Clinical reasoning development in medical students: an educational transcultural comparative study

Clinical reasoning research has concluded that experts use less, but more selective, knowledge in a more efficient way, based on the construction of schema, scripts and other representations of the relation between signs, symptoms and diagnoses, derived from their experience. However, this conclusion does not help Medical Schools to decide which pedagogical strategies should be adopted to foster clinical reasoning in undergraduates. This study aims to investigate how medical students, approach clinical cases and the impact of three types of curriculum upon their clinical reasoning. Two studies were carried out. The first analysed 60 hours of Problem-Based Learning sessions using electronic content analysis and corpus analysis. A second used a cross-sectional approach assessing and comparing students’ clinical reasoning in three different medical schools (Derby, Nottingham and Coimbra)based on a Clinical Reasoning Test (CRT) developed and validated for the purposes of this research. The clinical reasoning test prove to be a valid and reliable tool to assess clinical reasoning. The analysis of the PBL sessions indicated that early contact with clinical cases might favour students’ encapsulation of knowledge. First year students use more words, are more descriptive and make significantly more use of explanations. Second year students are more focused using less words, focusing more on the biomedical sciences aspect of the cases and engaging more in questions. The comparisons between different medical curricula show some differences between groups, at the entry to practice level in favour of the PBL and the integrated curricula. However, at the graduation level only small differences remain between the groups. Clinical exposure has a significant impact in improving students’ clinical reasoning, with differences in exposure time between curricula possibly accounting for such results. Additionally, differences in the strategies used to approach the cases were noted. Students from the traditional curriculum seem to be waiting until all information is displayed to make a decision, while their peers from other curricula seem to be more willing to make decisions based on initial patient’s information. No significant correlations with knowledge about the cases, or confidence on the diagnosis were found; possible reasons for these results will be discussed and implications for curriculum development and future research highlighted