a clinician, including a failure to adequately synthesize all of a patient’s information correctly or identify key physical examination findings or test results, can contribute to diagnostic errors.^5,6 Such errors do not only occur in complex cases, but also in common diseases seen frequently and taught early in training. These include malignancy, congestive heart failure, pulmonary embolism, and urinary tract infections.⁷ In response to these findings, medical schools have introduced clinical reasoning courses into the preclinical curriculum, explicitly acknowledging the need to teach this critical ability much earlier in clinical training. Despite this evolution in curricular design, medical educators continue to struggle to know what an effective clinical reasoning curriculum should look like, how it should be delivered, how it should be assessed, or what faculty development is necessary to succeed as few studies have been published on this topic.⁸

This paper provides a description of our clinical reasoning course spanning the entire preclinical curriculum to add to the currently available literature and help educators engaged in this topic. It is an introductory course on clinical reasoning that can be taught without extensive faculty training in medical education or clinical reasoning theory. It can also be widely applied and adapted into different instructional formats that cover many topics to provide the early learner sequential exposure and practice in diagnostic reasoning.

COURSE OBJECTIVES

The course aims to introduce clinical reasoning through interactive lectures and small group activities that explicitly focus on diagnostic reasoning. Students apply diagnostic reasoning strategies to common symptoms, physical exam findings, laboratory test abnormalities, and syndromes presented during small group case discussions. Emphasis is placed on building the student’s semantic competence (e.g., terminology and taxonomy), constructing problem lists, comparing and contrasting similar diagnoses, constructing a summary statement, and formulating a prioritized differential diagnosis that the student can justify and defend.

The goal is to help students transition from reliably identifying and reporting a patient’s history and physical examination (reporter) to translating the patient’s history into a prioritized and synthesized problem list and differential diagnosis (interpreter).⁹ Management reasoning, which focuses on formulating a treatment plan that is specific to a patient’s circumstances and preferences, is occasionally touched upon later in the course and is not a primary focus.

COURSE FORMAT

Our Introduction to Clinical Reasoning (ICR) course is a longitudinal course that is integrated into a comprehensive, 16 month-long module called Physician in Society for first- and early second-year medical students at the Uniformed Services University of the Health Sciences (USU) located in Bethesda, MD. USU is a federally funded university whose primary mission is to prepare graduates for service and leadership in the medical corps as physicians, nurses, and dentists. The course combines a hybrid of large group lectures and 28 case-based small group sessions. The preclinical curriculum at USU spans over 16 months and is organized into organ system modules. In addition to offering specific and explicit sessions on the development of clinical reasoning, the Physician in Society module provides students with early exposure to medical interviewing, physical examination, reflective practice, health systems science, and ethical foundations of medicine.

COURSE MATERIALS

Students are provided with a syllabus composed of faculty-written handouts. Each of the 28 small group sessions has a corresponding handout.¹⁰ A complete list of the small group topics can be found in Table I. Students are instructed to read through the material before attending the small group session. Each handout begins with a list of learning objectives and additional assigned readings. They have four distinct sections: (1) an overview of the topic, (2) example cases, (3) multiple choice questions (MCQs), and (4) cases for the small group session.

The topic overview is primarily grounded in script theory, a theoretical framework to explain how medical knowledge can be organized for diagnostic problem-solving. This approach helps students organize their knowledge and facilitates their ability to recall key concepts when solving clinical problems.^11,12 The section reviews the underlying pathophysiology, epidemiology, time course of the disease, and salient signs and symptoms relevant to the topic. Emphasis is often placed on identifying discriminating features of each diagnosis whose presence or absence significantly changes the likelihood of a particular diagnosis. Appropriate diagnostic testing and treatment are also provided but are less emphasized, particularly early in the course.

The students are then provided with sample cases that are fully worked through to demonstrate how to approach the specific topic clinically. Several reasoning strategies are incorporated into these case explanations to help students develop flexibility when approaching a clinical case. Examples of strategies illustrated include hypothetico-deductive reasoning, identifying key features of a presentation, using schemas, introducing heuristics, and considering the “must not miss” diagnoses. Following the case illustrations, multiple-choice questions with answers and explanations are provided for the students to check their knowledge.

Finally, at the end of the handout the students are provided with two or three realistic cases they will discuss during their small group ICR session. Each case scenario contains questions for the students to work through. While the specific questions vary from session to session, they primarily center around identifying critical features of the case, identifying pertinent positives and negatives, developing problem lists, developing differential diagnoses, explaining the pathophysiology of disease, providing a summary statement, or proposing a diagnostic workup or management plan with justification.

