Exploring the development of clinical reasoning skills among doctors-in-training

Welch, Paul Gordon John (2018) Exploring the development of clinical reasoning skills among doctors-in-training. PhD thesis, James Cook University.

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View at Publisher Website: https://doi.org/10.25903/5d801a540f786


Clinical reasoning is complex, difficult to conceptualise and learn, and important as it is closely linked with medical expertise. Learning clinical reasoning skills is primarily an unguided and subconscious process for doctors-in-training, and there is a need for an evidence based, explicit approach to support the learning of these core skills. The focus of this research is the process by which doctors-in-training learn clinical reasoning skills within the context of General Medicine in north Queensland. The literature to date has been extensive but has struggled to identify a practical framework for doctors-in-training which clearly supports their learning of clinical reasoning skills.

This program of research investigated four factors identified in the literature as influencing the development of clinical reasoning skills: the metacognitive awareness levels of doctors-in-training; the learning climate of Intern doctors in their first year of clinical work; the influence of Consultants; and the role of Interns as learners.

The first factor was investigated by exploring whether metacognitive awareness correlated with performance in medical undergraduate examinations, and whether there was an increase in metacognitive awareness from the first to the fifth-year of the undergraduate medical course. Volunteer medical students completed the Metacognitive Awareness Inventory (MAI), as well as consenting to give access to their examination scores for this study. For the first-year undergraduate doctors-in-training there were correlations between the Knowledge of Cognition domain of the MAI and their end of year examination results, but not with the Regulation of Cognition domain. For fifth-year students there were correlations between both the Knowledge and Regulation of Cognition domains and their end of year examination results. This study found that the overall MAI scores were not significantly different between first and fifth-year undergraduates in this sample. The Regulation of Cognition domain and its sub-domains, regarded as key factors in clinical reasoning skill development, did not significantly differ between first and fifth-year undergraduate doctors-in-training.

The second factor investigated was whether the learning climate of Intern doctors-in-training was conducive to learning. The validated Dutch Resident Educational Climate Test (D-RECT) was used, and written responses invited to the question 'What three aspects of the junior doctor learning environment would you alter?' The Coaching and Assessment and the Relations between Consultants domains were identified as significantly lower in General Medicine than for other units, triangulating the written comments provided by the Interns.

The third factor investigated Consultant Physicians as role models for doctors-in-training learning clinical reasoning skills. The focus of the semi-structured interviews explored how the Physicians understood clinical reasoning, their understanding of how they had acquired these skills, and the ways they sought to foster these skills among their doctors-in-training. The seven Consultants described their journey to gaining clinical reasoning expertise as being unguided, generally subconscious and seldom discussed. Most Consultants spoke of being unaware of their own journey to gaining clinical reasoning expertise, and did not regard themselves as role models for doctors-in-training. Most Consultants indicated that acquiring clinical knowledge and learning to think about their decision-making processes (metacognition), were crucial for acquiring expertise, but very few Consultants explained how they could intentionally foster these skills.

The final factor was explored by investigating how Intern doctors-in-training understood their own development of clinical reasoning skills. At the start of their General Medicine term, Interns were presented with basic information about clinical reasoning. At the end of that term, participating Interns were interviewed. A paper copy of the presentation given at the start of the term was used to stimulate Intern reflections on their learning during the General Medicine term. The 27 Interns interviewed identified that learning clinical reasoning was a tacit, personal journey influenced by enabling and inhibitory factors. The Interns attributed the differences between their clinical reasoning skills and those of their Consultants as being primarily due to the experience and superior clinical knowledge of the Consultants.

A multi-methods research design was used to answer the research questions across the four studies. The first two factors were investigated using quantitative methods, while qualitative methods were employed for the last two. The multi-methods approach enabled findings from the separate studies to be triangulated, supporting confidence in the trustworthiness of the synthesised outcomes and reducing an over-dependence on any individual study.

The Synthesis and Proposed Framework chapter initially integrates the findings from the four studies to provide an overall understanding of how clinical reasoning skills are currently fostered in north Queensland. These synthesised results are then used to propose an evidence-based learning model and a method for its implementation at the teaching hospital. The modified Cognitive Apprenticeship Learning Model (mCALM) could help to make expert thinking visible by explicitly supporting constructivist learning practices, metacognitive skills, deliberate practice and a conducive learning climate. The mCALM appears well suited to explicitly fostering the learning of clinical reasoning skills for doctors-in-training in north Queensland.

Item ID: 60376
Item Type: Thesis (PhD)
Keywords: clinical interviewing, clinical reasoning, diagnosis, education, expertise, grounded theory, learning, metacognition, researching clinical reasoning, teaching clinical reasoning, teaching methods, undergraduate examinations
Related URLs:
Copyright Information: Copyright © 2018 Paul Gordon John Welch.
Additional Information:

Publications arising from this thesis are available from the Related URLs field. The publications are:

Chapter 1: Pinnock, Ralph, and Welch, Paul (2014) Learning clinical reasoning. Journal of Paediatrics and Child Health, 50 (4). pp. 253-257.

Chapter 3: Welch, Paul, Young, Louise, Johnson, Peter, and Lindsay, Daniel (2018) Metacognitive awareness and the link with undergraduate examination performance and clinical reasoning. MedEdPublish, 7 (2). 32.

Chapter 7: Welch, Paul, Plummer, David, Young, Louise, Quirk, Frances, Larkins, Sarah, Evans, Rebecca, and Sen Gupta, Tarun (2017) Grounded theory - a lens to understanding clinical reasoning. MedEdPublish, 5 January 2017.

Date Deposited: 16 Sep 2019 23:53
FoR Codes: 13 EDUCATION > 1302 Curriculum and Pedagogy > 130209 Medicine, Nursing and Health Curriculum and Pedagogy @ 100%
SEO Codes: 93 EDUCATION AND TRAINING > 9303 Curriculum > 930302 Syllabus and Curriculum Development @ 30%
93 EDUCATION AND TRAINING > 9302 Teaching and Instruction > 930201 Pedagogy @ 35%
93 EDUCATION AND TRAINING > 9301 Learner and Learning > 930102 Learner and Learning Processes @ 35%
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