Criteria for describing and evaluating training interventions in healthcare professions - CRe-DEPTH.

Background: Focused history taking, knowledge-based clinical reasoning, and adequate case presentation during hand-offs represent important facets of competence of practicing physicians. Based on a validated 360-degree assessment simulating a first day of residency we developed a training for final-year medical students including patient consultation, patient management, and patient hand-off. Due to the COVID-19 pandemic the training was changed to a telemedicine format and evaluated. Methods: In 2019, 103 final-year students participated in a newly designed competence-based training including a consultation hour with simulated patients, a patient management phase with an electronic patient chart, and a case presentation in hand-off format. Due to social distancing regulations, the training was not allowed to take place in this way. Therefore, we changed the training to a telemedicine format. In May 2020, 32 students participated in the telemedicine training. A 5-point Likert scale (1: does not apply to 5: fully applies) was used for the evaluation items. The two formats were compared with t-tests. Results: The students were similarly satisfied with the content of the training independently of its format. Both groups found the patient cases interesting (presence: 4.68 ± 0.49, telemedicine: 4.66 ± 0.48). With respect to the telemedicine format, participants were glad that an option had been found that could be offered throughout the final year (4.94 ± 0.24) despite the COVID-19 pandemic and they regarded it as a very useful training for their final examination (4.94 ± 0.24). Conclusion: The telemedicine format of the competence-based training worked as well as the presence format. In its telemedicine format, the training can be offered to students independently of their location.

Evaluation of a telemedicine-based training for final-year medical students including simulated patient consultations, documentation, and case presentation.

The clinical reasoning process, which requires biomedical knowledge, knowledge about problem-solving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians’ daily practice but difficult to assess. The aim of this study was to empirically develop a Clinical Reasoning Indicators-History Taking-Scale (CRI-HT-S) and to assess the clinical reasoning ability of advanced medical students during a simulation involving history taking. The Clinical Reasoning Indictors-History Taking-Scale (CRI-HT-S) including a 5-point Likert scale for assessment was designed from clinical reasoning indicators identified in a qualitative study in 2017. To assess indicators of clinical reasoning ability, 65 advanced medical students (semester 10, n = 25 versus final year, n = 40) from three medical schools participated in a 360-degree competence assessment in the role of beginning residents during a simulated first workday in hospital. This assessment included a consultation hour with five simulated patients which was videotaped. Videos of 325 patient consultations were assessed using the CRI-HT-S. A factor analysis was conducted and the students’ results were compared according to their advancement in undergraduate medical training. The clinical reasoning indicators of the CRI-HT-S loaded on three factors relevant for clinical reasoning: 1) focusing questions, 2) creating context, and 3) securing information. Students reached significantly different scores (p < .001) for the three factors (factor 1: 4.07 ± .47, factor 2: 3.72 ± .43, factor 3: 2.79 ± .83). Students in semester 10 reached significantly lower scores for factor 3 than students in their final year (p < .05). The newly developed CRI-HT-S worked well for quantitative assessment of clinical reasoning indicators during history taking. Its three-factored structure helped to explore different aspects of clinical reasoning. Whether the CRI-HT-S has the potential to be used as a scale in objective structured clinical examinations (OCSEs) or in workplace-based assessments of clinical reasoning has to be investigated in further studies with larger student cohorts.

/pdf/assessing-clinical-reasoning-in-undergraduate-medical-43vtgg7rpv.pdf

Assessing clinical reasoning in undergraduate medical students during history taking with an empirically derived scale for clinical reasoning indicators.

Background: Clinical reasoning refers to a thinking process including medical problem solving and medical decision making skills. Several studies have shown that the clinical reasoning process can be influenced by a number of factors, e.g. context or personality traits, and the results of this thinking process are expressed in case presentation. The aim of this study was to identify factors, which predict the quality of case summary statements as an indicator of clinical reasoning of undergraduate medical students in an assessment simulating the first day of residency. Methods: To investigate factors predicting aspects of clinical reasoning 67 advanced undergraduate medical students participated in the role of a beginning resident in our competence-based assessment, which included a consultation hour, a patient management phase, and a handover. Participants filled out a Post Encounter Form (PEF) to document their case summary statements and other aspects of clinical reasoning. After each phase, they filled out the Strain Perception Questionnaire (STRAIPER) to measure their situation dependent mental strain. To assess medical knowledge the participants completed a 100 questions multiple choice test. To measure stress resistance, adherence to procedures, and teamwork students took part in the Group Assessment of Performance (GAP) test for flight school applicants. These factors were included in a multiple linear regression analysis. Results: Medical knowledge and teamwork predicted the quality of case summary statements as an indicator of clinical reasoning of undergraduate medical students and explained approximately 20.3% of the variance. Neither age, gender, undergraduate curriculum, academic advancement nor high school grade point average of the medical students of our sample had an effect on their clinical reasoning skills. Conclusion: The quality of case summary statements as an indicator of clinical reasoning can be predicted in undergraduate medical students by their medical knowledge and teamwork. Students should be supported in developing abilities to work in a team and to acquire long term knowledge for good case summary statements as an important aspect of clinical reasoning.