LECTURES

The course begins during the first month of school with an introductory large group seminar to provide a basic overview of the course. During this 50-min seminar, students are provided with the key elements of the diagnostic reasoning process. They are exposed to examples of various clinical reasoning strategies they will learn and use throughout the course. We specifically describe dual process theory to give students an awareness of the intuitive or nonanalytic (System 1) and effortful or analytic (System 2) types of strategies. We also discuss how contextual (patient, physician, and environmental) factors influence the reasoning process and contribute to diagnostic errors.^13,14

Lectures by clinical faculty are provided to the students for the majority of the topics covered in the course and are usually 30–45 min long. They provide an overview of the relevant medical terminology, review the pertinent pathophysiology, illustrate a practical clinical approach to the topic, and clarify common areas of confusion regarding the reasoning approach. As the course evolves, the small group lectures transition to more of a review session that follows the small group and then eventually is eliminated to promote the progressive independence of learners and to mimic what happens in clinical clerkships.

SMALL GROUP SESSIONS

Developing diagnostic competence and excellence requires deliberate practice with many different clinical problems.¹⁵ Our course offers 22 stand-alone case-based small group discussion sessions that form the core of the course. The small group sessions are arranged across the different system-based modules. They are integrated with the basic science topics that are concurrently being taught (i.e., anatomy, physiology, pathophysiology, microbiology, and pharmacology). Each small group of six to seven students is led by a faculty member and is 70 min long. The majority are offered in-person but virtual options are also in place for each topic covered. Six additional 30-min ICR sessions follow a clinical skills session in each module at our simulation center. During these clinical skills sessions, students are exposed to three standardized patients with similar complaints but different conditions. Following the student interviews and physical examinations, they meet in groups of six with a faculty member to discuss the discriminating features between the three cases to help them differentiate between the various conditions.

The curriculum and case scenarios are progressive in complexity. For example, in the early stages of the course more straightforward, prototypical presentations of common diseases are discussed along with the more serious and “must not miss” diagnoses. As the course progresses, more complex presentations are introduced. In this way, students can begin developing basic illness scripts they can further build upon as their knowledge and experience grow.

We use a whole-case approach during our small group sessions acknowledging that students early in their phase of training may benefit better from this approach.^2,16 Early in medical training, students form mental structures of rich and elaborate causal networks to help explain the causes of disease using the underlying biological or pathophysiological processes.⁹ This is an effortful process for students as they must consider specific signs and symptoms and relate them to disease. With this in mind, we aimed to minimize extrinsic cognitive load to enhance their initial script formation.

To address the unique educational needs of our students, military-specific concepts are integrated across the curriculum both as a way to foster the student’s professional identity formation as military physicians and also to expose them to the unique elements of military medicine. As an example, students discuss how specific medical conditions may impact a service member’s duty status or medical readiness for worldwide deployability. They also discuss how their clinical approach to diagnosis and treatment may be different based on where in the world they are stationed or what resources are available to them.

FACULTY

The course requires a minimum of nine faculty to run each small group session. We have nine sessions running simultaneously followed by two sequential sessions with a 10-min break between each. Faculty will often lead the discussions for three consecutive sessions but that is not always the case. We recruit a diverse group of faculty by level of training and specialty including internists, family physicians, medicine sub-specialists, neurologists, obstetrics and gynecology, and pediatricians. Most of the faculty are clinical faculty from our associated hospital, Walter Reed National Military Medical Center in Bethesda, MD, and teaching faculty from USU. Fellows and residents are also actively engaged as session preceptors. Fourth-year medical students enrolled in our medical education elective help co-teach the ICR small group sessions with the faculty and serve as powerful near-pear instructors.

Individual faculty members teach anywhere from one to six of the 28 different ICR small groups. Roughly, 50% to 60% of faculty return each year to teach and are familiar with the course and its objectives. With such a significant influx of faculty and graduate medical education (GME) trainees, whom all have busy schedules, offering formal course-specific faculty development training is not feasible. Instead, the course director sets up virtual sessions with faculty during the week leading into the small group session or provides them with an orientation immediately before the session. During these faculty sessions the course director reviews the goals and objectives of the session, provides faculty with the key teaching points highlighted in the faculty guide, and provides information on how the students are assessed. Because of the nature of our medical education program requiring graduating students to pay back their educational scholarship and serve as clinicians in our health care system, some faculty are prior graduates of the school and are very familiar with the course and its objectives. In addition, our university offers a week-long faculty development course that many of our faculty have taken.

