An online course to teach clinical reasoning skills: Students’ perspectives and short-term outcomes

INTRODUCTION

Clinical reasoning (CR) is a process through which physicians gather clinical data, process the information, arrive at the most probable differential diagnoses, plan and implement the necessary interventions and evaluate the responses.¹ CR goes beyond the initial diagnosis and extends into all aspects of clinical practice and management.

CR is central to the practice of clinical medicine and an essential skill for a physician. CR is not an innate ability but rather a professional skill to be developed. Educators recognise its importance in developing expertise, but it is often not an explicit educational objective.^2,3 Instead, it is assumed that this skill will be automatically learnt as the student engages with the curriculum.²

Reasoning through a patient’s presentation is described to occur in one of two processes: system 1-intuitive (non-analytical), fast, used by experts, based on pattern recognition; and system 2-analytical, rational, slower, deliberate, reliable and focuses on hypothetical-deductive reasoning. System 2 is the primary process of reasoning, and the clinician moves towards system 1 reasoning with growing experience.^3–5

Traditionally, CR is taught using bedside case presentations/ discussions.⁶ While more emphasis is given to data gathering during the MBBS course, there is less time spent on understanding the process of clinical reasoning by systematic analysis of data to arrive at a differential diagnosis.⁷ Several studies have examined the effectiveness of training programmes for improving specific competency in CR. The few studies from India focus on laying the foundations of CR in the first year of the curriculum.^8–10 Previous studies from India have shown improvements in CR using methods like SNAPPS and the one-minute preceptor (OMP)^11–16 and some studies have used illness scripts to teach CR.^17,18 Most have assessed the perception of students about CR.^6,19,20 Only some have used tools such as script concordance, Clinical Reasoning Process score and Diagnostic Thinking Inventory to evaluate the understanding and practice of the process.^21–23

We aimed to enhance the CR skills among final-year MBBS students through an online CR course using the structured framework for a system 2 approach. The research objectives were: (i) to compare the CR skills of final year MBBS students before and after the online CR course; and (ii) to assess the perceptions of these students about the online CR course.

METHODS

Training method

The CR course focused on organizing data, problem representation, arriving at a differential diagnosis and selecting appropriate investigations (Fig. 1). The participants were introduced to the structured framework approach for CR using the example of the case created for pneumonia. They were then given an assignment where they were instructed to complete the initial steps in the CR process (Table I). The cases assigned to the groups were jaundice, headache, and acute abdomen. Each case was worked on by two groups. The students were expected to individually apply the initial steps of the CR process and come prepared for an online group discussion with team members and assigned faculty facilitators. A faculty-led discussion of the assignment occurred at the start of the following online session for all participants before a new step in the framework was discussed. This process was repeated for the subsequent three sessions. For the last two sessions, all the groups were given two cases of chest pain and stroke, for which they had to apply the steps in the structured framework and discuss them on the lines mentioned previously.

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FIG 1.

The structured framework approach used during the course

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TABLE I. Schedule of the online clinical reasoning course

Session	Topic
1	Course outline
	Clinical reasoning: What it is and why it is important
2	Clinical reasoning: The process
	Assignment 1: Creating a problem list, medicalizing and
	applying semantic qualifiers
3	Discussion of assignment 1
	Assignment 2: Problem representation and differential
	diagnosis
4	Discussion of assignment 2
5	Clinical reasoning: Plan investigations
	Assignment 3: Plan investigations
6	Discussion of assignment 3
	Assignment 4: Apply all the steps to 2 case scenarios
7	Discussion of assignment 4

Evaluation

After the final session, the students had to complete a post-course assignment, which served as a post-test. For the pre-test and post-test, students had to individually create a problem list, medicalise and apply semantic qualifiers, frame a summary statement and suggest the three most probable differential diagnoses with suitable justification. The cases used for the pre- and post-test were pneumonia and fever with rash, respectively. Both the pre- and post-tests were done on Microsoft Teams, and the students were given 24 hours to complete them. An appropriate rubric was used to assess the pre- and post-test (Table II). This rubric was developed by incorporating elements of other available rubrics to assess CR.^24–26 For statistical analysis, the pre and post-test scores were converted to percentages.

TABLE II. The rubric used for assessment of the pre and post-test assignments.

