Cahyaningrum, Suhoyo, and Rahayu: Facilitating clinical reasoning for medical students in clinical settings: a scoping review
Abstract
This scoping review describes the responsibilities of facilitators, especially clinical teachers, in facilitating clinical reasoning and factors affecting the implementation of the strategies. This review was conducted by collecting and identifying original data in peer-reviewed full English journals published between 2004 and 2021. It followed Arksey and O’Malley’s framework and adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. The process included formulating review questions, developing a comprehensive search strategy, selecting relevant studies, extracting data, and presenting findings. Initial searches were conducted on PubMed, EBSCO, Scopus, and EMBASE, with a research librarian ensuring the efficiency and comprehensiveness of the search. The search based on the PCC approach (population, concept, context approach) encompassed “clinical reasoning,” “facilitation,” and “clinical teachers.” Out of the initial 2,004 records retrieved from the four databases, a thorough screening process led to the 30 studies included in the review, revealing three primary themes and multiple strategies related to clinical reasoning facilitation in clinical settings. These themes involved the responsibilities of clinical teachers, strategies utilized, and factors influencing clinical reasoning learning in clinical settings. In the clinical settings, clinical teachers have crucial responsibilities in facilitating clinical reasoning learning, including creating a safe environment, demonstrating effective practices, using appropriate strategies, and assessing students’ abilities. While this review has explored the responsibilities of clinical teachers, specific strategies that enhance clinical reasoning abilities need further investigation. Additionally, the impacts of identified factors on strengthening clinical reasoning abilities require more analysis.
Keywords: Clinical reasoning, Cognition, Critical thinking, Medical students
Introduction
Clinical reasoning is a multifaceted process that combines knowledge, cognition, and metacognition and is inherently tied to specific contexts [ 1- 3]. It is a complex field that plays a crucial role in successfully diagnosing patients, as it constitutes a cognitive process and employs an organized and analytical approach for determining diagnoses, treatments, and investigations [ 1, 4- 9]. An accurate diagnosis is integral to a doctor’s professional competence, and developing strong clinical reasoning skills plays a vital role in mitigating diagnostic errors [ 10]. Several studies revealed that diagnostic errors affect approximately 5%–15% of cases, with contributing factors including deficient diagnostic skills, premature closure, failure to identify mistakes, inaccurate estimations, and a lack of hypotheses [ 11, 12]. Inaccurate diagnoses can lead to inappropriate treatments, delays in necessary interventions, and unnecessary procedures, which can result in adverse health outcomes, prolonged suffering, and increased medical costs. Addressing and reducing diagnostic errors through enhancing clinical reasoning skills is essential for healthcare professionals to uphold the highest standards of patient care and maintain the integrity of the healthcare system [ 13]. Mastering clinical reasoning is a gradual process requiring well-structured learning processes and strategies [ 2]. Therefore, facilitating clinical reasoning should focus on optimizing strategies that can enhance roles of clinical reasoning in advanced clinical practices [ 14- 18]. Some strategies used to cultivate clinical reasoning abilities include case-based learning, problem-solving activities, and directed self-learning [ 19]. Therefore, facilitating clinical reasoning should focus on both cognitive and metacognitive skills to develop proficient clinical reasoning skills in healthcare professionals [ 19]. Health profession students who can effectively implement metacognition skills can have more organized thoughts for learning, problem-solving, and clinical practices [ 16- 18, 20]. Clinical teachers who facilitate within clinical settings with students are expected to actively engage in the learning process, such as providing specific examples or brief case studies to support the strategy of facilitating clinical reasoning [ 2, 21]. In addition, clinical teachers should promote active learning by encouraging learners to set new learning aims, keeping an interest in the learner’s application of newly learned knowledge and skills, repeatedly providing constructive feedback, and setting a role model of lifelong learning themselves [ 22]. They should orient students to the healthcare environment’s cultural and social aspects and shape students’ professional values as they prepare for practices [ 23]. Clinical teachers have a responsibility to help students overcome any deficiencies in their materials by integrating them into the curriculum. Therefore, they should adopt strategies that can optimize experiential learning for individual or a group of learners, such as promoting active learning and engaging learners in deliberate practices, reviewing knowledge and prior experiences to enhance motivation, supporting a psychologically safe learning environment, helping learners to set goals, fostering collaborative learning, structuring facilitations to link them to authentic responsibilities and tasks, and customizing content to individual learners [ 22, 23]. As reported in several previous studies, clinical teachers have implemented various strategies to enhance clinical reasoning skills in healthcare professionals [ 2, 19]. These strategies include case-based discussions, gamification, illness script worksheet approach, clinical simulations, and team debates. Recent studies have identified several effective approaches for strengthening diagnostic abilities, such as reflective reasoning, structured reflection, selfexplanation, a six-step pneumonic SNAPPS (summarize history and findings; narrow differentials; analyze differentials; probe preceptor about uncertainties; plan management; select case-related issues for self-study), workshops on clinical reasoning using illness scripts, and schema-based learning [ 24, 25]. Reflective reasoning enhances self-awareness and improves diagnostic accuracy but may require more time and facilitators. Meanwhile, a structured reflection provides a systematic thinking framework, which helps beginners grasp the concepts more quickly, but excessive dependence on the structure may impede cognitive flexibility [ 26, 27]. Selfexplanation promotes self-directed learning and emphasizes conceptual understanding, but some students may struggle to self-explain effectively without proper guidance [ 28- 31]. Another study illustrated that problem-based learning significantly improved the clinical reasoning skills of medical students. The study found that small group learning platforms such as problem-based learning (PBL) are more effective in improving academic performance than traditional lectures for facilitating clinical reasoning skills [ 32]. Subsequently, the effectiveness of hybrid was compared to pure PBL in facilitating clinical reasoning skills to medical students. The integration of video materials and virtual patients in PBL were able to enhance clinical reasoning skills among medical students. Video materials can offer visual and auditory information, facilitating non-verbal communication and aiding in developing clinical reasoning skills [ 33]. Similarly, a study found that a simulation with problem-based learning (S-PBL) using high-risk obstetrics-gynecology scenarios effectively strengthened nursing students’ clinical reasoning ability [ 34]. These studies suggest that problembased learning is an effective method for developing clinical reasoning skills in healthcare professionals. Although some literatures have explored various teaching strategies, there remains a gap in understanding the roles of clinical facilitators in facilitating these strategies. Facilitating clinical reasoning in clinical settings is challenging due to its abstract nature and the limitations faced by clinical teachers. These educators juggle various responsibilities, such as providing healthcare services, turning clinical moments into learning opportunities, giving feedback, and conducting assessments. Previous studies highlight the importance of understanding the responsibilities of clinical teachers in different strategies to enhance clinical reasoning [ 35- 38]. However, the existing literature reveals a significant gap in understanding how clinical reasoning is taught and learned in clinical settings. Critical aspects and specific facets of clinical reasoning are insufficiently addressed, indicating a need for a thorough review. This gap is evident in the limited exploration of facilitating and learning processes, educators’ responsibilities, and translations of theoretical knowledge into practical decision-making. Addressing these limitations is crucial in the current healthcare field, in which recent developments and evolving challenges underscore the heightened importance of enhancing clinical reasoning skills. Therefore, this scoping review is to demonstrate responsibilities of facilitators, strategies in facilitating clinical reasoning, and factors affecting the implementation of the strategy. The concepts on how clinical educators facilitate clinical reasoning will be formulated to strengthen clinical reasoning skills in learning. Hence, this scoping review will give insight into implementing clinical reasoning learning strategies. Medical education stakeholders, including clinical facilitators and students, can benefit from this review as it provides insights into optimizing interactions between clinical facilitators and students during clinical reasoning learning.
