An introduction to Clinical Reasoning Assessment

2. An introduction toClinical Reasoning Assessment MinooYaghmaei, MD-PhD Alireza Monajemi, MD-PhD 11/26/2015

3. Overview • The concept and theory of clinical reasoning • Assessment of clinical reasoning • samples of clinical reasoning exams

4. What is clinical reasoning?

5. Higher cognitive process that integrates information from a clinical encounter with an existing knowledge, which then enables to diagnose and manage patients.

6. Clinical Reasoning • “the cognitive process necessary to arriving at a diagnosis and a management plan”

7. Clinical Reasoning = Medical decision making = Clinical judgment = Clinical Problem Solving = Medical thinking

8. Clinical Reasoning Process

9. Data Information Gathering Final Dx & Mx Hypothesis formation Patient Hypothesis Evaluation Data Inquiry

10. Clinical Reasoning Assessment • Natural task (case-based & Dx or Mx) • Multi-dimensional (Process-oriented) • Novice-Expert discrimination • Problem specificity • Contents specificity (Blue printing)

11. Clinical Reasoning

12. Clinical Reasoning test : Overview • Each test regardless of its structure consist of these elements:

13. MCQ(Multiple choice question)

14. Evidences have shown that MCQ could assess clinical reasoning.

15. USMLE- step 2 • Short cases are presented that require some form of judgment or decision. • This may be related to data gathering, to case management or to any other phase of the clinical problem.

16. کار گروهی اولبرای هر کدام از این مراحل یک تست چهارجوابی طراحی بفرمایید.

18. The scenarios should be based on • clinical presentations • not no C.C or D.Dx.

19. Scenario • Short cases are presented that require some form of judgment or decision.

20. Instruction • This may be related to data gathering, to case management or to any other phase of the clinical problem.

21. Item • Symptom, signs or background information • Doing an action

22. The major Problems of MCQ • Long duration exam (over 8 h) • Just one answer • Too simple – not assessed complex cognitive process

23. Clinical Reasoning Assessment What is clinical reasoning? = What is the difference between expert and novice?

24. Ref: Cook, 2014

25. Expertise studies in cognitive science

26. Expert superiority • Pattern recognition • Knowledge organization • Chunking

27. Expertise is not Knowledge expansion But It is Knowledge restructuring

28. The concept of the script

29. The structure of script

30. Illness script

31. Illness scripts among different levels of expertise

32. Illness script • Richness • Accuracy • Different weight

33. Clinical reasoning process

34. The definition of expert influence the way we define clinical reasoning

35. Paradigm Shift in Clinical Reasoning Assessment

36. Alternative assessment • Synonyms: Authentic =performance-based assessment • Emphasis on doing • Close to real context • No correct and objective answer • Extended period of time • Assesses higher level of thinking

37. Clinical reasoning main features • Necessary for independent practice • Cognitive based • Process oriented • Implicit knowledge • Constructive • Meta-cognitive

38. Clinical Reasoning Assessment is not only an assessment of outputs! The process is also very important.

39. Major misconceptions • Complete history taking • Clinical Reasoning = Analytical Reasoning • Clinical Reasoning= Diagnostic Reasoning • Clinical Reasoning = Final Products

40. Clinical Reasoning test : Overview • Each test regardless of its structure consist of these elements:

41. Scenario • short scenarios, present challenging clinical situations in a few sentences. • Ambiguous, not straight forward • Not only one answer • Based on the instruction

42. Types of scenarios • An undifferentiated problem • A typical problem • Multisystem involvement • Life threatening situations • Preventive or health promotion

43. Blue prints for selecting cases

44. Instruction • Very very important: • Should ask for an action or decision • Explicit • About Dx or Mx

45. Items • Extended matching in order to avoid cueing effect • More than one correct answer • Uncertainty context • Weighting items( Likert scale) • Sorting or priorizing • Because of feasibility open ended questions are not recommended

46. Clinical Reasoning Assessment Assess all parts of the process. • MCQ • KF • CRP • Puzzle • SFT

47. Key Features(KF)

48. Examinations using KFQs appear capable ofmeasuring the construct of clinical reasoning

49. KF show construct validity because practitioners with greater experience demonstrate higher scores.

50. examinations using KFQs should include a large number of cases (approximately 40) • blueprinted to the desired content area • Shows predictive validity for future performance