Item	Emerging (1 point)	Acquiring (2 points)	Mastering (3 points)
Identifies the pertinent facts of a clinical case	Identifies some of the main problems from the scenario. Does not identify pertinent positives/negatives, risk factors, social/cultural factors, etc.	Identifies most of the problems from the scenario. Begins to identify some of relevant negative positives/negatives, risk factors, social/cultural factors.	Identifies all clinical problems in the scenario including all the relevant positives/negatives, risk factors, social/cultural factors. Omits irrelevant information.
Applies medical terms to the problems identified	Does not apply medical terms at all or only minimally.	Applies medical terms to most of the problems identified.	Applies medical terms wherever applicable.
Formulates a concise summary statement	Summary statement contains a few pertinent facts and medical terms related to the clinical case.	Summary statement contains many pertinent facts and medical terms related to the clinical case.	Summary statement contains all the pertinent facts and medical terms related to the clinical case. Omits irrelevant information.
Develops multiple working differential diagnoses	Proposes one or two differential diagnoses not necessarily the right ones.	Develops multiple working differential diagnoses but not necessarily in the right order. Perseveres in hypotheses despite contradictory evidence.	Develops multiple working diagnoses in a manner that demonstrates an organized approach or structure (e.g. ranks or groups hypotheses by likelihood, risk level, etc.).
Provides a rationale for each hypothesis	Provides no or incorrect rationales for most or all hypotheses.	Provides insufficient rationales for hypotheses. Uses opinion or unsupported hunches (faith-based problem solving: ‘I believe…’).	Articulates reasoning by providing a relevant basic science rationale/ explanation for each hypothesis. Usually relates key elements of the case to the differential diagnoses.

A confidence rating questionnaire and two open-ended questions were also administered to the participants after the course. The confidence rating questionnaire had 6 items related to the CR skills learnt during the course (Fig. 2). The response was on a five-point Likert scale for each item, with one indicating ‘not at all confident’ and five indicating ‘very confident’. The students had to indicate their confidence levels prior to and after the course. The two open-ended questions were ‘Which aspects of the clinical reasoning course were the most useful for your learning? Please explain in as much detail as possible as to why you thought that these aspects were useful’ and ‘Which aspects of the clinical reasoning course do you think could be improved? Please explain in as much detail as possible as to how these aspects could be improved.’ The study received clearance from the institutional ethics committee.

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FIG 2.

The confidence of students regarding various components of the clinical reasoning process before and after the workshop. The Y-axis represents the percentage of students who were either confident or very confident. All the differences were significant (p<0.001).

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RESULTS

A total of 57 medical students (20 males and 37 females) from the final year MBBS participated in the course. As 2 students did not submit their post-tests on time, their scores were not included in the analysis. The mean (SD) pre-test and post-test scores were 58.83 (18.74) and 70.47 (20.83), respectively, with a statistically significant improvement in the post-test scores compared to the pre-test scores (p<0.001). Thirty-three students answered the confidence rating questionnaire. The confidence rating scores for their CR ability showed a significant improvement (p<0.001 for all components) following the course when compared to the pre-course rating scores (Fig. 2).

The students’ perspectives about the course were focused on the beneficial aspects of the course and suggestions for improvement. Twenty-eight students provided answers to the open-ended questions. Five themes emerged regarding the beneficial aspects of the course. These were the structured approach to CR, the use of case discussions, working in groups, the expertise of the teacher and course structure. The themes related to the possible improvements to the course were the inclusion of more cases, timing of the course, contact with patients and course structure. Some students felt that the course was fine in the current format and did not require any improvements (Tables III and IV).

DISCUSSION

CR is an important competency that all doctors should have and is a complex skill to learn. It is, however, not explicitly taught in most medical colleges,²⁷ and it is assumed that students will acquire this skill by increasing their knowledge base and observing teachers.¹⁹ During their clinical postings, medical students focus mainly on data gathering from history taking and physical examination. Less emphasis is placed on the analysis of this data systematically to arrive at an accurate differential diagnosis. We aimed to address this gap by conducting a CR course for final-year medical students using a structured framework. The extended lockdown due to the Covid-19 pandemic provided an opportunity to conduct this online course. With the implementation of the new competency-based curriculum (CBC), courses such as these assume even greater importance.

Previous studies from India regarding teaching CR skills have been conducted among first-year MBBS students and postgraduate students.^19,23–30 The methods used in these studies, such as SNAPPS and OMP, have been shown to be effective at improving CR abilities.^19,26–30 Students need to have the ability to summarise the data collected by history and physical examination for these methods to be effective. The structured framework method used in this study specifically addresses this area. Our study showed that the confidence levels and skills related to CR improved significantly after the course. These findings are similar to other studies where a structured format was used to teach CR.^{6,18,20,27–31}

The participants’ perceptions about the course provided valuable insights that could be used to modify the course in the future. There is a strong case to be made for teaching CR using the structured format when students begin their clinical postings at the beginning of the second year of the MBBS course. This would give students enough time to practice this method until they become proficient in CR. Concurrent faculty development programmes to sensitise all the faculty from clinical departments to integrate this format into routine bedside teaching and clinical assessments would go a long way in ensuring its effectiveness. The methods suggested in the new CBC to develop CR skills, like OMP and SNAPPS, could also be more easily implemented if students already have a grounding in the principles of CR provided by the structured format.³² The students will also learn to embed new knowledge in a clinical situation, which may be more readily retrieved during future clinical encounters.

Our study has some limitations. The assessment tool used in this study was a rubric that provided data about the thought process of the students as they arrived at a differential diagnosis. Other assessment methods, such as the script concordance test, extended matching questions and the key answer test, would have provided more objective evidence about the participant’s ability to make an accurate diagnosis. Only students who volunteered participated in the course. This might have introduced a self-selection bias that could have influenced the results. Our study used a single group before and after study design. A randomized control study design would have been ideal.