Materials and Methods
This study applied a scoping review methodology to map the available evidence regarding the facilitations of clinical reasoning development. Following the framework proposed by Arksey and O’Malley and the recommendation from the Joanna Briggs Institute, this scoping review was conducted through several key processes: (1) formulating scoping review questions, (2) developing a comprehensive search strategy, (3) screening and selecting relevant studies, (4) charting and extracting data from selected studies, and (5) analyzing and presenting the review results [ 39, 40].
1. Formulating scoping review questions
This scoping review aims to address the following key questions, which guide the focus and scope of this study: (1) Question 1: How do clinical facilitators facilitate clinical reasoning learning for students in clinical settings? (2) Question 2: What factors influence the facilitation of clinical reasoning in clinical settings?
Answering these questions fills the existing research gap and provides actionable insights for medical educators and students.
2. Developing a comprehensive search strategy
To ensure the rigor of the review processes, this study adhered to the established Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews guidelines during the initial search and study selection process [ 41, 42]. An experienced research librarian was involved in designing the search strategy to ensure its efficiency and comprehensiveness. The initial search was conducted using Google Scholar and PubMed, focusing on facilitation processes of clinical reasoning in clinical settings. Keywords for the search were derived from the population, concept, and context (PCC) approach. The studies identified during the early search became a reference for conducting a more specified and refined subsequent search: (1) P: clinical teachers, physician, students, medical students; (2) C: education strategy, facilitation, teaching, clinical reasoning; and (3) C: medical education. The systematic screening phase of the scoping review involved searching four major databases: PubMed, EBSCO, Scopus, and EMBASE. The search process utilized relevant keywords following the PCC approach. The keywords entered were as follows: (1) Clinical Teacher* OR Physician* OR Teacher* OR student* OR Medic* Student* (to capture relevant studies involving clinical teachers, physicians, students, and medical students in the context of medical education); (2) AND Education* strategy* OR facilitation* OR Teach* (to identify studies related to educational strategies, facilitation, and teaching methods); and (3) AND Clinical reasoning OR Diagnostic Reasoning OR Clinical Decision Making AND Medical Education (to retrieve studies focusing on clinical reasoning, diagnostic reasoning, and clinical decision-making within the context of medical education).
The comprehensive use of these keywords allowed for a thorough and targeted search to identify relevant literature related to the facilitation of clinical reasoning development in clinical settings. Furthermore, the literature data search for conducting the scoping review was conducted with approval from the Medical and Health Research Ethics Committee (MHREC) of the Faculty of Medicine, Public Health and Nursing at Universitas Gadjah Mada–Dr. Sardjito General Hospital (approval number: KE/FK/1175/EC/2021). The study protocol was not registered in any registry databases.
In addition, the inclusion and exclusion criteria applied in this study were as follows:
1) Inclusion criteria
The studies or the literature were included if they focused on PCC approach, as mentioned in the previous section. Additionally, this scoping review considered peer-reviewed full journal with original data, published in English between 2004 and 2021, as well as dissertations and theses. The availability of the studies in full-text was required for this review.
2) Exclusion criteria
The studies were excluded if they focused on other health allied (e.g., nurses, physios, occupational therapists, dentists, and so forth). This review excluded non-peerreviewed journal, conference abstracts, letters, reviews, and studies without full-text availability.
3. Screening and selecting relevant studies
The search was performed from four databases: PubMed, EBSCO, Scopus, and EMBASE. Following the search process, duplicates were eliminated before compiling and uploading all found citations to web-based application namely Rayyan (Rayyan, Cambridge, USA; https://www.rayyan.ai) [ 43]. Each database’s screening was completed independently by both the first (Y.D.C.) and second (Y.S.) reviewers. In case of disagreements, a third (G.R.R.) reviewer facilitated discussions. Furthermore, all reviewers (G.R.R., Y.S., and Y.D.C.) assessed the full texts of the studies for eligibility based on the pre-defined inclusion and exclusion criteria. A further systematic screening was conducted following the PRISMA guidelines. Review articles were excluded from data extraction but were utilized to identify additional studies through snowballing. Finally, the full-text reports of the selected records were retrieved.
4. Charting and extracting data
As scoping reviews typically do not involve formal quality appraisal [ 39, 40], studies in this review were not subjected to quality appraisal. All reviewers (G.R.R., Y.S., and Y.D.C.) individually reviewed the included studies to generate a description for each study using predefined, pilot-tested data extraction tools. The extracted data included details such as publication year, country where the study was conducted, study locations, study population characteristics, methodology employed, participant demographics, responsibilities of the facilitators, strategies employed for facilitating clinical reasoning, and factors that influence clinical reasoning. The research team thoroughly reviewed and discussed the charting process before its implementation.
