Teaching Clinical Reasoning to Veterinary Medical Learners: History
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Subjects: Veterinary Sciences
Contributor:
Amanda (Mandi) Nichole Carr
,
Gustavo Ferlini Agne
,
Roy Neville Kirkwood
,
Kiro Risto Petrovski

Clinical reasoning is an essential competence of veterinary graduands. It is a complex competence with cognitive, metacognitive, social, and situational activities. The literature on clinical reasoning in veterinary medical education is relatively scarce or focused on theoretical rather than practical applications. In this review, we address the practicality of teaching clinical reasoning to veterinary learners utilizing a practical example of a cow with allergic rhinitis. Learners should be guided through all the domains of clinical reasoning, including concepts, data collection and analysis, take action, and reflection on an encounter. Each of these domains needs to be clearly but concisely explained and practiced repeatedly by learners throughout the veterinary curricula. The teaching of clinical reasoning should start as early in the curriculum as possible, preferably in the pre-clinical years, with a gradual scaffolding and building of complexity before work-based learning begins, with an increase in demanding for advanced clinical reasoning competence. The teaching of clinical reasoning is best performed in specialized sessions and continued as a horizontally and vertically integrated activity.

  • clinical teaching
  • veterinary learners
  • instructors
  • clinical encounter
  • deep learning
Accurate diagnosis and appropriate management of the clinical encounter are essential to the provision of quality veterinary medical services. Diagnostic accuracy is heavily reliant on the ability to reason based on the clinical presentation of the patient [1]. Most clinical reasoning errors are not the result of a lack of knowledge but rather reflect the complexity of the clinical presentation coupled with minor to major faults in cognition or contextualization of the clinical encounter, and the defective synthesis of information [1][2][3][4][5][6][7][8][9][10][11]. Errors in clinical reasoning, particularly in diagnosis, in human medicine range between 4% and 25% [3][12][13][14], with errors in adherence to best practice reaching up to 45% [3]. Some 30–70% of these errors are preventable [6][13]. These error proportions are probably similar in veterinary medical practice [15], emphasizing the importance of learning the clinical reasoning process for veterinary learners [16][17][18][19][20][21][22]. Clinical reasoning is also considered an essential requirement by many accreditation bodies of veterinary medical educators [23][24][25].
The learning and teaching of clinical reasoning has been an area of significant importance in other medical fields [26], starting with the pioneering work of Ledley and Lusted in the 1950s [27], followed by the seminal work of Elstein in the 1970s [28]. Instructors and learners in various medical fields, including veterinary medicine, have stated that the learning and teaching of clinical reasoning are challenging (Table 1). The challenge derives from the complexity of what the clinical reasoning process entails [9][10][29][30]. However, the process can be simplified into three basic concepts—clinical reasoning as a (1) cognitive and metacognitive activity; (2) contextually situated activity; and (3) socially mediated activity [12][31][32].
Table 1. Reasons for finding teaching or learning clinical reasoning challenging.

Instructors

Learners

Ambiguity and complexity of the process

[22][30][33][34][35]

Being at level of educator in (O)RIME and using a lot of intuitive types of clinical reasoning

[36]

Curriculum design lacking stimulation of storage of knowledge in clinically relevant manner

[30][36][37][38]

Difficulty in explanation of cognitive processing of information to learner/s

[34][36][37]

Lack of awareness of clinical reasoning concepts

[35]

Lack of consideration of the clinical reasoning process when dealing with clinical encounters

[39]

Lack of training in teaching clinical reasoning

[30][34][35][37]

Relative lack of literature in journals frequently read by instructors involved with clinical teaching that are not directly employed in academia

[34][36]

Ambiguity and complexity of the process

[22][30][33][35]

Being at levels lower than educator and using a lot the analytical type of clinical reasoning

[36]

Being unfamiliar with the work-based learning context

Belief that clinical reasoning is ‘an art’

[36]

Content-loaded curriculum

[38]

Curriculum design lacking stimulation of storage of knowledge in clinically relevant manner

[30][36][37][38]

Lack of ‘real-life’ situations training during theoretical portion of the curriculum

[40]

Lack of awareness of clinical reasoning concepts

[35]

Lack of confidence

[38]

Lack of explanation of cognitive processing of information by instructor/s

[37][39][41]

Lack of opportunities to practice clinical reasoning in safe environment

[37][38]

Lack of qualified instructors in teaching clinical reasoning

[37][38]

Lack of specific teaching of clinical reasoning processes

[30][38][40]

Late introduction of clinical reasoning into the curriculum

[40]
We found scarce literature related to teaching clinical reasoning related to veterinary medical education and, as such, the statements used will be predominantly evidence-based literature related to medical professions. The clinical instructor (instructor hereafter) plays a double role in the teaching of clinical reasoning, a clinician and a pedagogist [35]. We would like to stress that our recommendations in teaching clinical reasoning are dependent on the appropriate training of these instructors in clinical teaching, and, in particular, clinical reasoning.

