Clinical Reasoning Education Sparse in Medical Schools

Marcia Frellick

September 01, 2017

Most medical students enter clinical clerkships with only poor to fair knowledge of clinical reasoning concepts and receive few hours of dedicated training during clerkships, according to a survey of internal medicine clerkship directors.

Joseph Rencic, MD, from Tufts Medical Center in Boston, Massachusetts, and colleagues sent the survey in May 2015 to 123 institutional members of the Clerkship Directors in Internal Medicine.

Results show that while 75% of respondents thought clinical reasoning should be taught in all 4 years of medical school, 57% offered no courses on these topics. Fewer than 5% of the directors said students had an excellent understanding of the concepts.

Dr Rencic and colleagues reported the survey results in an article published online August 24 in the Journal of General Internal Medicine.

"It's very sad to see that fewer than half of the schools have anything and those that do just have a few hours," Mark L. Graber, MD, president and founder of the Society to Improve Diagnosis in Medicine, told Medscape Medical News.

"This is the most fundamental skill that's used to make a diagnosis," he noted.

Reports such as the National Academies of Sciences, Engineering, and Medicine's "Improving Diagnosis in Health Care," point out that diagnostic mistakes account for a substantial amount of patient harm and up to 80,000 deaths each year in the United States.

"The best estimates we have are that 1 in 10 diagnoses is wrong," Dr Graber said. "We'd clearly like to see more specific training related to clinical decision making and other aspects of diagnosis in medical school."

The medical school model for clinical reasoning has always been an apprentice model. Students learn through watching more senior trainees and doctors "think out loud" while treating patients.

"This unstandardized process depends on the teaching skills of role models," the authors write. "Stated another way, clinical reasoning ability is often 'caught' by learners as opposed to being explicitly 'taught' to them."

However, Dr Graber says, beyond learning by shadowing, students need training in critical thinking, cognition, cognitive errors, and identifying biases. Training should also include how the health system works, which tests are best to order, and which tests are more likely to give false-negative or false-positive results.

Of survey respondents who said they didn't offer dedicated sessions, 88% cited lack of time in the curriculum and 69% cited lack of faculty expertise. Only 16% said a barrier was that clinical reasoning can't be taught.

Those barriers will be hard to overcome, Dr Graber said. Curriculum choices are steeped in tradition, and different disciplines fiercely defend their turf.

"An additional problem is the lack of a gold standard for assessing clinical reasoning skills, making it difficult to determine the efficacy of educational interventions," the authors write.

The survey response rate was high at 77% (95 of 123). Every region of the country was represented, with 62% of respondents from public schools and 38% from private.

Time devoted to clinical reasoning in the internal medicine clerkships ranged from 0 to 32 hours, with an average of 6.4 hours.

"Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error," the authors write.

They note that they studied only internal medicine clerkships, which depend heavily on these skills, and the findings may represent a best-case scenario.

The authors have disclosed no relevant financial relationships. Dr Graber founded the nonprofit Society to Improve Diagnosis in Medicine.

J Gen Intern Med. Published online August 24, 2017. Abstract

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