Clinical Reasoning or what's going on in a Doctor's Brain?

Ulrich Woermann, MD
Division for Instructional Media, University of Bern, Bern, Switzerland

Clinical reasoning is an essential skill for medical doctors. Despite this fact, there is no structured way of teaching this skill to the medical students at the University of Bern. As a consequence, our medical doctors in their first year of postgraduate training complain about their lack of clinical reasoning skills.

The case-based interactive learning program "Diagnostic Reasoning" from the DxR Development Group, Inc. allows medical students to learn and practice clinical reasoning in a safe environment. Collecting data from the history and the physical examination of a virtual patient, they generate a list of hypotheses and have to link further investigations such as lab test or x-rays to theses hypotheses. Having reached a final diagnosis, they can establish a management plan for the patient. All student activities are tracked and used to give students immediate feedback after having finished the case. These log files can be reviewed by the teachers allowing for specific feedback to single students or a group of students.

In January 2001, we conducted a first feasibility study for the use of "Diagnotic Reasoning" with medical students form the first and second clinical year. We were interested to know whether the English language was a problem for our students, whether an adaptation to Swiss standards was necessary, whether technical problems were of importance, and whether the students liked to work with the program and thought it was valuable for them.

Twelve students of the third and fourth year (first and second clinical year of our 6-year curriculum) voluntarily enrolled in this study. They were asked to do four cases over the Internet and give feedback on their experience. There was a striking difference in judgment between the students of third and fourth year. While the former reacted negatively because they thought "Diagnotic Reasoning" was a program to learn history taking and physical examination, the latter had a much more positive experience and were partly even enthusiastic. The English language was not considered to be a problem, but adaptation to Swiss standards was perceived as necessary. Students learned quickly to use the program, but minor technical problems caused major frustration.

We now plan to use "Diagnotic Reasoning" in the fourth and fifth year in the Internal Medicine clerkship. Adaptation to Swiss standards will be done before. Introduction to the use of the program will be given. A German manual will be handed out to the students.

Finally, we are considering using the "Clinical Competence Examination" which is the companion program to "Diagnotic Reasoning" that has been designed to work with a Standardized Patient, to administer a performance-based final examination to assess clinical practice behavior. The use of these software programs is considered ideal for allowing students more opportunity to practice the clinical reasoning process and faculty members quantitative tools to evaluate clinical skills, thus giving "clinical reasoning" in patient care the importance it deserve.

Clinical Reasoning is often neglected in medical education. Using a program like "Diagnotic Reasoning" can help to improve this essential skill in medical students. We show how the University of Bern is proceeding to implement a structured method for learning clinical reasoning using the software "Diagnotic Reasoning"

Ulrich Woermann, MD
Division for Instructional Media
Institute of Medical Education
University of Bern
Inselspital 38
3010 Bern
Switzerland
Phone: +41 (0)31 632 2534
Fax: +41 (0)31 632 4998
Email: woermann@aum.unibe.ch
Website: http://www.aum.iawf.unibe.ch/

CO-AUTHORS:

Hurley Myers
Professor of Physiology and Medicine
Southern Illinois University
School of Medicine
Carbondale, IL 62901
USA
Phone: 618-453-1140
Fax: 618-453-5309
Email: hurley.myers@dxrgroup.com
Website:http://www.dxrgroup.com