This entry is adapted from the peer-reviewed paper 10.3390/encyclopedia4020048

References

  1. Neill, C.; Vinten, C.; Maddison, J. Use of inductive, Problem-Based clinical reasoning enhances diagnostic accuracy in final-year veterinary students. J. Vet. Med. Educ. 2020, 47, 506–515.
  2. Audétat, M.C.; Laurin, S.; Sanche, G.; Béïque, C.; Fon, N.C.; Blais, J.G.; Charlin, B. Clinical reasoning difficulties: A taxonomy for clinical teachers. Med. Teach. 2013, 35, e984–e989.
  3. Scott, I.A. Errors in clinical reasoning: Causes and remedial strategies. BMJ 2009, 338, b1860.
  4. Audétat, M.-C.; Laurin, S.; Dory, V.; Charlin, B.; Nendaz, M.R. Diagnosis and management of clinical reasoning difficulties: Part II. Clinical reasoning difficulties: Management and remediation strategies. Med. Teach. 2017, 39, 797–801.
  5. Amey, L.; Donald, K.J.; Teodorczuk, A. Teaching clinical reasoning to medical students. Br. J. Hosp. Med. 2017, 78, 399–401.
  6. Lambe, K.A.; O’Reilly, G.; Kelly, B.D.; Curristan, S. Dual-process cognitive interventions to enhance diagnostic reasoning: A systematic review. BMJ Qual. Saf. 2016, 25, 808–820.
  7. Daniel, M.; Carney, M.; Khandelwal, S.; Merritt, C.; Cole, M.; Malone, M.; Hemphill, R.R.; Peterson, W.; Burkhardt, J.; Hopson, L.; et al. Cognitive debiasing strategies: A faculty development workshop for clinical teachers in emergency medicine. MedEdPORTAL 2017, 13, 10646.
  8. Graber, M.L. Educational strategies to reduce diagnostic error: Can you teach this stuff? Adv. Health Sci. Educ. Theory Pract. 2009, 14, 63–69.
  9. Cutrer, W.B.; Sullivan, W.M.; Fleming, A.E. Educational strategies for improving clinical reasoning. Curr. Probl. Pediatr. Adolesc. Health Care 2013, 43, 248–257.
  10. Cohen, A.; Sur, M.; Weisse, M.; Moffett, K.; Lancaster, J.; Saggio, R.; Singhal, G.; Thammasitboon, S. Teaching diagnostic reasoning to faculty using an assessment for learning tool: Training the trainer. MedEdPORTAL 2020, 16, 10938.
  11. O’Sullivan, E.; Schofield, S. Cognitive bias in clinical medicine. J. R. Coll. Physicians Edinb. 2018, 48, 225–232.
  12. Konopasky, A.; Artino, A.R.; Battista, A.; Ohmer, M.; Hemmer, P.A.; Torre, D.; Ramani, D.; Merrienboer, J.V.; Teunissen, P.W.; McBee, E.; et al. Understanding context specificity: The effect of contextual factors on clinical reasoning. Diagnosis 2020, 7, 257–264.
  13. Bordage, G. Why did I miss the diagnosis? Some cognitive explanations and educational implications. Acad. Med. 1999, 74, S138–S143.
  14. Graber, M.L.; Kissam, S.; Payne, V.L.; Meyer, A.N.D.; Sorensen, A.; Lenfestey, N.; Tant, E.; Henriksen, K.; LaBresh, K.; Singh, H. Cognitive interventions to reduce diagnostic error: A narrative review. BMJ Qual. Saf. 2012, 21, 535–557.
  15. Oxtoby, C.; Ferguson, E.; White, K.; Mossop, L. We need to talk about error: Causes and types of error in veterinary practice. Vet. Rec. 2015, 177, 438.
  16. Rogers, J.C.; Swee, D.E.; Ullian, J.A. Teaching medical decision making and students’ clinical problem solving skills. Med. Teach. 1991, 13, 157–164.
  17. Koufidis, C.; Manninen, K.; Nieminen, J.; Wohlin, M.; Silén, C. Unravelling the polyphony in clinical reasoning research in medical education. J. Eval. Clin. Pract. 2021, 27, 438–450.
  18. Ramaekers, S.P.J.; Van Beukelen, P.; Kremer, W.D.J.; Van Keulen, H.; Pilot, A. Instructional model for training competence in solving clinical problems. J. Vet. Med. Educ. 2011, 38, 360–372.
  19. Humm, K.R.; May, S.A. Clinical reasoning by veterinary students in the first-opinion setting: Is it encouraged? Is it practiced? J. Vet. Med. Educ. 2018, 45, 156–162.
  20. Young, M.E.; Thomas, A.; Lubarsky, S.; Gordon, D.; Gruppen, L.D.; Rencic, J.; Ballard, T.; Holmboe, E.; Da Silva, A.; Ratcliffe, T.; et al. Mapping clinical reasoning literature across the health professions: A scoping review. BMC Med. Educ. 2020, 20, 107.
