Clinical Reasoning Skills

Basic Steps in the Clinical Reasoning Process

The following steps use a case-based approach. The case is chosen to match the level of the learner. Initially, novice and intermediate learners will have to spend independent study time reading textbooks to gain a basic level of factual knowledge, including vocabulary and definitions of terms, in order to understand and apply the information given in the cases.

• For novice learners: use fully worked examples of cases to help build constructs and schemas from the knowledge presented.

• For intermediate learners: begin to introduce variables in the context of real cases.

• For more advanced learners: use real cases with real dilemmas and real distractors. Real cases are preferred because they often reflect difficulties and issues encountered in actual medical practice.

Constructs and schemas require linkage of concepts. A concept may be defined as an encapsulation of ideas attributable to a single class or grouping. Learners must move beyond rote memorization of factual material. The facts must be applied in the framework of concepts (e.g., neutrophilia is part of acute inflammation). The concepts must be linked to a clinical context (e.g., a patient with neutrophilia, fever, productive cough, and rales has pneumonia). The causal connections between basic science concepts and categories of disease contribute to the construction of illness scripts (schemas) that are individual theoretical frameworks of disease. Repeated exposure to cases demonstrating the linkage of concepts builds pattern recognition. Increasing levels of expertise are required to generalize the concepts and apply them in the context of novel clinical scenarios.

In summary, learners must use acquired knowledge to obtain and recognize the meaning of data, they must apply the data within concepts linked to a clinical context, and they must use experience to apply constructs and schemas for formulation of a diagnosis.

An illness script (schema) can be represented by a structured case presentation. Novice students have difficulty applying their knowledge in a clinical context, and they do not have scripts in long-term memory for immediate recall and usage. Experts use pre-existing illness scripts in their long-term memory from past experiences for clinical reasoning with pattern recognition.

References:

Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med 2006;355:2217-2225.

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; 85:1118-1124.

McMillan WJ. Teaching for clinical reasoning - helping students make the conceptual links. Med Teach. 2010;32(10):e436-42.