Clinical reasoning is an essential competence of veterinary graduands. Unfortunately, clinical reasoning and, therefore, the quality of provided veterinary medical services are prone to bias, difficulties, and errors. The literature on biases, difficulties, and errors in clinical reasoning in veterinary medical education is scarce or focused on theoretical rather than practical application. In this review, we address the practicality of learning and teaching biases, difficulties, and errors in clinical reasoning to veterinary learners utilizing a practical example of a cow with a prolapsed uterus complicated by hypocalcemia and hypomagnesemia. Learners should be guided through all of the stages of clinical reasoning as much as possible under direct supervision. The common clinical biases, difficulties, or errors in veterinary medical encounters may differ between stages of development of the learner, with more difficulties occurring in earlier stages (Observer, Reporter, ±Interpreter) but more heuristic biases occurring at later stages (Manager, Educator, ±Interpreter). However, clinical errors may occur at any learner development stage. Therefore, remediation of clinical biases, difficulties, and errors in veterinary medical encounters should use strategies that are tailored to the level of development of the learner, but also to the specific encounter (e.g., client, patient, and context).
Similar to other medical professions
[1][2], clinical reasoning errors have a major influence on the quality of veterinary medical services
[3]. It is a common misconception that being older or more experienced means fewer errors in clinical reasoning, as experience is not synonymous with expertise
[2][4]. Becoming an expert means mastering clinical reasoning
[5][6][7] but it is not directly proportional to the time spent in practice. This paper addresses only the common biases, difficulties, and errors in clinical reasoning in veterinary medical encounters with a case example. It also proposes a framework for the remediation of common difficulties and errors in clinical reasoning in veterinary encounters, again utilizing the case example. The lack of veterinary medical literature related to this area will be identified and areas requiring urgent research pointed out. The clinical reasoning cycle with its stages, the types of clinical reasoning, and skills and competencies used in learning and teaching clinical reasoning for veterinary instructors and learners were covered in previous papers from our team
[8][9].
Accurate diagnosis and appropriate management of the encounter are essential for quality veterinary medical services. Diagnostic accuracy heavily relies on the practitioner’s clinical reasoning
[10]. Most clinical reasoning errors are not a result of a lack of practitioner’s knowledge but rather an effect of the complexity of the clinical work coupled with minor to major faults in cognition or contextualization of the clinical encounter
[2][10][11][12][13][14][15]. Errors in the human internal medicine field are high, not as a result of insufficient knowledge but, rather, the defective synthesis of information
[14][16][17][18]. Errors in clinical reasoning, and particularly in diagnosis in medical fields, range between 4% and 25%
[2][19][20][21][22], whilst errors in adherence to best practices may reach up to 45%
[2], of which 30–70% are preventable
[14][20]. Although speculative, these proportions are probably similar in veterinary medical practice
[3]. Therefore, learning the clinical reasoning process is essential to any medical field, including veterinary medicine
[5][6][23][24][25][26][27]. Clinical reasoning is also a requirement by many accreditation bodies of veterinary medical educators
[28][29][30].
Learning and teaching clinical reasoning should be planned activities. One important task is making learners aware of the potential common biases, difficulties, and errors in clinical reasoning
[4][13][17][31][32]. This allows for their prevention or the taking of action to moderate the consequences when bias, difficulty, or error in clinical reasoning in a veterinary clinical encounter has occurred (remediation;
Figure 1). This is only possible with awareness and recognition of the common clinical veterinary medical biases, difficulties, and errors, coupled with a detailed knowledge of the veterinary medical clinical reasoning circle
[8][9]. Veterinary medical learners and their clinical instructors who are aware of the common clinical veterinary medical biases, difficulties, and errors should minimize their occurrence, and when they do occur, they should be able to timely implement appropriate remediation strategies.
Figure 1. The prevention of veterinary medical clinical reasoning bias, difficulty, or errors is possible by being aware of them, as well as having awareness of strategies that can minimize or prevent them.
Biases, difficulties, and/or errors in clinical reasoning can be classified into four major categories, namely cognitive, client ± patient-related, process-related, and system-related factors (
Table 1;
[21][22]). Many of these factors are similar to, or the same as, the context factors affecting the clinical reasoning in learners
[9]. Unfortunately, the lack of veterinary literature prevents their ranking. Therefore, we urge research in this area.
Table 1. Biases, difficulties and/or errors in the clinical reasoning of learners can be classified into four major categories, cognitive, client ± patient-related, process-related, and system-related factors.