5. Analyzing and presenting the review results
A thematic analysis was undertaken for the content codes pertaining to the focus of the studies. Subsequently, the team met to develop themes from the included studies across various content criteria. This approach allowed for including all studies, even studies describing facilitations of clinical reasoning that were not explicitly defined. Each included study was used to produce multiple themes. Regular meetings throughout the process enabled the team to resolve conflicts and ensure coding consistency. This collaborative approach to data coding ensured the accuracy and reliability of the results and findings of the scoping review.
Results
1. Selection of sources of evidence
A total of 2,004 records were obtained from four databases, including PubMed, EBSCO, Scopus, and EMBASE. Following the manual deduplication in Rayyan, 52 duplicates were eliminated, reducing their number to 1,952 records. During the screening process based on title and abstract, 1,850 records were excluded as they did not meet the inclusion criteria. The remaining 102 reports underwent eligibility assessment; however, the full text of two reports could not be retrieved. Ultimately, 100 reports were assessed for eligibility, excluding 70 reports that did not meet the inclusion criteria. Consequently, 30 studies were included in the review. Fig. 1 illustrates the flow of the search process and the results.
2. Themes
This scoping review identified three main themes concerning the facilitations of clinical reasoning in clinical settings. These themes encompass the responsibilities of clinical teachers, strategies employed in the process of clinical reasoning, and factors that impact clinical reasoning learning in clinical settings.
1) Roles of clinical teachers
The clinical teachers play various important responsibilities in facilitating clinical reasoning in clinical settings. Firstly, they are responsible for creating an optimal learning environment, which involves supervising and ensuring the quality of learning while fostering a positive atmosphere among patients, students, and themselves [ 8, 44]. Secondly, they actively engage in describing the clinical reasoning processes to students. They demonstrate their clinical reasoning skills during interactions with the students, allowing them to become familiar with different cases and scenarios [ 45]. The responsibilities of them in facilitating clinical reasoning can be summarized into several aspects, as shown in Table 1 [ 44- 64]. These aspects include providing an optimal learning environment, describing the process of clinical reasoning, assessing students’ abilities, and implementing effective learning techniques and methods. These responsibilities collectively contribute to enhancing students’ clinical reasoning skills and understanding in the clinical setting [ 54].
2) Facilitation techniques
Clinical reasoning can be facilitated through both analytical and non-analytical approaches ( Table 2) [ 46, 48- 54, 57, 59]. Analytical facilitation involves methods such as explaining the reasoning behind a diagnosis, engaging in discussions on relevant topics, and interpreting obtained results [ 48, 49, 65]. Analytical learning can be approached in various ways, such as encouraging students to identify differences and similarities between categories by comparing and contrasting examination features of different diagnoses, and asking them to make assumptions to establish a diagnosis through collaborative discussions [ 50, 57]. If the students face difficulties in identifying clinical aspects, the clinical teachers can provide cues in forms of questions [ 59]. Non-analytical reasoning can be fostered by observing the intuition demonstrated by clinical facilitators, learning from related cases, watching videos that exemplify anchoring and heuristic-intuitive-Bayesian reasoning, and encouraging students to make oral case presentations using a pattern recognition approach [ 46, 51- 53]. These non-analytical methods enable them to develop their intuitive decision-making skills in clinical reasoning. By incorporating both analytical and non-analytical approaches, the clinical teachers can effectively support and enhance the students’ clinical reasoning abilities in the clinical setting. Apart from using a thinking approach, clinical teachers should assess student abilities. Clinical teachers are responsible for assessing students’ abilities and implementing appropriate learning techniques and methods. To assess the students, they can administer pre- and postlearning tests and provide feedback based on their performance [ 56]. Feedback is used as a tool for reflection and evaluation of learning strategies [ 44, 60]. It can be given after clinical procedures or tasks, providing justifications for correct actions and explanations for any errors [ 47, 55, 65]. In terms of facilitation methods, clinical teachers can implement diverse techniques, such as the “think-aloud” approach, using semantic qualifiers, self-explanation by students, illness script approach, peer teaching, presenting clinical cases, and conducting small group learning [ 44, 48, 56, 60]. The clinical cases used for learning can be real cases or simulations, including case presentations, paper-based clinical scenarios, virtual case distribution, case distribution followed by semi-open questions from experts, and tutorials with problem-based learning [ 43- 45, 61, 63, 66, 67]. Furthermore, clinical teachers can utilize a real case approach, engaging the students to handle and discuss actual cases with the guidance of experts. They can also provide opportunities for the students to practice with undifferentiated patients and solve cases under time constraints [ 47, 54, 63]. Learning with a clinical case approach can be done by learning in small groups. Learning can involve role-playing as a doctor and patient, and providing study materials [ 48, 57, 60]. Responsibilities within the group can be structured as one student as a doctor and one as a patient, or two students as doctors and one as a patient. Interactive learning techniques can also be used, such as telling a case story and engaging students in discussions [ 56, 59, 62].
