Diagnosis and management of clinical

reasoning difficulties

Marie-Claude Audétat
Suzanne Laurin
Valérie Dory
Bernard Charlin
Mathieu Nendaz

AMEE GUIDE
Teaching and Learning 117

AMEE Guides in
Medical Education www.amee.org
Diagnosis and management
of clinical reasoning difficulties

Institution | Corresponding Address:

Marie-Claude Audétat
Unité des Internistes Généralistes et Pédiatres (UIGP) and Unit of Development and Research (UDREM)
Centre Médical Universitaire
Rue Michel-Servet 1
1211 Genève 4 Email : Marie-Claude.Audetat@unige.ch
Bureau 4091 Tel : +41 22 379 50 61

The Authors:

Marie-Claude Audétat, M.Ps., Ma (Ed), Ph.D., is Associate Professor at the faculty of Medicine, University of Geneva.
She is also a Clinical Professor in Family and Emergency Medicine at Université de Montréal, where she served as
Faculty Development Director, from 2010 to 2014.

Since May 2014, she is in charge of the axis of educational research in the Primary Care Unit at the University of
Geneva, Switzerland. She is also involved in innovative projects regarding clinical reasoning and faculty
development in the Unit of Development and Research (UDREM).

Suzanne Laurin MD, FCCFP is a family physician, an Associate Clinical Professor, and an educational leader in clinical
reasoning at the Family and Emergency Medicine Department of Université de Montréal (Canada). She is also a
visiting professor at the Faculty of Medicine of Liège (Belgium). She has extensive experience in clinical supervision,
educational diagnosis and remediation, and acts as an educational consultant and coach for the Université de
Montréal’s Faculty of Medicine teachers.

Valérie Dory, MD, MMedEd, Ph.D., is the Assessment and Evaluation Specialist for Undergraduate Medical Education,
and Core Faculty at the Centre for Medical Education, McGill University. She trained as a general practitioner at
Université catholique de Louvain, Belgium. She completed a PhD on the self-assessment of general practice trainees
at UCL, during which time she also obtained a Master’s in Medical Education from University of Dundee.

Bernard Charlin, MD, Ph.Dis a Professor at the Department of Surgery at Université de Montréal. He trained as a head
and neck surgeon in Montpellier, France. He holds a Master’s degree in Education from Harvard University and a PhD
in Education from the University of Maastricht. He is a member of CPASS (Center for Pedagogy Applied to Health
Sciences). His research field is reasoning in the context of uncertainty (theory, acquisition, assessment). He has written
or co-written more than 100 papers in the peer reviewed scientific literature.

Mathieu Nendaz, MD, MHPE is an internist at the Geneva University Hospitals and trained in health professions
education at the University of Illinois at Chicago. He is presently Director of the Unit of Development and Research
(UDREM) and Professor at the Faculty of Medicine, University of Geneva, Switzerland. His research interests include
Internal Medicine and medical education.

A related paper was published in Medical Teacher: Marie-Claude Audétat; Suzanne Laurin, Valerie Dory, Bernard Charlin,
Mathieu Nendaz 2017. Diagnosis and management of clinical reasoning difficulties Part I. Clinical reasoning supervision and
educational diagnosis & Part 2. Clinical reasoning difficulties: management and remediation strategies :
Medical Teacher, 39(8), 792-801

Guide Series Editor : Trevor Gibbs (tjg.gibbs@gmail.com)

Production Editor : Pat Lilley
Published by : Association for Medical Education in Europe (AMEE), Dundee, UK
Designed by : Coleen McLaren
© AMEE 2017
ISBN : 978-1-910612-38-5
 Guide 117
Diagnosis and management
of clinical reasoning difficulties

PART I. CLINICAL REASONING SUPERVISION AND EDUCATIONAL DIAGNOSIS

Abstract 1
Take home messages 1
Introduction 1-3
Why the need for such a Guide? 1-3
Aims and outline of the Guide 3

Clinical reasoning: how does it work? Reasoning processes and characteristics 3-6
Dual process theory 3-4
Problem representation 4-6
Networks of knowledge 6
Clinical reasoning in context 6

