Types of clinical reasoning in a summative clerkship oral examination

Abstract

Introduction

Dual-process theory characterizes clinical reasoning (CR) as Type 1 (intuitive) and Type 2 (analytical) thinking. This study examined CR on a summative clinical clerkship structured clinical oral examination (SCOE).

Methods and subjects

511 clinical clerks at the University of Toronto underwent SCOEs. Type 1, Type 2, and Global CR performance were compared to other internal medicine clerkship assessments using descriptive statistics and Spearman correlations.

Results

Clinical clerks achieved mean marks >75% on the three clinical reasoning stations, on Type 1 and 2 CR tasks, and the overall SCOE. Performance on the SCOE CR stations correlated with each of the other clerkship assessments: written examination, inpatient, and ambulatory clinic assessments. The correlation of performance between Type 1 and Type 2 clinical reasoning tasks was statistically significant but weak (r_s = 0.28). This suggests that defined measures of Type 1 and Type 2 reasoning were indeed assessing distinct constructs.

Conclusion

Clinical clerks used both Type 1 and Type 2 reasoning with success. This study’s characterization of Type 1 and Type 2 CR as separate domains, distinct from existing measures on the SCOE as well as the other clerkship assessments, can suggest a further addition to multimodal clerkship assessment.

Keywords:

• Undergraduate medical education
• clinical clerkship
• clinical reasoning
• assessment
• dual process theory

Disclosure statement

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

Glossary

Clerkships: Rotations around the clinical settings of the medical school. Some clerkships are obligatory (e.g. internal medicine, paediatrics, surgery), while others are elective or selective. In the United States, medical students do clerkships in their third and fourth year while in Europe, this typically occurs in the fourth through sixth year of medical school (Wojtczak 2003).

Dual-process theory: One approach to describing clinical reasoning processes, whereby clinicians use a combination of Type 1 and Type 2 processes. Type 1 processing is passive, intuitive, unconscious, rapid, requires little effort, and is contextualised based on prior experience. Type 2 processing is analytic, conscious, slow, systematic, and resource-intensive (Croskerry 2009a; Norman and Eva 2010).

Additional information

Notes on contributors

Vamana Rajeswaran

Vamana Rajeswaran, MD, completed post-graduate training in internal medicine and endocrinology at the Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.

Luke Devine

Luke Devine, MD, MHPE, is an Assistant Professor and the Director of Undergraduate Medical Education in the Department of Medicine, Temerty Faculty of Medicine, University of Toronto. He is an Internist who has educational interests in assessment and simulation.

Edmund Lorens

Edmund Lorens, B.Sc., MEd, Statistics & Evaluation, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.

Sumitra Robertson

Sumitra Robertson, BA, was the Undergraduate Medical Education Coordinator in the Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.

Ella Huszti

Ella Huszti, MSc, PhD, Biostatistics Research Unit, University Health Network, Toronto, Canada.

Daniel M. Panisko

Daniel M. Panisko, MD, Department of Medicine, Faculty of Medicine, University of Toronto, The HoPingKong Centre, University Health Network, Toronto, Canada, is a General Internist, Professor of Medicine, and the Gladstone and Maisie Chang Chair in the Teaching of Internal Medicine.