Teaching and assessment of clinical diagnostic reasoning in medical students

Abstract

Background

Teaching diagnostic reasoning and giving feedback has an important role in medical education. Clinicians who teach may recognise errors, but be unfamiliar with the terminology used to describe them, leading to a lack of consistent and useful student feedback.

Objective

This prospective project evaluation study aimed to develop an examiner training package regarding errors in diagnostic reasoning, utilising consistent language and feedback tool, and report on diagnostic reasoning errors in second year medical students over the transition from preclinical to early clinical training at objective structured clinical exams (OSCEs).

Results

Likert questionnaire regarding examining, assessment and feedback pre- and post-training showed improvement in all measures, including examiner feedback confidence post training (p < .001). Students (n = 235) within the cohort were examined at the first preclinical OSCE 12 weeks into the teaching year and 236 students at the end of year OSCE. A range of 0–6 diagnostic reasoning errors were reported for individual students. When comparing mean history station scores at the preclinical OSCE for students who were observed to have diagnostic reasoning errors, students with ‘poor pattern recognition’ had a 4.2% lower score than those without this error type (p = .04, 95% CI of difference .14, 8.32), while those with ‘unfocused data collection’ error had a station score 7.7% lower than those without this error (p < .001, 95% CI of difference 3.50, 11.99). At the end of teaching year clinical OSCE, all common error types were associated with poorer performance. Error pattern shifted through the two longitudinal assessments, resulting in ‘poor pattern recognition’ having reduced and ‘too narrow’ and ‘premature closure’ increased rates.

Conclusions

Incorporating the identification and feedback of common diagnostic reasoning errors into existing clinical assessments was feasible and easy to implement. Understanding, identifying and providing consistent feedback on common errors assists educators and could guide curriculum design.

Keywords:

• Clinical reasoning
• common diagnostic errors
• medical students
• assessment

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Glossary

Clinical diagnostic reasoning: A definition of clinical reasoning includes an ability to integrate and apply different types of knowledge, to weigh evidence, critically think about arguments and to reflect upon the process used to arrive at a diagnosis.

Linn A, Khaw C, Kildea H, et al. Clinical reasoning – a guide to improving teaching and practice. Aust Fam Physician. 2012 Jan–Feb;41(1–2):18–20.

Additional information

Notes on contributors

Lucy Gilkes

Associate Professor Lucy Gilkes, MBBS (UWA), FRACGP, MClinRes, General practitioner, Discipline Lead General Practice, University of Notre, Dame, Fremantle.

Narelle Kealley

Dr. Narelle Kealley, MBBS, FRACGP, Senior lecturer in discipline of General Practice at University of Western Australia.

Jacqueline Frayne

Dr. Jacqueline Frayne, MBBS, DRANZCOG, FRACGP, MMed, PhD, General Practitioner, Senior lecturer in discipline of General Practice at University of Western Australia.

At the time of this study LG, JF and NK all worked at the University of Western Australia in MD program with roles in the early teaching of clinical skills to medical students.