Medical knowledge and teamwork predict the quality of case summary statements as an indicator of clinical reasoning in undergraduate medical students.

Over-testing of patients is a significant problem in clinical medicine that can be tackled by education. Clinical reasoning learning (CRL) is a potentially relevant method for teaching test ordering and interpretation. The feasibility might be improved by using an interactive whiteboard (IWB) during the CRL sessions to enhance student perceptions and behaviours around diagnostic tests. Overall, IWB/CRL could improve their skills. Third-year undergraduate medical students enrolled in a vertically integrated curriculum were randomized into two groups before clinical placement in either a respiratory disease or respiratory physiology unit: IWB-based CRL plus clinical mentoring (IWB/CRL + CM: n = 40) or clinical mentoring only (CM-only: n = 40). Feasibility and learning outcomes were assessed. In addition, feedback via questionnaire of the IWB students and their classmates (n = 233) was compared. Analyses of the IWB/CRL sessions (n = 40, 27 paperboards) revealed that they met validated learning objectives. Students perceived IWB as useful and easy to use. After the IWB/CRL + CM sessions, students mentioned more hypothesis-based indications in a test ordering file (p <  0.001) and looked for more nonclinical signs directly on raw data tests (p <  0.01) compared with students in the CM-only group. Last, among students who attended pre- and post-assessments (n = 23), the number of diagnostic tests ordered did not change in the IWB/CRL + CM group (+ 7%; p = N.S), whereas it increased among CM-only students (+ 30%; p <  0.001). Test interpretability increased significantly in the IWB/CRL + CM group (from 4.7 to 37.2%; p <  0.01) but not significantly in the CM-only group (from 2.4 to 9.8%; p = 0.36). Integrating IWB into CRL sessions is feasible to teach test ordering and interpretation to undergraduate students. Moreover, student feedback and prospective assessment suggested a positive impact of IWB/CRL sessions on students’ learning.

/pdf/interactive-whiteboard-use-in-clinical-reasoning-sessions-to-s1kbagz5vf.pdf

Interactive whiteboard use in clinical reasoning sessions to teach diagnostic test ordering and interpretation to undergraduate medical students

Background: Clinical reasoning, comprising the processes of clinical thinking, which form the basis of medical decisions, constitutes a central competence in the clinical routine on which diagnostic and therapeutic steps are based. In medical curricula in Germany, clinical reasoning is currently taught explicitly only to a small extend. Therefore, the aim of this project was to develop and implement a clinical reasoning course in the final year of undergraduate medical training.

Project description: A clinical reasoning course with six learning units and 18 learning objectives was developed, which was taught by two to four instructors on the basis of 32 paper cases from the clinical practice of the instructors. In the years 2011 to 2013, the course of eight weeks with two hours per week was taught seven times. Before the first and after the last seminar, the participating students filled out a self-assessment questionnaire with a 6-point Likert scale regarding eight different clinical reasoning skills. At the same times, they received a patient case with the assignment to prepare a case presentation and differential diagnoses.

Results: From 128 participating students altogether, 42 complete data sets were available. After the course, participants assessed themselves significantly better than before the course in all eight clinical reasoning skills, for example in “Summarizing and presentation of a paper case” or in the “Skill to enumerate differential diagnoses” (p<0.05). The greatest increase occurred in the skill to recognize typical cognitive errors in medicine and to identify risk situations for their occurrence (pre: 2.98±0.92 and retro-pre: 2.64±1.01, respectively, versus post: 4.38±0.88). Based on the ratio of number of words used per keywords used the problem presentation of the paper case was significantly more focused after the course (p=0.011). A significant increase in the number of gathered differential diagnoses was not detected after the course.

Conclusion: The newly developed and established Clinical Reasoning Course leads to a gain in the desired skills from the students’ self-assessment perspective and to a more structured case presentation. To establish better options to exercise clinical reasoning, a longitudinal implementation in the medical curriculum seems to be desirable. Faculty training would be useful to implement the concept as standardized as possible.

Implementation of a Clinical Reasoning Course in the Internal Medicine trimester of the final year of undergraduate medical training and its effect on students' case presentation and differential diagnostic skills.

Andreas Klinge

Papers

Implementation of a Clinical Reasoning Course in the Internal Medicine trimester of the final year of undergraduate medical training and its effect on students' case presentation and differential diagnostic skills.