The essential teaching points for each case are heavily based on script theory. Faculty help students compare and contrast related diagnoses by changing a key symptom or finding or by asking “what if” questions that are provided to them in the faculty guide. There are whiteboards available in each room that the group often uses for illustrations and note-taking. Computers with mounted wall monitors are available in each room for additional images or teaching materials that a faculty member might incorporate into the session. Otherwise, no other materials or equipment are required for the small groups to proceed. The small group sessions also allow students to clarify any questions about the case and solidify the basic science concepts covered in their other coursework. Common questions for faculty include nuances in medical terminology, interpretation of diagnostic tests, the pathophysiology of the topic, and approaches to management or treatment.

ASSESSMENTS

Given the poor predictive correlation between a student’s performance on a particular problem and their performance on a new or different problem, the course uses several complementary methods of assessment that are administered longitudinally to cover all of the 28 topics.¹⁷ There are both assessments of learning as well as assessments for learning. Each method has its advantages and disadvantages, but these methods are combined to assign a global passing or failing grade for the course. The methods described below assess a student’s ability to generate a hypothesis, generate a synthesized problem list, develop a differential diagnosis and leading diagnosis, and provide diagnostic justification.

For the small group discussion sessions, faculty fill out a grade sheet for each student and assign a grade of an observer, participant, or editor/synthesizer (see Fig 1). Descriptive behavioral anchors are aligned with each category to guide the faculty. In addition, faculty are encouraged to provide specific comments on what individual students did particularly well or how they could better develop their reasoning skills. As the students proceed through the course, the threshold assessment rating necessary to receive a passing grade increases. For example, a grade of “observer” earlier in the curriculum constitutes a passing grade. However, a grade of “observer” later in the course prompts a formal review by the course director who meets individually with the student to determine if additional instruction or remediation is required.

Multiple choice questions (MCQs) are included in the midterm and final examinations within the organ-specific modules and cover many but not all ICR topics. We also developed three different short answer examinations that are administered during the musculoskeletal, cardiovascular/pulmonary/renal, and gastroenterology modules. For these examinations, students are provided clinical vignettes and asked to answer specific questions using free-text responses that range in length from a few words to several sentences. Relevant questions include generating a problem list, providing a differential diagnosis, committing to a leading or working diagnosis, providing diagnostic justification, and writing a summary statement. The course director grades their answers and gives students detailed written feedback. There is also a post-encounter form the students complete during their final Objective Structured Clinical Examination administered just before entering their clerkship rotations. Students complete two post-encounter forms after performing a comprehensive medical interview and physical examination on two standardized patients. They are asked to provide a problem list pertaining to the chief complaint, a differential diagnosis, a leading diagnosis, and supporting evidence for their leading diagnosis.

We also developed a variety of formative assessments for students that are associated with various sessions in the course. These exercises include concept maps and clinically integrated puzzles (CIPs) to help students develop and build their illness scripts, pre- and post-session MCQ-based quizzes, and short answer case vignettes. An example of one of our CIPs is provided in Supplement 1.

COURSE FEEDBACK

Students are asked to complete a short anonymous survey following each small group session. The response rate for each session generally runs between 60% and 85%. Students provide comments on what they liked best about the session and how it could improve. In addition to the individual session feedback, there is a mandatory survey developed by the Office of Medical Education at the university that collects feedback on the entire curriculum at the close of each module. Specific questions regarding ICR are included in that survey and generate several comments from students.

Globally, the feedback on the course from students is very positive. Specific examples of suggestions students have made to strengthen the course include shorter student handouts, making the sessions longer than 70 min and offering more virtual sessions. The ICR course is consistently highlighted by students in the university-led survey as the most valuable and helpful course the students participate in throughout the entire preclinical period. Around 87% state that the faculty are approachable and facilitate the small group sessions well, 81.5% feel the preparatory materials and handouts are helpful, 80.2% feel the sessions solidified their understanding of key concepts learned in other lectures, and 80% feel that the sessions were a valuable use of their time. Some examples of student comments are listed in Table II.

The course director actively engages with each faculty to obtain their feedback on the session and the cases used for discussion. Faculty often remark on how engaged the students are and how much they appreciate the opportunity to connect with learners in the preclinical period. It is not infrequent to have faculty request to teach additional small group sessions. Resident instructors often state that this course helps enhance their clinical reasoning abilities.

