Analysing clinical reasoning characteristics using a combined methods approach

BMC Medical Education

Justin Bilszta¹  Geoff McColl¹  Marie-Louise Dick³  Michele Groves² 

[1] Melbourne Medical School, The University of Melbourne, Melbourne, Australia;Faculty of Health Sciences, The University of Queensland, Queensland, Australia;School of Medicine, The University of Queensland, Queensland, Australia

关键词: Clinical skills;    Medical education;    Evaluation;    Assessment;    Diagnosis;    Medical;    Clinical reasoning;   

Others  :  1138591
DOI  :  10.1186/1472-6920-13-144

 received in 2013-03-27, accepted in 2013-10-15,  发布年份 2013

【 摘 要 】

Background

Despite a major research focus on clinical reasoning over the last several decades, a method of evaluating the clinical reasoning process that is both objective and comprehensive is yet to be developed.

The aim of this study was to test whether a dual approach, using two measures of clinical reasoning, the Clinical Reasoning Problem (CRP) and the Script Concordance Test (SCT), provides a valid, reliable and targeted analysis of clinical reasoning characteristics to facilitate the development of diagnostic thinking in medical students.

Methods

Three groups of participants, general practitioners, and third and fourth (final) year medical students completed 20 on-line clinical scenarios -10 in CRP and 10 in SCT format. Scores for each format were analysed for reliability, correlation between the two formats and differences between subject-groups.

Results

Cronbach’s alpha coefficient ranged from 0.36 for SCT 1 to 0.61 for CRP 2, Statistically significant correlations were found between the mean f-score of the CRP 2 and total SCT 2 score (0.69); and between the mean f-score for all CRPs and all mean SCT scores (0.57 and 0.47 respectively). The pass/fail rates of the SCT and CRP f-score are in keeping with the findings from the correlation analysis (i.e. 31% of students (11/35) passed both, 26% failed both, and 43% (15/35) of students passed one but not the other test), and suggest that the two formats measure overlapping but not identical characteristics. One-way ANOVA showed consistent differences in scores between levels of expertise with these differences being significant or approaching significance for the CRPs.

Conclusion

SCTs and CRPs are overlapping and complementary measures of clinical reasoning. Whilst SCTs are more efficient to administer, the use of both measures provides a more comprehensive appraisal of clinical skills than either single measure alone, and as such could potentially facilitate the customised teaching of clinical reasoning for individuals. The modest reliability of SCTs and CRPs in this study suggests the need for an increased number of items for testing. Further work is needed to determine the suitability of a combined approach for assessment purposes.

【 授权许可】

   
2013 Groves et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Wilson RML, Harrison BT, Gibberd RW, Hamilton JD: An analysis of the cause of adverse events from the quality in Australian health care study. Med J Aust 1999, 170:411-415.
• [2]Bhasale A: The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident monitoring. Fam Pract 1998, 15(4):308-318.
• [3]Graber ML, Franklin N, Gordon R: Diagnostic error in internal medicine. Arch Intern Med 2005, 165(13):1493-1499.
• [4]Bordage G: Why did I miss the diagnosis? Some cognitive explanations and educational implications. Acad Med 1999, 74(10 Suppl):S138-S143.
• [5]Scott IA: Errors in clinical reasoning: causes and remedial strategies. BMJ 2009, 338:b1860.
• [6]Norman G: Research in clinical reasoning: past history and current trends. Med Educ 2005, 39(4):418-427.
• [7]Eva KW: What every teacher needs to know about clinical reasoning. Med Educ 2005, 39(1):98-106.
• [8]Papa FJ, Oglesbt MW, Aldrich DJ, Schaller F, Cipher DJ: Improving diagnostic capabilities of medical students via application of cognitive sciences-derived learning principles. Med Educ 2007, 41(4):419-425.
• [9]Klein JG: Five pitfalls in decisions about diagnosis and prescribing. BMJ 2005, 330(7494):781-783.
• [10]Kassirer JP: Teaching clinical reasoning: case-based and coached. Acad Med 2010, 85(7):1118-1124.
• [11]Wolpaw T, Papp K, Bordage G: Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Acad Med 2009, 84(4):517-524.
• [12]Bowen JL: Educational strategies to promote clinical diagnostic reasoning. N Engl J Med 2006, 355(21):2217-2225.
• [13]Nendaz MR, Bordage G: Promoting diagnostic problem representation. Med Educ 2002, 36(8):760-766.
• [14]Schuwirth L: Is assessment of clinical reasoning still the Holy Grail? Med Educ 2009, 43(4):298-300.
• [15]Groves M, Scott I, Alexander H: Assessing clinical reasoning: a method to monitor its development in a PBL curriculum. Med Teach 2002, 24(5):507-515.
• [16]Charlin B, Roy L, Brailovsky C, Goulet F, van der Vleuten C: The Script Concordance test: a tool to assess the reflective clinician. Teach Learn Med 2000, 12(4):189-195.
• [17]Groves M: Fostering clinical reasoning in medical students. Med Educ 2011, 45(5):518-519.
• [18]Charlin B, van der Vleuten C: Standardized assessment of reasoning in contexts of uncertainty: the script concordance approach. Eval Health Prof 2004, 27(3):304-319.
• [19]Gagnon R, Charlin B, Lambert C, Carriere B, van der Vleuten C: Script concordance testing: more cases or more questions? Adv Health Sci Educ Theory Pract 2009, 14(3):367-375.
• [20]Groves M, O’Rourke P, Alexander H: Clinical reasoning: the relative contribution of identification, interpretation and hypothesis errors to misdiagnosis. Med Teach 2003, 25(6):621-625.
• [21]Duggan P, Charlin B: Summative assessment of 5th year medical students’ clinical reasoning by script concordance test: requirements and challenges. BMC Med Educ 2012, 12(29): . http://www.biomedcentral.com/1472-6920/12/29 webcite
• [22]Bordage G, Grant J, Marsden P: Quantitative assessment of diagnostic ability. Med Educ 1990, 24(5):413-425.