Theory-guided teaching: Implementation of a clinical reasoning curriculum in residents

Abstract

Introduction: Educators have theorized that interventions grounded in dual process theory (DPT) and script theory (ST) may improve the diagnostic reasoning process of physicians but little empirical evidence exists.

Methods: In this quasi-experimental study, we assessed the impact of a clinical reasoning (CR) curriculum grounded in DPT and ST on medicine residents participating in one of three groups during a 6-month period: no, partial, or full intervention. Residents completed the diagnostic thinking inventory (DTI) at baseline and 6 months. At 6 months, participants also completed a post-survey assessing application of concepts to cases.

Results: There was a significant difference between groups in application of concepts (no intervention 1.6 (0.65) compared to partial 2.3 (0.81) and full 2.2 (0.91), p = 0.05), as well as describing cases in problem representation format (no intervention 1.2 (0.38) and partial 1.5 (0.55) compared to full 2.1 (0.93), p = 0.004). There was no significant difference in change in DTI scores (no intervention 7.0 (16.3), partial 8.8 (9.8), full 7.8 (12.0)).

Conclusions: Residents who participated in a CR curriculum grounded in DPT and ST were effective in applying principles of CR in cases from their practice. To our knowledge, this is the first workplace-based CR educational intervention study showing differences in the reasoning process residents apply to patients.

Acknowledgements

The authors thank Dr. Georges Bordage for his permission to use the DTI as well as his colleagues, Dr. Janet Grant and Dr. Rodney Gale for assistance in processing the DTI results.

Disclosure statement

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

Glossary

Dual Process Theory: According to dual-process theory, the diagnostic process advances through two interacting cognitive processes: a fast, intuitive, pattern recognition process (System 1) and a slow, analytic, deliberate process (System 2). Clinical decisions typically require some component of each type of reasoning.

Croskerry P. 2009. A universal model of diagnostic reasoning. Acad Med. 84(8):1022–1028.

Script Theory: Explains how information is stored and retrieved in the human mind. Organized mental representations of disease stored in memory—illness scripts—are the medical application of this theory. Organizing medical knowledge into illness scripts allows for enhanced storage and future retrieval of that information during clinical encounters.

Lubarsky S, Dory V, Audetat MC, Custers E, Charlin B. 2015. Using script theory to cultivate illness script formation and clinical reasoning in health professions education. Can Med Educ J. 6(2):e61–e70.

Additional information

Notes on contributors

Verity Schaye

Verity Schaye, MD, MHPE is an Assistant Professor in the Department of Medicine at New York University School of Medicine, serves as the Director of Inpatient General Medicine at NYC Health & Hospitals/Bellevue, codirects the Bedside Teaching Service, and is a core faculty member of the Education for Educators E4E faculty development program.

Kinga L. Eliasz

Kinga L. Eliasz, PhD is a Postdoctoral Research Scientist for the Program for Medical Education Innovations and Research (PrMEIR) at New York University School of Medicine, New York, NY, United States.

Michael Janjigian

Michael Janjigian, MD serves as Associate Chief of Medicine at NYC Health & Hospitals/Bellevue, co-directs the Bedside Teaching Service, is Associate Director of the Merrin Bedside Teaching Program and is a core member of the Education for Educators E4E faculty development program.

David T. Stern

David T. Stern, MD, PhD is the Chief of the Medical Service at VA New York Harbor Healthcare System and Vice Chair for Education and Faculty Affairs in the Department of Medicine at New York University School of Medicine.