Facilitating the development of clinical reasoning and engaging in educational diagnosis 7-13
The basic principles of educational diagnosis 8-12
Teaching scripts 12
Using different supervisory settings to assess clinical reasoning 12-13

Factors affecting the quality of clinical reasoning 13-16

Stages of development 13
Various difficulties in clinical reasoning 13
Other factors as potential sources of clinical reasoning difficulties 13-16

Diagnosing clinical reasoning difficulties 16-18

Issues related to educational reasoning 16-17
A taxonomy of clinical reasoning difficulties 17
What about other types of difficulties? 18
Remediation strategies: Part II of the Guide 18

Conclusion 18
References 19-23

PART II. CLINICAL REASONING DIFFICULTIES’ MANAGEMENT AND REMEDIATION STRATEGIES

Abstract 25
Take home messages 25
Introduction 25
Key elements mentioned in Part I and objectives of this part of the Guide 25

Effective remediation: winning conditions 25-27

Remediation of clinical reasoning difficulties: is it effective? 25-26
General successful remediation strategies 26-27
Developing competencies to diagnose clinical reasoning difficulties 27

Frequent clinical reasoning difficulties and targeted remediation strategies 27-37

A taxonomy of clinical reasoning difficulties for each step of the clinical reasoning process 27-32
Targeted strategies to support the development of organised knowledge 33
Specific remediation strategies for clinical reasoning difficulties 33-36
Examples to develop teaching scripts 36-37

Challenges and issues related to the diagnosis and management of clinical

reasoning difficulties 38-40
Issues related to clinical teachers 38
Issues related to the supervisor-learner relationship 38-39
Issues related to institutional procedures and teaching paradigms 39
What kind of faculty development for the management of learners with difficulties in clinical reasoning? 40

Conclusion 41
References 41-43
PART 1
CLINICAL REASONING SUPERVISION AND
EDUCATIONAL DIAGNOSIS
Abstract
There are many obstacles to the timely identification of clinical reasoning
difficulties in health professions education. This Guide aims to provide readers
with a framework for supervising clinical reasoning and identifying the potential
difficulties as they may occur at each step of the reasoning process.

This Guide consists of two sections. Part I will provide an overview of the literature
on clinical reasoning and practical tips to facilitate its development. It will then
describe the educational process of supporting clinical reasoning and
diagnosing potential clinical reasoning difficulties.

Part II will focus on the management of these difficulties, providing a more

detailed description and specific remediation strategies.

We hope this Guide will help supervisors to both facilitate the normal development
of clinical reasoning and take steps when there are specific difficulties.

Take Home Messages

• Knowledge of clinical reasoning processes, as well as strong educational
skills are critical to the teaching and assessment of clinical reasoning in
the clinical setting.

• Supervisors play a key role both in fostering the ‘normal’ development of

clinical reasoning and in identifying difficulties.

• Despite the challenges posed by the clinical setting, there are feasible Despite the challenges
strategies to identify the strengths and weaknesses of learners’ clinical posed by the clinical setting,
reasoning. there are feasible strategies
to identify the strengths and
• Like clinical reasoning, supervisors’ educational reasoning develops weaknesses of learners’
through repeated practice in authentic settings, by generating and clinical reasoning.
testing educational hypotheses during clinical supervision.

Introduction
Why the need for such a Guide?
It is the responsibility of Faculties and Schools to ensure that the health It is the responsibility
professionals they educate are able to provide the best care for their patients. of Faculties and Schools
One of the key aspects of clinical competence is clinical reasoning. to ensure that the health
professionals they educate
The clinical setting, which allows learners to engage in authentic professional tasks are able to provide the best
care for their patients.
and problem-solving, and confronts them with the complexity of patients and
clinical care, provides the most fertile learning environment (Schön, 1983; Knowles,
1984; Kolb, 1984; Schön, 1987; Brown et al.,, 1989; McLellan, 1996; Rudaz et al.,
2013). Several authors have described the specific opportunities it provides (Spencer,
2003; Koens et al., 2005; Chamberland & Hivon, 2005; Irby & Wilkerson, 2008).
Faced with patients, learners reorganize their knowledge so that their networks of
clinical knowledge become task-oriented (Charlin et al.,, 2007; H. Boshuizen &
Schmidt, 2008) and develop their clinical reasoning and the related skills, e.g. skills
involved in data collection and in managing clinical situations (Windish, 2000).