DISCUSSION

Our clinical reasoning course offers first- and second-year medical students multiple sequential opportunities across the preclinical curriculum to develop and practice their clinical reasoning abilities. It offers a unique opportunity for students to meet in small groups with clinical faculty and apply their basic science knowledge to clinical scenarios. The course is highly regarded by students, faculty, and the university leadership as a highly effective way to teach clinical reasoning. It serves as a key source for curricular integration pertaining to all aspects of the clinical reasoning process. Specific strengths of our course include a theory-based curriculum designed to promote the progressive independence of learners, a diversity of assessment methods, and faculty preceptors across multiple disciplines to facilitate the discussions.

The primary goal of the course is to facilitate the student’s transition from the basic mechanisms of disease to abstracting the important details of a clinical case and organizing them into a succinct and meaningful patient assessment. This is accomplished through the use of lectures and small group case discussions designed to promote the progressive independence of the learner. We provide students with both analytic and nonanalytic reasoning strategies in the curricula to foster flexibility in their clinical reasoning which has been shown to reduce clinician error in more complex cases.¹⁸ The repeated application of their knowledge to new problems helps facilitate the encapsulation of their knowledge into syndromes or specific diagnoses.¹¹ This is not an easy task for novice learners who frequently get distracted by the specific details of a clinical case.¹⁹

Having access to expert faculty educators to teach across a longitudinal curriculum is a consistent barrier cited by curriculum developers.⁶ We face the same challenge at our institution. However, our course illustrates how a longitudinal curriculum can still be successful using clinical faculty as well as GME trainees. This can be accomplished by providing faculty with practical tips on teaching preclinical students, providing detailed faculty guides highlighting the key teaching points for case-based discussions, and holding just-in-time training for faculty. Also, by offering both virtual and in-person sessions we can recruit national and international teaching faculty who are both subject matter experts in their fields and are excellent medical educators.

It has been our experience that GME trainees and senior medical students serve as powerful and effective near-peer instructors in clinical reasoning discussions.²⁰ Their experience giving “chalk talks” while on clinical rotations translates well into our small group case discussions. Students frequently comment on how residents and fourth-year medical students effectively break the topic down into digestible chunks that help them develop a systematic approach to a clinical problem. This should be something for other programs to consider when developing a clinical reasoning curriculum.

Our course offers a diversity of complimentary assessments that each have their advantages and disadvantages, feasibility considerations, and levels of validity. This approach helps to ensure a broad sampling with an assessment of all components of clinical reasoning highlighted in the course (hypothesis generation, summary statement, differential diagnosis, leading diagnosis, and diagnostic justification).¹ The formative assessments provided to students help augment their development of clinical reasoning and provide opportunities for additional progress testing to determine the student’s developmental growth. For those students who do not achieve a passing grade for a particular assessment item, they are given an opportunity to remediate that assessment until they are able to achieve a passing grade. An area for future growth is to expand our assessments of clinical reasoning skills across the entire four years of medical school to map the progression of clinical reasoning skills for each student throughout their undergraduate education.

A limitation of our course that should be highlighted is the fact that it is offered at a single institution with military-specific themes incorporated into the curriculum. However, the curriculum is easily generalizable to students across other institutions and settings in the preclinical years. The educational framework can be widely applied and adapted into different instructional formats that cover many topics to provide the early learner with sequential exposure and practice in diagnostic reasoning. For example, clinical cases and topics covered can be modified for use with medics, corpsmen, nurse practitioners, and physician assistants to address high-yield topics and health complaints they may encounter both in garrison as well as in a deployed setting. Utilizing various educational strategies such as schemas, CIPs, and concept maps can be powerful teaching and assessment tools for educators to use in such learning environments.

CONCLUSION

Our longitudinal clinical reasoning course offers students several robust opportunities to learn key concepts of clinical reasoning, while allowing them deliberate practice to apply those concepts in a supportive environment. The course is theory-based to provide the structure, process, and content required to help students organize complex material presented in their basic science courses and apply it to clinical case scenarios. A variety of assessments are utilized across the course including formative assessments for learning. The course leverages local and national clinical faculty, GME trainees, and senior medical students as small group facilitators which should be considered by other institutions.

ACKNOWLEDGMENTS

None.

SUPPLEMENTARY MATERIAL

SUPPLEMENTARY MATERIAL is available at Military Medicine online.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

The content to support this paper is available on request from the corresponding author.

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

Not applicable.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

R.M. drafted the original manuscript. S.J.D. designed the original curriculum described. S.J.D., J.M., and M.R. reviewed and edited the manuscript. All authors read and approved the final manuscript.

INSTITUTIONAL CLEARANCE

Not applicable.

REFERENCES

Author notes