3) Factors affecting the facilitations
The processes of facilitating clinical reasoning are influenced by both internal and external factors ( Table 3) [ 8, 46, 47, 50, 53, 54, 56- 58, 60- 64, 67- 73]. Internal factors pertain to psychological and cognitive abilities, personality traits, learning styles, and motivation. Psychological abilities include the ability to recognize differences in clinical situations, psychological conditions, self-confidence, and students’ readiness to cooperate, and so forth [ 52, 59, 70, 71, 74, 75]. Cognitive abilities are influenced by basic cognition, concepts, and relational cognition. Basic cognition involves essential clinical reasoning abilities, knowledge inadequacy in pathophysiology, critical thinking skills, conceptual abilities, and information filtering [ 10, 47, 50, 53, 62, 64, 65, 75]. Concepts and relational cognition affect cognitive abilities by impacting the understanding of cause-andeffect relationships, handling uncertainty, selecting standardized diagnostic criteria, and drawing upon prior knowledge [ 10, 46, 56]. Personality abilities are influenced by interactions with experts and cases, problem-solving skills, and the frequency of patient encounters [ 8, 57, 65, 67, 71, 76]. Next, external factors consist of environmental and clinical facilitator-related aspects. Environmental factors encompass clinical settings and interactions, while clinical teachers-related factors include their facilitation styles, the consistency of feedback provision, team/clinical theme sustainability, and the clinical teachers’ abilities to recognize students’ challenges [ 8, 57, 58, 62, 63, 77]. These internal and external factors collectively shape the facilitations of clinical reasoning in the clinical settings. The clinical teachers can implement various techniques to facilitate clinical reasoning for the students. These techniques include: (1) verbal case reports (this technique involves presenting a clinical case to students verbally and asking them to identify the relevant clinical features and to make a diagnosis), (2) prompt of illness scripts (this technique involves providing students with a set of symptoms and asking them to generate a list of possible diagnoses based on their knowledge of illness scripts), (3) integrated case learning with patients’ treatment experiences (this technique involves integrating the patient’s treatment experiences into the learning process to help students understand the clinical reasoning behind the treatment decisions), (4) virtual patient case simulation (this technique involves using computer-based simulations to provide students with realistic clinical scenarios and opportunities to practice clinical reasoning), (5) problem-based learning tutorials (this technique involves presenting students with a clinical problem and asking them to work together to identify relevant clinical features and develop a diagnosis and treatment plan), and (6) Bayesian learning method (this technique involves using probability theory to help students make clinical decisions based on the available evidence [ 46, 55, 56, 60, 62, 67, 69, 76, 78]. To enhance the students’ capacity, the clinical teachers can utilize techniques such as the self-explanation method, think aloud approach, and prompting students to conduct literature searches [ 58, 64, 65]. Additionally, various educational training programs have been proven effective in improving clinical reasoning. These include interactive case-based didactic sessions, role-play exercises, learner-centered teleconferences, clinical seminars, case-based collaborative learning in PBL, clinical reasoning workshops and seminars, lectures with feedback, clinical reasoning courses, and case discussions [ 8, 48, 51, 55, 63, 70, 71, 73]. Furthermore, characteristics of included reports can be seen in Table 4 [ 8, 44- 64, 67- 72, 76, 77].
Discussion
The clinical teachers are multifaceted responsible in facilitating clinical reasoning in clinical settings, as shown in Table 1. Those responsibilities can be summarized into several aspects, including (1) creating a culturally safe learning environment, (2) elucidating the clinical reasoning process, (3) implementing diverse learning techniques, and (4) evaluating students’ progress, which contributes to the effective development and application of clinical reasoning skills among the students in the clinical settings. In the clinical settings, clinical teachers should be concerned about the learning environment. Creating a safe and supportive learning environment is crucial for them to enhance student competency in the clinical settings. Direct interactions between students, patients, and medical staff are vital for experiential learning, but they can also trigger emotional adjustments, leading to their anxiety. Mild anxiety can be beneficial, promoting heightened awareness and control, while excessive anxiety can hinder productivity and negatively impact learning effectiveness and professional behavior [ 79, 80]. Therefore, the clinical teachers play a vital role in maintaining a comfortable learning atmosphere, optimizing student performance, and encouraging continuous improvement in clinical reasoning capacities. A positive learning environment fosters patient interaction and provides ample opportunities for hands-on practice and active engagement in the learning process [ 81]. In addition, clinical teachers are also responsible for facilitating effective techniques of the thinking process. The facilitation techniques employed will significantly impact students’ learning experiences and outcomes [ 82]. This underscores the importance of clinical teachers in shaping their students’ understanding of clinical reasoning and their ability to apply it effectively in real-world scenarios. This scoping review identified various techniques to facilitate clinical reasoning, including utilizing clinical cases, conducting small group discussions, promoting students’ thinking aloud, employing semantic qualifiers, and constructing illness scripts during the learning process [ 56, 60, 83]. These techniques are adapted to meet the specific requirements for facilitating and enhancing students’ clinical reasoning learning experiences. Clinical reasoning, an essential skill for medical professionals, can be taught by clinical teachers who demonstrate their professional thought processes during the learning session. It involves two techniques: the analytical approach, in which information is analyzed and hypotheses are formed, and the non-analytical approach, in which reasoning is based on existing patterns and automated responses [ 84]. The analytical approach is commonly used in learning, involving making hypotheses and guesses based on observed clinical conditions [ 54]. It deepens understanding and enhances students’ clinical reasoning skills. In this approach, the facilitation process emphasizes “why” and “how” during learning interactions [ 83]. Various methods can facilitate learning, such as explaining reasons for a diagnosis and discussing observations and aspects from patient histories [ 50]. Encouraging students to identify differences and similarities in each category and comparing examination features in different diagnoses also supports the analytical approach [ 57]. In clinical settings, the students use the analytical approach for clinical reasoning [ 49]. Clinical teachers can facilitate this approach by giving clues, encouraging differentiation between categories, and using the hypothetico-deductive model [ 50, 57]. Meanwhile, in the non-analytical approach, the learning is focused on recognizing disease patterns from numerous clinical cases, leading to intuitive observation in handling cases [ 51, 53]. This method is effective for frequently encountered cases, enhancing their independent clinical reasoning skills [ 85]. The primary method to enhance students’ clinical reasoning is through providing clinical cases, which simplifies cognitive load and consolidates partially stored knowledge into a comprehensive form [ 86, 87]. The cognitive and intellectual load in the clinical reasoning session can be optimized by Young et al. [ 88]. Cognitive load theory (CLT) addresses intrinsic, extraneous, and germane load in the memory system during the learning process, aiming to reduce extraneous load and utilize working memory capacity efficiently to enhance learning [ 88- 90]. In addition, CLT is consistent with constructivism learning theory, which posits that learners actively construct their understanding and knowledge through interactions with their environment, including patients, experts, and peers [ 91]. Constructivism, rooted in the works of Piaget, Vygotsky, and Bruner, emphasizes the active construction of knowledge based on learners’ prior experiences [ 91]. Learning