The clinical setting, however, poses specific challenges for supervisors, rendering
their task particularly difficult (Hoffman & Donaldson, 2004). Clinical teachers Guide 117
Diagnosis and management of
play both a clinical role, ensuring that patients receive adequate care, and an clinical reasoning difficulties
educational one. In their educational role, they must do their best to manage Part I. Clinical reasoning supervision
and educational diagnosis
the affordances of the clinical setting such as clinical load, variety of clinical
problems, and work organisation, to meet the needs of learners. They must make page | 1
the most of each clinical problem as a learning opportunity by assessing learners’

... clinical teachers are
simultaneously involved in
two reasoning processes:
clinical reasoning and
educational reasoning
Teachers may feel more
comfortable addressing
gaps in knowledge even if
other difficulties are
identified, or in focusing
supervision almost
exclusively on solving the
patient’s problem
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 2
performance, identifying their strengths and weaknesses, and providing
constructive feedback (Prideaux et al., 2000). In other words, clinical teachers
are simultaneously involved in two reasoning processes: clinical reasoning and
educational reasoning (Irby, 1992; Audétat & Laurin, 2010; Irby, 2014).
Poor learner performance should be swiftly addressed. Identifying and
delineating concerns early may facilitate timely remediation of problems
(Hauer et al., 2009a; Cleland et al., 2013; Steinert, 2013). Nevertheless, it may
be difficult for teachers to take on this educational role. Teachers may avoid
the difficult conversations associated with giving negative feedback (Dudek et
al.,2005; Hicks et al., 2005). They may also lack confidence in their judgments and
in suggesting support or remediation, because their perception of difficulties is
not founded on a clear understanding of the development of clinical reasoning
(Audétat et al., 2011). Unfortunately, there is often a substantial time lag before
an educational diagnosis is made (Audétat, 2011). Many studies indicate that
delayed or poor identification and remediation of clinical reasoning difficulties
can lead to clinician underperformance and can ultimately, risk compromising
patient care (Hicks et al., 2005; Hauer et al., 2007; Frellsen et al., 2008; Hauer et
al., 2009a; Audétat, 2011).
Teachers may feel more comfortable addressing gaps in knowledge even if
other difficulties are identified, or in focusing supervision almost exclusively on
solving the patient’s problem (Laidley et al., 2000; Audétat et al., 2011; Audétat
et al., 2011; Audétat, 2011). In our experience of faculty development,
supervisors consistently concur with these exploratory findings, i.e. despite their
awareness of their dual role, supervisors tend to remain in their more comfortable
zone, which is clinical expertise, rather than step out into the more challenging
territories of educational diagnosis and remediation (Figure 1).
Teaching clinical reasoning: proposed zones of comfort and discomfort for supervisors
Figure 1:
(Audétat et al., 2011)
Less comfortable Zone
• Educational Diagnosis
• Remediation Strategies
Comfortable Zone
• Clinical expertise
Nonetheless, an exploratory study (Audétat et al., 2011) found that clinical
supervisors quickly sense that something is amiss in their learner’s clinical reasoning.
This ‘hunch’ is often borne out but it usually remains at a global and non-specific
level (Audétat et al., 2011). Such ‘Gestalt’-type impressions have been associated
with tacit knowledge, that cannot be articulated because it has become
embedded in automatic cognitive processes (Eraut, 2000; Irby, 2014). Faculty
development should therefore focus on building on supervisors’ intuition to allow
them to more clearly delineate what the problem is, and address it purposefully.
Another challenge for supervisors is the fact that they only have access to the
result of learners’ clinical reasoning process (e.g. the diagnosis or management
plan) or to the manifestations of various steps of the process (e.g. how a learner
takes a history based on diagnostic hypotheses). Clinical supervisors must
therefore possess sufficient understanding of clinical reasoning (Faustinella et al.,
2004) and strong pedagogical skills to be able to interpret these manifestations
and recognize cues of reasoning difficulties. This will enable them not only to
rapidly detect and diagnose potential reasoning difficulties but also to articulate
their findings to their learners.
Unfortunately, the literature on clinical reasoning is complex and based on uses a
Unfortunately, the
variety of approaches, making knowledge translation challenging for supervisors.
literature on clinical
reasoning is complex and
The final challenge for supervisors is that they cannot fully rely on learners to based on uses a variety of
identify their own learning needs (Eva, 2004; Regehr & Eva, 2006). approaches, making
knowledge translation
Aims and outline of the Guide: challenging for
We would hope that this Guide: supervisors.
• explains clinical reasoning theory,
• highlights the parallelism between clinical reasoning and the educational
process of diagnosing and remediating clinical reasoning difficulties,
• helps supervisors facilitate the normal development of clinical reasoning
• helps supervisors take steps when there are specific difficulties.

