Richmond, Anna
(2023)
Developing clinical reasoning in medical students: a realist review and evaluation.
PhD thesis, University of Nottingham.
Abstract
Background
Clinical reasoning (CR) is a complex process which doctors utilise to diagnose and manage patients’ problems. CR comprises both intuitive, non- analytical reasoning (NAR) and deliberate, analytical reasoning (AR) interacting with contextual factors. CR development occurs through acquisition of knowledge and experience and consequent development of mental models of disease called illness scripts. Accurate CR is important to provide patients with accurate diagnoses and effective management plans for their problem. Therefore, developing the foundations of CR in medical students is an important aspect of their education. Education to develop CR in the real world is highly complex, with multiple factors or contexts impacting outcome. How educational interventions interact with context to develop CR in medical students as an outcome is understudied. This research aims to examine the ways in which educational interventions develop CR, how, in which circumstances and for which groups they are more likely to be effective.
Methodology and methods
This research comprises a realist review of the literature and a realist evaluation of CR development in medical students at the University of Nottingham Medical School. A realist methodological approach to research considers the contexts that impact interventions and considers the ways in which interventions produce their results by analysis of interactions between context, mechanism and outcome. Initial programme theory was developed and refined iteratively through a realist review including twenty-eight primary studies. This resulted in a refined programme theory which was further tested and refined using individual and group interviews. The thirty-one participants comprised of medical students, clinical teachers and faculty members. Data were analysed using a realist logic including abductive and retroductive inference to create context mechanism outcome configurations (CMOCs). The output of the research is a refined programme theory which was utilised to suggest recommendations for educational practice and policy.
Results
Educational interventions, including but not limited to simulation, interacting with patients and discussion with clinical teachers, provide five key resources to students. These include learning about the CR process, participation in CR tasks, learning from mistakes, encouragement of NAR or AR and integration of strategies that promote effective long-term acquisition of knowledge.
These educational resources are affected by students’ clinical domain knowledge, self-confidence, clinical experience and goal orientation or mindset; by teachers’ motivation, confidence and rapport or relationship with students; and by the wider organisational factors such as available time, space and resources, perception of assessment practices and curricula prioritisation. The student, teacher and wider organisational contexts impact both how the educational interventions develop CR in individuals and impact opportunities for CR development.
Discussion and conclusions
This research has determined how, why and in what circumstances CR develops in medical students. The resultant programme theory has enabled a deeper and holistic understanding of CR development in the real world and subsequent recommendations for how this might be improved. To promote the most effective CR development, education should be individualised to students’ clinical domain knowledge, self-confidence, experience and motivation. Teachers will be better able to assess individual students’ characteristics when curricula promote continuity of education through building of positive student-teacher relationships. Building confidence in clinical environments through early years experiences or promotion of interventions such as students working as health care assistants (HCAs) will aid engagement and learning the clinical environments. Students should be taught how to learn effectively through integration of learning strategies to aid long term knowledge retention and through reinforcement of a growth mindset to aid development of mastery goal orientation. Additionally, engagement in the clinical environment is more likely when assessments are aligned with real, uncertain clinical practice which increases opportunities for CR development.
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