Client ± Patient-Related |
Cognition-Related |
Process-Related |
System-Related |
Challenging learners/practitioner’s credentials [19][33][34] Client’s ± patient’s characteristics [4][19][20][34][35][36][37][38] Client’s wish/es and perceptions [34][38][39] Incorrect hypothesis suggestions [19][33][39][40] Language and vocabulary [19] Understanding of the problem [34][40] |
Awareness of common clinical reasoning biases, difficulties, or errors [9][11][12][16][17][20][21][41][42][43][44][45][46][47][48][49][50] Awareness of bias, difficulty, or error in clinical reasoning remediation strategies [9][11][12][16][17][20][21][41][42][43][44][45][46][47][48][49][50][51] Breadth and depth of veterinary medical cognition [12][32][52][53] Expertise/level of development [7][19][21][53][54] Metacognitive competences Organization of mental representation [16][55] Personal attitude (e.g., beliefs, confidence, contemplation, creativity, curiosity, flexibility, inquisitiveness, intellectual integrity, intuition, motivation, open-mindedness, perseverance, prejudices, and values) [2][4][34][36][38][56][57] Personal psychomotor state (e.g., fatigue, sleep deprivation, and stress) [2][4][19][20][34][35][40][51][57][58][59] |
Available versus required time for the encounter [2][4][19][20][57] Depth and level of supervision [50][51][60] Error management Individual versus teamwork Method of clinical teaching [9][50][61][62] Reflection [16][63][64] |
Available resources [2][19][20][35][39] Available versus required time for the encounter [2][4][19][20][57] Client-learner/practitioner relationship [33][34][38][40] Clinical encounter (e.g., urgency) [34][35] Clinical settings [35][36][39][65] Communication skills [33][34][39][40][42][66][67] Cultural environment [39] Distractors (e.g., noise) [4][35][57] Environment [34][57] Ethical issues [35][39] Financial constraints [2][39] Frequency of encounter Group/team size Industry-related factors and issues [39] Legal factors and issues [39] Level of complexity Level of supervision [50][60][62] Social environment [1][2][5][19][20][58][64][68][69][70][71][72] Support from the team [20][50] Team dynamics [57] |
The biases, difficulties, and/or errors in clinical reasoning classification and occurrence are scarcely elaborated in the veterinary medical field. Moreover, even the available literature is mainly based on reviews, not research papers. We believe these reviews have drawn on human medical research and reviews. Therefore, this is an area of veterinary medical education that urgently requires research. Client ± patient-related factors leading to the occurrence of biases, difficulties, and/or errors in clinical reasoning have been investigated in human medical fields (10 of 11 papers), and only one review paper by our team
[39] has addressed some aspects of biases, difficulties, and/or errors in clinical reasoning in the veterinary medical field related to client ± patient characteristics. The majority of the literature on cognitive effects on the biases, difficulties, and/or errors in clinical reasoning also arises from the human medical field (31 of 35 papers), but one research article
[53] and three review papers
[39][54][59] have addressed this aspect in the veterinary medical field. Process-related biases, difficulties, and/or errors in clinical reasoning are addressed in human medical fields (11 of 14 papers), and in three review papers
[9][61][62] in the veterinary medical field. Finally, system-related biases, difficulties, and/or errors in clinical reasoning are addressed in human medical fields (23 of 27 papers), and in four review papers
[9][62][66][72] in the veterinary medical field.
The likelihood of the occurrence of biases, difficulties, and errors in clinical reasoning in veterinary medical clinical encounters varies, inextricably influenced by many external and internal factors (
Figure 2;
[8][19][34][40]). All these factors may result in errors or delays in clinical reasoning decisions, ultimately decreasing the quality of provided veterinary services.
Figure 2. Factors affecting clinical reasoning and outcomes in veterinary clinical encounters.
It was believed that more errors occur when a learner uses an exclusively analytical or intuitive type of reasoning compared to reasoning using the dual type of clinical reasoning
[4][31]. This belief is now challenged
[6][31]. Difficulties and errors in clinical reasoning may occur due to faulty heuristic recall (intuitive type of clinical reasoning) that has generated the problem, but there is also a failure in the analytical type of clinical reasoning that fails to recognize the problem, and no remediation occurs
[15][31][59]. Yet, in practice, the separation of purely analytical and intuitive, or the use of dual clinical reasoning, is difficult. In reality, any errors in the intuitive type are associated with biases, whilst in analytical types of clinical reasoning, errors occur from the limited capacity of the working memory
[55], and deficient medical cognition/metacognition
[31]. For an extensive explanation of the types of clinical reasoning in veterinary medical teaching and learning, refer to a previous paper from our group
[9].
The primary internal factors supporting clinical reasoning, leading to improved outcomes in veterinary clinical encounters, include increasing age (better general problem-solving competence), experience and expertise in the applicable discipline, frequency of the encounter, and the mental organization of medical knowledge of the learner. In contrast, for the learner, an altered affective or psychomotor state, cognitive overload, deficient communication skills, and the lack of awareness of biases and/or errors in clinical reasoning, are internal factors likely to impair clinical reasoning, with less predictable outcomes.
Difficulties and errors in clinical reasoning are often connected to the learners’ metacognitive competence
[21][47][73][74][75] (e.g., general problem-solving skills, reflective practice, and/or self-confidence). As metacognition is affected by internal and external factors, general metacognitive competencies, and clinical reasoning in particular, should be intertwined with variability in contexts. Therefore, to decrease the proportion of clinical reasoning difficulties and errors, an important portion of the veterinary medical curricula should address the development of heuristic recall and metacognitive competence in veterinary medical learners (e.g., continual and targeted education, good organization skills, life-work balance, and selection of encounters seen by the learner).
External factors are related to the client ± patient (e.g., characteristics, wishes and perceptions, and challenging learner’s credentials), encounter-related (e.g., available resources and time, level of complexity, and presence of distractors), and system-related (e.g., financial constraints, ethical issues). In many cases, the external factors that affect clinical reasoning can be relatively controlled, particularly in encounter-based discussions. A more detailed discussion of the effects of these factors on clinical reasoning and outcomes of the encounters is beyond the scope of this paper.