Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors

Abstract

Objectives Clinical reasoning skills are essential for sound medical decision-making. Though many have suggested that clinical reasoning instruction should begin in pre-clerkship curricula, neither pre-clerkship clinical skills director perspectives nor extent of instruction is known. This survey study serves as part of a needs assessment for United States medical school pre-clerkship clinical reasoning curricula. Methods United States medical school pre-clerkship clinical skills course directors were surveyed about perceived importance of formal instruction on clinical reasoning concepts, inclusion of these concepts in the curricula, barriers to instruction, and familiarity with clerkship curricula. Results were analyzed using descriptive and analytic statistics. Narrative comments were analyzed qualitatively for themes. Results Of 148 directors surveyed, 102 (69%) participated and 89 (60%) completed all closed-ended items. Each clinical reasoning concept was identified as somewhat to extremely important to include in pre-clerkship curricula by 90–99% of respondents. Pre-clerkship curricula included variable degrees of formal instruction for concepts, though most respondents rated their inclusion as moderate or extensive. Perceived importance of teaching most concepts moderately correlated with the degree of inclusion in the curriculum (Spearman’s rho 0.39–0.44). Curricular time constraints and lack of faculty with skills to teach these concepts were the most frequently cited barriers to instruction. Respondents indicated being somewhat 57% (n=54) to extremely 29% (n=27) familiar with clerkship curricula at their institutions. Conclusions This study is the first to examine pre-clerkship clinical skills course director perspectives about clinical reasoning instruction and extent of its inclusion in their curricula.

Clinical reasoning education in the clerkship years: A cross-disciplinary national needs assessment

“…Some facets of the diagnostic process—namely history taking, physical examination, and rudimentary differential diagnosis—are standard components of the pre-clerkship curriculum. In recent years, directors of clinical skills courses have begun to incorporate other aspects of clinical reasoning into their pre-clerkship courses [ 12 ]. One study of internal medicine clerkships suggested that clinical reasoning education is more ‘caught’ (i.e.…”

Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition

“…The DOCS institutional representative response rate was 69% (102/148) of targeted respondents answering 1 or more survey items. More detailed respondent demographics have been previously reported [ 15 ]. This overall response rate for the clerkship leaders survey was 19% (305/1859) and ranged from 3% to 30% across specialties.…”

“…The authors previously reported separately on cross-sectional surveys of pre-clerkship clinical skills course directors serving as institutional representatives to the DOCS organization, and clerkship leaders (clerkship directors and co-directors, associate clerkship directors, and clerkship clinical site directors) from organizations that comprise ACE [ 15 , 16 ]. This report represents the analysis comparing the results from these two surveys.…”

“…This led to a collaboration between the Directors of Clinical Skills Education (DOCS), a consortium of educators who direct clinical skills education in the pre-clerkship curriculum, and the Alliance for Clinical Education (ACE), an organization encompassing members from clerkship specialty organizations. Both surveyed their members to characterize the current state of clinical reasoning education in their respective UME phase [ 15 , 16 ]. This study examined these data through the lens of the first UME transition.…”

Current status and ongoing needs for the teaching and assessment of clinical reasoning – an international mixed-methods study from the students` and teachers` perspective

“…[ 9 – 14 ].). Moreover, teachers are often not trained to explicitly teach CR, including explaining their own reasoning to others [ 10 – 12 ] although this appears to be an important factor in the implementation of a CR curriculum [ 15 ]. Some teachers even question whether CR can be explicitly taught [ 16 ].…”