We would like to stress from the outset that the content of the Guide broadly
applies to all health professions; however we will not address the specifics of
each profession and have opted to focus on commonalities between them.
We will use the profession which we are most familiar with, i.e. medicine, as an
example. The perspective we describe in this Guide rests on a certain number of
assumptions (Charlin et al., 2012; Audétat, et al., 2013):

a) Diagnostic reasoning is a process allowing for categorization of a patient’s

clinical problem. In some cases, this may refer to ascribing a specific
diagnostic label to the problem, but in other situations, the category may
remain broader, at the level of a syndrome (e.g. sepsis, fever of undetermined
origin), or a system (e.g. respiratory failure), to name but a few. Before the
determination of a specific diagnosis, in certain situations the primary aim of
the reasoning process may be then to recognize a life-threatening condition,
to assess its severity, and to determine whether diagnostic investigations or
immediate manoeuvres or treatments are required (Charlin et al., 2012;
Pelaccia et al., 2015).
b) Clinicians also reason about management. Although the literature has
focused more on diagnostic reasoning, clinicians continue to reason once
they have reached a diagnosis when determining management, e.g.
weighing patients’ preferences, feasibility of tests, risks of drug interactions-
(Reid et al., 2001; Heneghan et al., 2009).
c) Supervision plays a key role in learning to reason clinically. Kilminster defined
supervision in medicine as ‘‘the provision of monitoring, guidance and feed
back on matters of personal, professional and educational development in
the context of the doctor’s care of patients’’ (Kilminster et al., 2007).
Supervision can foster learning through role-modelling, feedback, and
encouragement to articulate one’s thinking (Collins et al., 1989; Johnson, 2004;
Stalmeijer et al., 2009).

Finally, the Guide will not discuss formal assessment methods that are dealt with
elsewhere (van der Vleuten & Newble, 1995; Wass et al., 2001; Groves et al., 2002;
Kreiter & Bergus, 2009; Charlin et al., 2010; including in AMEE Guide 75 (Lubarsky
et al., 2013).

This Guide consists of two sections: Part I will begin with an overview of clinical
reasoning and methods to facilitate its development. The educational process of
supporting clinical reasoning and diagnosing potential clinical reasoning
difficulties will then be described.