with clinical cases stimulates the reasoning process and activates working memory, which has limited capacity; the students must focus intensely on incoming information. Prior knowledge is activated and processed in working memory through chunking, dividing incoming information into manageable parts to store information and knowledge in long-term memory [ 88]. It will emphasize the importance of managing working memory during clinical reasoning learning. Further, increasing the germane load involves incorporating clinical contexts in medical education [ 92]. The CLT emphasizes the importance of aligning the learning process with the structure of the human brain for effective approaches [ 90]. Thus, the clinical teachers should assess students’ existing knowledge before providing clinical practice knowledge [ 82]. Clinical practice knowledge can be delivered to medical students through direct patient encounters or separate case discussions. In the previous systematic review, this learning can be facilitated by the virtual simulations with virtual patients [ 93]. This learning not only improves the clinical reasoning skills of individual students but also of teams [ 94]. However, the role of clinical teachers in facilitating this clinical reasoning will be vague. Meanwhile, learning using real cases and simulations is the most useful way to improve students’ clinical reasoning [ 93], and it will not be separated from the role of clinical educator lecturers. It is included in one of the challenges for effective educational strategies: overcoming knowledge gaps, using clinical examples, and strengthening reflection on diagnostic justification [ 95]. This learning certainly encourages lecturers’ active and essential role as facilitators in learning clinical reasoning. Moreover, case discussions are more effective in small groups, enabling better interactions between the students and clinical teachers, and allowing the clinical teachers to observe students’ clinical reasoning skills. These discussions can involve real cases or simulations and cover various aspects such as formulating a diagnosis, understanding disease pathogenesis, and treatment options. Goals setting in practical discussions will promote effective learning, aligning with the positive impacts of goal setting, mastery learning, and small group learning in the clinical facilitating process [ 83]. The activity of clinical teachersstudent discussions about clinical reasoning during patient examinations will also result in optimum germane load and minimum extraneous and intrinsic load. Another technique to facilitate clinical reasoning is thinking aloud. “Thinking aloud” is a learning technique that enhances knowledge transfer by promoting retention and understanding. When the students think aloud, they explain their understanding, which expands with feedback. Apart from asking students to convey their ideas in thinking aloud, there is also a technique for encouraging students’ clinical reasoning abilities with a semantic qualifier approach. Semantic qualifiers aid in analyzing learning activities by reprocessing patient terms into relevant medical terminology. The learning technique reduces cognitive load and lowers working memory demands. It fosters students’ opinions, improves reasoning skills through effective feedback, and improves motivation, emotion, and cognitive performance [ 88, 96]. Clinical teachers should provide numerous cases to develop schemata and utilize videos for intuitive understanding [ 46, 52]. Additionally, oral presentations with a pattern recognition approach can improve students’ clinical analysis and reasoning [ 53]. Furthermore, clinical teachers facilitate clinical reasoning by conducting assessments that monitor their competence and thinking skills. Assessment for learning, including pre-tests and post-tests, helps gauge their abilities. Understanding students’ levels enable the clinical teachers to tailor learning approaches and optimize learning outcomes. Providing feedback and assessing cognitive abilities aid in this assessment process. The strength of this study lies in its novelty, underscored by its comprehensive exploration of multifaceted roles and practical recommendations, which fill a gap in the existing literature. As there are limited papers with similar scopes, this study provides significant value by delivering nuanced guidance for optimizing clinical reasoning instruction, addressing a critical aspect of medical education.
However, limitations are evident in this review. While the review provides a comprehensive exploration of the multifaceted roles and strategies in clinical reasoning, it does not delve into specific contextual variations or cultural influences that may impact the effectiveness of these techniques. Recognizing the diversity of healthcare settings and student populations, future research should consider these contextual factors to provide a more nuanced understanding of clinical reasoning facilitations. Additionally, the time frame of searching was limited to the years 2004–2021, and the search was restricted to just four databases, potentially excluding some relevant literature. Furthermore, there may have been a lack of information on clinical reasoning facilitations in other healthcare professions, as these were not included. This study also included only studies published in English which may constrain the comprehensiveness of the searching process.
Conclusion
In conclusion, this scoping review highlights the pivotal responsibilities of clinical teachers in shaping and enhancing clinical reasoning skills among students. While acknowledging the foundational significance of the facilitators in stimulating learning, this study suggests several applicable insights for educators. The recommendation of this study includes formulating the role of clinical lecturers to facilitate clinical reasoning based on the scope obtained in this scoping review. In addition, lecturers’ role in facilitating clinical reasoning also needs to be integrated with the currently developing technology. Lecturers can further assist students in acquiring clinical reasoning skills without ignoring where the information was obtained. These insights contribute to a more nuanced understanding of the multifaceted responsibilities of clinical facilitators and provide practical guidance for optimizing clinical reasoning instruction. In the future, clinical reasoning learning must also prioritize ethical considerations, cultural competence, and societal implications in healthcare decisions. Preparing students for a socially aware and ethically responsible medical practice becomes increasingly vital, ensuring healthcare professionals manage complexities with sensitivity and contribute to a holistic and socially conscious healthcare environment.
Fig. 1.
Flowchart of the Study Selection Process based on PRISMA Guideline
PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analyses.
Table 1.
The Responsibilities of Clinical Teacher in Facilitating Clinical Reasoning
|
The responsibilities of clinical teacher |
Example |
Sources |
|
Provide an optimal learning environment |
• Creating a good atmosphere between patients, students, and clinical lectures |
[45,46] |
|
Describe the process of clinical reasoning |
• Analytic |
[46-53] |
|
• Non-analytic |
|
Assessing students’ ability |
• Giving pre-test and post-test |
[44,48,49,54-56] |
|
• Giving feedback |
|
Conduct learning approaches/methods |
• Think aloud |
[44,45,49,56-64] |
|
• Semantic qualifier |
|
• Self-explain |
|
• Illness script |
|
• Peer teaching |
|
• Clinical case |
Table 2.
The Facilitating Techniques of Clinical Teacher Based on the Thinking Process
|
Responsibilities of clinical teacher |
Thinking process |
Facilitating technique |
Sources |
|
Describe the ability of clinical reasoning and the clinical reasoning process |
Analytic |
Explaining the reasons for the diagnosis given |
[54] |
|
|
Discussing clinical things that have been procured |
[48] |
|
|
Encouraging the students to interpret the results that have been obtained |
[49] |
|
|
Encouraging the students to identify differences and similarities from each category by comparing and contrasting examination features found in several diagnoses |
[50] |
|
|
Pushing the students to think of assumptions to establish the diagnosis, which has been made together after discussions |
[57] |
|
|
Giving clues in identifying clinical things that will be encountered in the form of questions |
[59] |
|
Non-analytic |
Observing the intuition done by the clinical teacher |
[51] |
|
|
Learning from many cases |
[52] |
|
|
Watching videos related to anchoring and heuristic—Bayesian reasoning |
[46] |
|
|
Asking students to make an oral case presentation using the approach of pattern recognition |
[53] |
Table 3.