  21. Harasym, P.H.; Tsai, T.-C.; Hemmati, P. Current trends in developing medical students’ critical thinking abilities. Kaohsiung J. Med. Sci. 2008, 24, 341–355.
  22. Young, M.; Thomas, A.; Gordon, D.; Gruppen, L.; Lubarsky, S.; Rencic, J.; Ballard, T.; Holmboe, E.; Da Silva, A.; Ratcliffe, T.; et al. The terminology of clinical reasoning in health professions education: Implications and considerations. Med. Teach. 2019, 41, 1277–1284.
  23. Australian Veterinary Boards Council. AVBC Day One Competencies—Version 1 January 2024. Available online: https://avbc.asn.au/wp-content/uploads/2023/01/AVBC-Day-One-Competencies_Final_2024-v1-Jan-24.pdf (accessed on 21 October 2023).
  24. Royal College of Veterinary Surgeons. RCVS Day One Competences. Available online: https://www.rcvs.org.uk/news-and-views/publications/rcvs-day-one-competences-feb-2022/ (accessed on 21 October 2023).
  25. European Coordinating Committee on Veterinary Training. List of subjects and Day One Competences as approved by ECCVT on 17 January 2019. Available online: https://www.eaeve.org/fileadmin/downloads/eccvt/List_of_subjects_and_Day_One_Competences_approved_on_17_January_2019.pdf (accessed on 21 October 2023).
  26. Croskerry, P. A universal model of diagnostic reasoning. Acad. Med. 2009, 84, 1022–1028.
  27. Ledley, R.S.; Lusted, L.B. Reasoning foundations of medical diagnosis; symbolic logic, probability, and value theory aid our understanding of how physicians reason. Science 1959, 130, 9–21.
  28. Elstein, A.S.; Shulman, L.S.; Sprafka, S.A. Medical Problem Solving: An Analysis of Clinical Reasoning; Harvard University Press: Cambridge, MA, USA, 1978.
  29. Ruczynski, L.I.; van de Pol, M.H.; Schouwenberg, B.J.; Laan, R.F.; Fluit, C.R. Learning clinical reasoning in the workplace: A student perspective. BMC Med. Educ. 2022, 22, 19.
  30. Gruppen, L.D. Clinical reasoning: Defining it, teaching it, assessing it, studying it. West. J. Emerg. Med. 2017, 18, 4–7.
  31. Koufidis, C.; Manninen, K.; Nieminen, J.; Wohlin, M.; Silén, C. Grounding judgement in context: A conceptual learning model of clinical reasoning. Med. Educ. 2020, 54, 1019–1028.
  32. Abrandt Dahlgren, M.; Valeskog, K.; Johansson, K.; Edelbring, S. Understanding clinical reasoning: A phenomenographic study with entry-level physiotherapy students. Physiother. Theory Pract. 2022, 38, 2817–2826.
  33. Weinstein, A.; Gupta, S.; Pinto-Powell, R.; Jackson, J.; Appel, J.; Roussel, D.; Daniel, M. Diagnosing and remediating clinical reasoning difficulties: A faculty development workshop. MedEdPORTAL 2017, 13, 10650.
  34. Dhaliwal, G. Developing teachers of clinical reasoning. Clin. Teach. 2013, 10, 313–317.
  35. Audétat, M.-C.; Lubarsky, S.; Blais, J.-G.; Charlin, B. Clinical reasoning: Where do we stand on identifying and remediating difficulties? Creat. Educ. 2013, 4, 42–48.
  36. Pinnock, R.; Welch, P. Learning clinical reasoning. J. Paediatr. Child Health 2014, 50, 253–257.
  37. Mohd Tambeh, S.N.; Yaman, M.N. Clinical reasoning training sessions for health educators—A scoping review. J. Taibah Univ. Med. Sci. 2023, 18, 1480–1492.
  38. Gonzalez, L.; Nielsen, A.; Lasater, K. Developing students’ clinical reasoning skills: A faculty guide. J. Nurs. Educ. 2021, 60, 485–493.
  39. Linn, A.; Khaw, C.; Kildea, H.; Tonkin, A. Clinical reasoning: A guide to improving teaching and practice. Aust. Fam. Physician 2012, 41, 18–20.
  40. Vinten, C.E.K.; Cobb, K.A.; Freeman, S.L.; Mossop, L.H. An investigation into the clinical reasoning development of veterinary students. J. Vet. Med. Educ. 2016, 43, 398–405.
  41. Weinstein, A.; Pinto-Powell, R. Introductory clinical reasoning curriculum. MedEdPORTAL 2016, 12, 10370.
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