Understanding of clinical reasoning and how it is taught and learned in undergraduate medical programs (Australia & Indonesia)

© 2012 Dr. Ardi FindyartiniBackground: The acquisition of clinical reasoning (CR) skills is one of the main goals of medical education, however, medical curricula do not necessarily elaborate the teaching and learning process for the acquisition of this skill explicitly. Method: This study explored CR teaching and learning in two undergraduate medical education settings at the University of Melbourne (UoM, Australia) and the University of Indonesia (UI, Indonesia) using quantitative and qualitative methods within a comparative case study framework. There were three sources of data used in this study: medical students enrolled in their final semester of pre-clinical training (semester 6) and their final semester of clinical training (semester 12), academic teachers, and curriculum documents. The students’ thinking styles and perceptions of CR teaching and learning were obtained by the administration of two quantitative instruments (Diagnostic Thinking Inventory (DTI) and a new Questionnaire on CR (QCR)) and qualitative focus group discussion. The academics’ views and curriculum documents were explored by conducting qualitative inquiries through semi-structured individual interviews and document analysis. Results: Students from UoM and UI who volunteered for the survey were 168 semester 6 and 12 UoM students and 209 semester 6 and 12 UI students. In addition to this, 4 student FGDs (2 for semester 6, and 2 for semester 12) were conducted at the UoM and 6 FGDs (3 for semester 6, and 3 for semester 12) were completed at the UI. Finally 13 UoM and 11 UI academics were interviewed. The data was collected in 2008 – 2009 in both settings. Following detailed quantitative and qualitative analysis, there were seven major findings from this study: a. The curriculum audit of medical education at UoM and UI demonstrated three issues in relation to CR skills development: that training expectations were often implicit rather than explicit. UoM introduced CR training in the preclinical years through PBL, while UI placed stronger reliance on the clinical training years. b. Semester 12 students in both settings had more flexibility of reasoning style and better structure of knowledge in memory, better awareness of the value of CR learning, and better self-reflection in relation to CR than their semester 6 counterparts. c. All informants in both institutions strongly agreed that the clinical years of training were the best preparation for developing CR skills. d. UoM students and academics more strongly endorsed the value of PBL in developing CR skills at both semester 6 and semester 12 levels than UI students and academics. f. Clear cultural differences in relation to attitudes to learning CR were evident in the two institutions, in particular in relation to the power distance between the academics as content experts and the students and preferences to uncertainty avoidance in teaching and learning CR. These were more evident in the UI context than they were in UoM context. g. There was little relationship between flexibility of reasoning style and structure of knowledge in memory, awareness of value of CR learning and self-reflection in relation to CR, and students’ pre-clinical and clinical grades in both institutions suggesting that they were independent aspects of medical learning in both courses. Conclusion: Despite CR being recognized as an essential skill for medical graduates, UoM and UI did not explicitly express the CR objectives or a specific teaching and learning process to acquire these skills. Despite this observation, students improved their diagnostic thinking style and perceptions during the course suggesting that CR was actually taught and learned during medical training at the UoM and UI. The role of PBL as well as clinical skills tutorials in preclinical years for CR development can be enhanced in both institutions, especially in UI. In the clinical years, both institutions seemed to face a similar challenge to provide a more explicit and systematic way of learning and practicing CR. Finally, the cultural aspects should be considered while improving the curriculum in regards to CR skill development