Factors Affecting the Facilitation of Students’ Clinical Reasoning
|
Affecting factor |
Classification |
Example |
Sources |
|
Internal |
Cognitive ability |
|
|
|
Basic cognitive ability |
• Students’ basic clinical reasoning skills |
[47,50,53,54,62,64,68,69] |
|
• Knowledge related to the pathophysiology |
|
• Intellectual ability |
|
• Critical thinking |
|
• Conceptual knowledge |
|
• Ability to filter information |
|
Concept and relationship-related skills |
• Ability to understand cause-and-effect relationships |
[46,56,61] |
|
• Ability to understand the uncertainty |
|
• Ability to recognize standard diagnostic criteria |
|
• Prior knowledge |
|
Psychological ability |
|
|
|
Cognitive |
• Ability to recognize differences related to clinical conditions |
[68] |
|
• Psychological ecology |
|
Behavior/interaction |
• Readiness to cooperate |
[68,70] |
|
• Students worry about being judged/criticized. |
|
Personality |
• Psychological condition |
[60,71] |
|
• Confidence |
|
Personality ability |
|
|
|
Inter-personal |
• Engagement with experts and cases |
[8,57,67,71-73] |
|
• Problem-solving ability |
|
• Frequency of meeting with patients |
|
Intra-personal |
• Students learning style |
[54] |
|
• Students learning activity |
|
• Motivation |
|
External |
Environment |
|
[8,57,58,62,63,72] |
|
Clinical settings |
NA |
|
|
Interaction with other people |
NA |
|
|
Clinical teacher |
|
[8,57,58,62,63,72] |
|
Teaching style |
NA |
|
|
Feedback |
NA |
|
|
Sustainability of the team/clinical theme |
NA |
|
|
The ability to recognize students |
NA |
|
Table 4.
Characteristics of Included Reports
|
Ref. |
Author (year), country, methodology |
Study population |
Teaching strategy for clinical reasoning |
Facilitating technique for clinical reasoning |
Impact of facilitating clinical reasoning |
Factor reported about clinical reasoning |
|
[59] |
Rizan et al. (2014), UK, qualitative |
Clinician and medical students |
Feedback within BST |
Students were doing BST with the clinical teacher. Students were supposed to follow up the patients and when the clinical teacher has arrived, they will observe and pay attention on how the they treat and behave around the patients. Students may or may not get immediate feedback from the clinical teacher in front of patients. Feedback could be an immediate correction or a trigger for students to think about the patient’s condition (“face-saving” feedback) |
Students: able to identify the source of their error and therefore can fix it and prepare more for the future encounters, trigger students to think and study more. |
(1) Students’ psychology and perception (students may lose their face in front of the patient, and it may cause learning problems later on) |
|
Educators: able to guide and correct students without embarrassing them in front of patient. |
|
[60] |
McBee et al. (2019), USA, qualitative |
Medical students |
Verbal case report |
Using think-aloud protocol where the student given several cases to identify and consider the diagnosis then verbalize the clinical reasoning |
Educator: knows medical students’ pattern on understanding the case and mitigate the diagnosis and therapeutic error. |
Ecological psychology of each individual |
|
Medical student: develop the ability to utilize their reasoning. |
|
[48] |
Schaye et al. (2019), USA, quantitative |
Medical students, intern, resident |
Education and training (interactive, cased based didactic, role play exercise) |
Workshop on how to do clinical reasoning: In groups of 3–4 participants, guided by trained facilitators, participants engaged in role-play exercises with participants each taking turns playing the role of teacher and learners (student, intern, resident, and/or fellow) on ward rounds. |
Educator: more confident about their ability to teach clinical reasoning using framework and clinical representation. |
(1) Insufficient time of training; (2) logistical barrier; (3) forgetting |
|
Reflection on the workshop and discussion of take-home points to be incorporated into practice completion |
Student: able to create a plan to master clinical reasoning through that learning strategies. |
|
[44] |
Koenemann et al. (2020), Germany, semi-qualitative |
Medical students |
Case-based collaborative learning in PBL format |
(1) Peer teaching, (2) supervision from clinicians, (3) case-based presentation by students, (3) feedback to evaluate the learning strategies. |
Student: experience the role of physician-lecturer, become a part, and participate directly in medical education activity in their university. |
(1) Academic credits could affect students’ motivation; (2) classes held on evening |
|
Moderator/clinicians: understanding the student, grow their role as lecturer. |
|
[49] |
Yoon et al. (2020), USA, mixed method, semi-qualitative |
Medical students and radiologist |
Verbal case report with direct feedback |
Series of radiograph were chosen and given to medical students, residents, also radiograph. The medical students were giving their best interpretation while verbalizing their thought and then gets the feedback from the expert (radiograph) afterward. |
Student: learned a lot from the experts such as gestalt interpretation, purposeful search, rule application, and reasoning from a prior case. |
(1) Motivation between the students and experts are relatively different |
|
[62] |
Lee et al. (2010), Australia, semi quantitative |
Medical students |
Illness script |
Students get a lecture for around 20 minutes then followed with 1–1/4 hour of small-group tutorial to represent and discuss about the case, and another 1–1/4 hour to develop and select a proper illness script |
Students: students able to understand and prioritize a diagnosis by discriminating features of each diagnosis consideration. |
(1) Short duration; (2) feedback wasn’t formally assessed; (3) different clinical reasoning skills baseline |
|
[61] |
Braun et al. (2019), Germany, quantitative |
Medical students |
Virtual patient case simulation |
Students were given virtual cases they need to solve via e-learning platform, they could access the patient’s history, data, and physical examination. After getting the information needed, student must state their final diagnosis including the explanation as to why they chose that diagnosis. |
Educator: knows that there was a well-thought-out diagnostic process behind almost all mentioned diagnoses by the students (it wasn’t guessed), few incorrect diagnoses are due to a complete lack of knowledge, teacher can find the solution how to fix this problem. |
(1) Lack of pathophysiological knowledge; (2) lack of diagnostic skills; (3) incorrect causal relationships; (4) the inability to reduce the diagnostic uncertainty through the diagnostic process |
|
[51] |
Findyartini et al. (2016), Indonesia, quantitative and qualitative |
Medical students |
Case-based collaborative learning in PBL format |
Observe clinical teacher intuition in clinical setting |
Students: able to identify their weakness so they can develop a better clinical reasoning skill. |
Different cultures |
|
[58] |
Houchens et al. (2017), USA, qualitative |
Clinical educators |
Exemplary attendings and explanation, organizing information, thinking aloud, literature research |
