Methods and Outcomes for the Remediation of Clinical Reasoning

Abstract

INTRODUCTION:There is no widely accepted structured, evidence based strategy for the remediation of clinical reasoning skills. AIM: To assess the effectiveness of a standardized clinical reasoning remediation plan for medical learners at various stages of training. SETTING: Learners enrolled in the University of Colorado School of Medicine Remediation Program. PROGRAM DESCRIPTION: From 2006 to 2012, the learner remediation program received 151 referrals. Referrals were made by medical student clerkship directors, residency and fellowship program directors, and through self-referrals. Each learner's deficiencies were identified using a standardized assessment process; 53 were noted to have clinical reasoning deficits. The authors developed and implemented a ten-step clinical reasoning remediation plan for each of these individuals, whose subsequent performance was independently assessed by unbiased faculty and senior trainees. Participant demographics, faculty time invested, and learner outcomes were tracked. PROGRAM EVALUATION: Prevalence of clinical reasoning deficits did not differ by level of training of the remediating individual (p=0.49). Overall, the mean amount of faculty time required for remediation was 29.6 h (SD=29.3), with a median of 18 h (IQR 5-39) and a range of 2-100 h. Fiftyone of the 53 (96 %) passed the post remediation reassessment. Thirty-eight (72 %) learners either graduated from their original program or continue to practice in good standing. Four (8 %) additional residents who were placed on probation and five (9 %) who transferred to another program have since graduated. DISCUSSION: The ten-step remediation plan proved to be successful for the majority of learners struggling with clinical reasoning based on reassessment and limited subsequent educational outcomes. Next steps include implementing the program at other institutions to assess generalizability and tracking long-term outcomes on clinical care.

When less is more for the struggling clinical reasoner

“…Formal remediation programs are effective [4], but they are labor intensive, require a longitudinal, institutional response, and are not well suited to the real-time clerkship environment where the unexpected struggling student is one of many learners on the teacher's team [5].…”

Is there a way for clinical teachers to assist struggling learners? A synthetic review of the literature

“…When considering which category is most likely involved, it must be borne in mind that causes of under-performance are often interrelated 34. A study by Guerrasio and Aagaard,14 for instance, showed that among 53 learners followed for clinical reasoning difficulties, three-quarters had “comorbidities”, ranging from insufficient knowledge (17% of students) to mental health issues (12% of residents). In such cases, the best approach is to address difficulties one by one, beginning with the predominant difficulty for that learner or the one that interferes most with their work.…”

“…Intervention studies regarding remediation have often been limited to small single-institution endeavors, and have focused on the remediation of cognitive difficulties 9,14. Although recommendations for remediation at an institutional level have recently been published,15 the best approach for clinical teachers in the field remains to be established.…”

Introduction

“…An inadequate knowledge base appears the most consistent reason for error (Norman et al 2017). A number of authors have recommended tailored teaching strategies for clinical reasoning (Rencic 2011;Guerrasio and Aagaard 2014;Posel et al 2014). Most approaches pertain to education in the clinical workplace.…”