(1) Emphasizing organizing information to ensure the diagnosis and learning process; (2) accessing prior knowledge; (3) using think aloud; (4) analyzing the literature: students were asked to read more clinical research to support their clinical reasoning. |
Educators: know what kind of strategies they could use to teach their students, which strategies that could be used to make a future physician with good clinical reasoning. |
The own style of educators on how to teach their students |
|
[54] |
Chamberland et al. (2015), Netherland, mixed method, semi-qualitative |
Medical students |
Self-explanation technique |
Students were given a case they need to solve under certain time. When they have finished their assignment, students were asked to explain why they chose the diagnosis, two main arguments that support the diagnose, and list two plausible alternative diagnosis. After doing the self-explanation, students would hear the self-explanation from residents or educator. |
Students: able to elaborate further on their idea, could get the idea and understanding which they cannot come up by themselves. |
Students’ active learning |
|
[70] |
Hoshina et al. (2021), Japan, quasi randomized crossover |
Medical students, facilitator, fellow, primary doctor, professor |
Students-centere d teleconference |
Live-style conference was organized in one room, and the learner-centered approach teleconference was held in a separate room, with a screen showing the real-time traditional, live-style conference. When students asked or answered any questions, they had a chance to self-explain their thinking process and were provided feedback by the facilitator. |
Students: feel psychologically safe and able to speak their mind, and able to understand better. |
Students afraid to be judged or criticized |
|
[56] |
Moghadami et al. (2021), USA, randomized control trial |
Medical students |
Illness script |
Students were given a multiple-choice question to test their knowledge before and after given the main task. Students given the illness script to study with, then 4 weeks after that students were given a traditional lecture and small group discussion. |
Students: able to differentiate each diagnosis much easily by understanding each key feature and standard diagnostic. |
The ability to recognize the standard diagnostic criteria help students to discriminate the key feature of each diagnosis |
|
[52] |
Bartlett et al. (2015), UK, qualitative |
Tutors |
Experiencing clinical environment, clinical clerkship |
Students develop their clinical reasoning by encountering many cases and learn from senior staff and doctor at the hospital. |
Students: student able to practice their clinical reasoning more factual and accurate guided by the senior staff and doctors. educator: become more confident to teach their skill to the young generation. |
Psychological condition of each individual |
|
[54] |
Chamberland et al. (2015), Canada, USA, mixed method |
Medical students |
Self-explanation technique |
Students were given a series of cases they need to solve, then explain it in front of peer and expert. students will have a training phase before having the self-explanation. they would also get the chance to listen to other’s explanation in turn. |
Students: listening to expert’s explanation help student’s knowledge construction therefore they could develop a better clinical reasoning. |
Student’s cognitive and active involvement also experts who act too casually out of habit and not providing an ideal example |
|
[63] |
Audétat et al. (2012), Switzerland, qualitative |
Clinical educators |
Case discussion |
Students encounter certain case which they will discuss it with the expert. Expert listen to student’s explanation about the case and their clinical reasoning, then correct them if students make error or mistakes. |
Educator: fulfil their role as educators and able to guide the students to become a better doctor. |
Environmental constraints (e.g., time pressures, discontinuity in the clinical team) |
|
Students: not only gain knowledge but also have a better attitude. |
|
[71] |
Struyf et al. (2005), Belgium, quantitative |
Medical students |
Clinical seminars |
Students were offered around 70 seminars in 28 weeks. For each seminar, students were prepared in groups of five students who worked on one or more clinical cases followed by half-open questions. Each group were assisted with 1 clinical teacher. |
Students: boost student’s self-learning and self-confident, especially students who’s going to get final exam. |
Student’s involvement and self-confident in solving problems |
|
[47] |
Chamberland et al. (2019), Canada, USA, semi-quantitative |
Medical students |
Self-explanation technique |
Students were given few clinical cases to be solved and explained in front of the expert, and the expert will give feedbacks about their performance |
Students: improve students’ ability to correctly diagnose similar cases, building proper clinical reasoning after given feedback and seeing the expert’s example. |
(1) Ability to received feedback that were given by expert; (2) student’s cognitive process |
|
[8] |
Campbell et al. (2017), Australia, qualitative |
Medical educators |
Workshop |
The component: patient’s story, the learners reasoning, context of learning, and the role of supervisor. Role of the supervisor: create a good atmosphere between patients and students. Supervisor should seek to demonstrate trust in the learner, including encouraging the learner to take responsibility for their patients. |
Educators: understanding students’ behavior on learning and acquiring clinical reasoning (such as by understanding patients and copying their supervisor’s teaching). |
(1) Frequency of student meeting patient; (2) student and teacher interaction; (3) clinician teaching technique |
|
[69] |
Radomski et al. (2009), Australia, qualitative |
Medical students |
Integrated case-based learning |
A group of students and clinician were made to simulate a certain case in hospital setting. The role of doctors was played by 2 students and the patients’ role were played by clinician. the remaining students acted as observers. |
Students: able to think more comprehensively, construct their clinical reasoning and knowledge before dealing with a real patient. |
(1) Student’s individual capacity |
|
[64] |
Kiesewetter et al. (2016), Germany, semi-quantitative |
Medical students |
Think aloud method |
Students were given a questionnaire before the session begin. students given a case theme and were allowed to re-study the specific content for given amount of time. After that, students were given a paper based clinical scenarios to work on using think aloud method. They were not explicitly asked to state a diagnosis. Only one student and the test instructor were present in the room during the case elaboration. The test instructor sat behind the participant to avoid any diversion of thought |
Educator: able to understand student’s thinking pattern and build a better learning strategy. |
(1) Student’s conceptual and strategic thinking process |
|
Students: able to understand how to construct clinical reasoning by collaborating their pre-existing knowledge, conceptual thought, and metacognition. |
|
[67] |
Ryan et al. (2004), Australia, qualitative |
Medical students |
PBL tutorial |
Case was given to the PBL group which consist of several students and one facilitator. The case will be read out by the students and the facilitator will role played as patient during anamnesis. Student were asked to formulate their diagnosis and differential diagnosis. Facilitator unpack their own clinical reasoning prior to students contact and to gain familiarity with the key issues of each case. |
Students: gave student the opportunity to practice their clinical reasoning by acting as the clinician itself, help student to understand the diagnostic process |
(1) Guide book; (2) tutor’s intervention |
|
[45] |
Djermester et al. (2021), Germany, short report |
Medical students |
Paper case as a substitute of bed site teaching |
Student was given paper cases and survey in Microsoft Forms following the history and examination path used in live BST with the addendum of clinical reasoning table. The expert then sees it and give feedback. Feedback concerned the uploaded differential diagnoses and diagnostics tables. Feedback is emphasizing again the importance of clinical reasoning and— in absence of pattern recognition due to lack of expertise— system 2 reasoning. |
Students: BST helps students recognize clinician's clinical reasoning pattern, gain expert's knowledge, and take them as a role model. Paper case system could help student to gain knowledge but missed the point of students need a role model to construct a proper clinical reasoning, how to implement it well while maintaining a good interaction with the patients. |
(1) Opportunity to perform clinical skills |
|
[46] |
Brush et al. (2019), USA, quantitative |
Medical students |
Bayesian method learning |
Learning by concept: students were shown an 18-minute instructional video in which they were introduced to the anchoring and adjusting heuristic as an intuitive equivalent to Bayesian reasoning. |
Students: able to estimate the probability of each diagnosis, the conceptual learning help student to construct conceptual framework and reasoning which in turn able to help them solve the clinical problem |
(1) Clinical education exposure; (2) prior knowledge |
|
Learning by experience: students worked through 9 written cases for each of 3 diagnostic categories and a corresponding diagnostic test, also provided with a history of the presenting illness, medical history, physical examination, and the results of the diagnostic test. Each student will get feedback on their work |
|
[50] |
Ark et al. (2007), Canada, USA, quantitative |
Medical students |
Clinical training |
Students’ participants were taught general information regarding the 12 leads in an ECG during one-to-one teaching sessions with the experimenter. In the training phase, participants were asked to compare and contrast the feature present on each example with those of a normal ECG with those of confusable differential. Participants were encouraged to self-generate the similarities and differences between categories as much as possible. after the training, students were being assessed using immediate test and delayed test (a week after training) |
Students: able to compare and contrast the categories which in turn help them improve their diagnostic accuracy, better understood the diagnostic of each symptom. |
(1) Learning instruction; (2) student’s critical thinking |
|
Educators: able to give guidance and instruction that will trigger student’s learning process. |
|
[53] |
Carter et al. (2017), USA, qualitative |
Medical students |
Oral case presentation |
Students were expected to make oral case presentation when they meet certain case using PBEAR (Problem Representation, Background Evidence, Analysis and Recommendation) format. |
Students: improve their cognitive error, improve their diagnostic reasoning, able to filter and synthetize important data, comparing and prioritizing the diagnosis. |
(1) Students’ cognitive; (2) ability to filter important data |
|
Students will get feedback afterwards. |
Educators: providing feedback and tools that could help students fixing their cognitive and reasoning error. |
|
[77] |
Hammi et al. (2020), Tunisia, quantitative |
Medical students |
CRL session |
Before the session begin, the teacher would act as the supervisor of the discussion, and give the pre- and post-test. Students were being grouped and given a topic to solve. Only one student was aware of the CRL and was chosen to be data custodian and provider. The other would play role as the doctors, each person could speak their opinion anytime they wished. The group will also choose one person to be a secretary to write down the diagnosis assumptions which arise from their discussion. |
Students: improve students’ knowledge, improve clinical reasoning acquisition. |
(1) Student’s excitement in learning and solving the problem; (2) students’ type of studying |
|
[55] |
Choi et al. (2020), South Korea, quantitative |
Medical students |
Lecture and feedback |
Students given 10 cases to solve then were requested to write down a description of the patient’s skin lesion using abstract terms called semantic qualifiers. Students were asked to state the most likely diagnosis for the case. Every student had to present his or her own diagnosis. The correct diagnosis of the case was shown after all students arrived at their initial diagnoses and they will be given a feedback and short lecture from lecturer. |
Students: improve dermatology knowledge, improve diagnosis making and clinical reasoning. |
(1) Student’s absence of many relevant clinical cases during dermatology rotations |
|
[73] |
Vidyarthi et al. (2015), Singapore, semi-qualitative |
Medical students |
Clinical reasoning course |
Students attending the clinical reasoning course. The course consisted of nine 2-hour sessions (two introduction sessions and seven clinical case presentations) delivered bimonthly. They were instructed to reveal the case in the first 75 minutes using interactive, teaching methods, encouraging the students to discuss question in small groups. In the second half of the session, students were asked to practice EBM steps. |
Educators: able to create a more effective and efficient curriculum to improve student’s studying. |
(1) Student’s behaviors; (2) capability of educators to directly attribute student behavior |
|
Students: able to learn clinical reasoning based on EBM more effective and efficiently. |
|
[57] |
Aljarallah et al. (20151, Saudi Arabia, quantitative |
Medical students |
PBL and case-based learning |
In a typical 5 working days, 3 days started with morning reports followed by bedside clinical teaching. The other two mornings devoted to self-learning time and other integrated courses (e.g., investigation session, lectures, and clinical reasoning session). |
Students: maximize their learning strategy, able to do self-management, and improve learning strategy on understanding clinical reasoning. |
(1) Students’ excitement in learning and solving the problem; (2) students’ type of studying |
|
[68] |
Anakin et al. (2019), New Zealand, qualitative |
Medical students |
NA |
(11 Practicing with undifferentiated patients; (2) willing to make thinking explicit |
NA |
(1) Learning environment; (2) acceptance to work together; (3) ability to reconcile contradictions amongst different sources of information about a clinical condition |
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