Part II will focus on the management of these difficulties and will address in more
detail the main difficulties in clinical reasoning along with specific remediation Guide 117
Diagnosis and management of
strategies. clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
Examples and practical tips will be featured throughout the Guide.
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Guide 117
Diagnosis and management of
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Part I. Clinical reasoning supervision
and educational diagnosis
page | 4
Clinical reasoning: How does it work?
Reasoning processes and characteristics
The following section provides an overview of the findings of several decades of
research in cognitive psychology, which have been synthesized in numerous
reviews (Eva, 2004; Nendaz et al., 2005; Norman, 2005; Bordage, 2007; Nendaz &
Perrier, 2012).
Dual process theory
Research in cognitive psychology has shown that thinking relies on two major
systems (Kahneman et al., 1982):
System 1, a more immediate, intuitive, and quicker approach, and
System 2, a more conscious, analytical, and slower approach.
Similar findings were found in research pertaining to clinical reasoning
(Norman et al., 2013), (see Figure 2). Although each process has historically been
uncovered and defended separately in the field of medical education, there
has been a certain consensus about the concept of a hybrid process of
reasoning (Schmidt et al., 1990; Patel et al., 1990; Elstein et al., Shulman &
Sprafka, 1990; Norman et al., 1994; Elstein, 1994). For the sake of clarity, we will first
describe each process, Systems 1 and 2, to help understand the concept of dual
process described thereafter.
Figure 2:
Schematic representation of the dual process of reasoning: immediate recognition
of the clinical picture (system 1, non-analytic process, right boxes) and
hypothetico-deductive process (system 2, analytic process, left boxes).
Both processes are involved and used most often in clinical practice (dual process).
System 1: Non-analytical process
According to the general literature on reasoning, this process is automatically
triggered when individuals are faced with a problem to solve (Kahneman,
2011). It consists of a quick and spontaneous recognition of the nature of a
problem. In clinical practice, it can lead to the generation of a working diagnostic
hypothesis or even immediate patient management decisions. The triggers of this
immediate recognition may be specific features of a case (pattern recognition,
e.g. male, smoker, hypertension, chest pain evokes coronary heart disease)
(Groen & Patel, 1985) or similar cases encountered in the past (e.g. this case
reminds me of Mr. X, the librarian I saw last week with viral encephalitis) (Schmidt
et al., 1990). Of note, instances of cases previously encountered can include
contextual information, such as a patient’s profession, even if it has no bearing
on the clinical problem (Hatala et al., 1996).
System 2: Analytical process (hypothetico-deductive reasoning)
The spontaneous solutions emerging from System 1 processes may be challenged
by a slower, more analytical approach aimed at confirming or refuting them.
Furthermore, when the clinician faces a less familiar clinical problem, or if the
case is more complex, System 2 process may be needed to generate hypotheses.

The initial information (which can be provided by the patient, another health
care professional, or be available from observation or from the setting) is
translated by the clinician into a mental representation of the problem, which
triggers a first set of diagnostic hypotheses (Chang et al.,). The data at hand are
interpreted to verify their fit with each hypothesis, so that each hypothesis is
verified and may be rejected, maintained, or further tested with the acquisition
of additional information. This additional information may, in turn, further modify
the problem representation, and the same cycle may continue until a final
working hypothesis is accepted. Hypotheses are thus iteratively tested and
ultimately ruled in or out by subsequent new information (hypothetico-deductive
process) (Elstein, et al., 1978).

Dual process
Dual-process theory posits that Systems 1 and 2 are at play and may be present
simultaneously (see Figure 2). However, how both systems are activated and
used is still under study and debated (Norman et al., 2013; Custers, 2013).
According to Hammond’s theory of “quasirationality”, problem solving occurs in
the continuum between pure intuitive and pure analytical processes, depending
on contextual factors (Hammond, 2010; Custers, 2013). Kahneman on the other
hand, argues that both systems work in opposition, System 2 controlling (or failing
to control) the product of System 1 (Kahneman, 2011).

Recent evidence indicates that encouraging the use of both systems increases
the accuracy of clinical reasoning (Kulatunga-Moruzi et al., 2001; Ark et al., 2006;
Norman, 2009), and that using System 2 is not per se a guarantee of success
(Norman et al., 2014), suggesting that both systems act in concert in an additive
model (Norman et al., 2013). Various circumstances may favour the use of one
system over the other. Routine problems with little uncertainty and/or situations
where the time pressures are high, lead to the use of a more intuitive approach,
while complex, ill-defined, or unusual situations trigger a more analytical
approach, particularly if there is enough time and if the outcomes are high
stakes (Moulton et al., 2007; Pelaccia et al., 2011). Of note, emergency situations
In summary, clinical
do not preclude the use of a hypothetico-deductive process (Elstein et al., 1990; reasoning is a dynamic
Pelaccia et al., 2014). Recently, a new concept of clinical expertise has been process proceeding in
proposed, consisting of knowing or feeling when one should slow down and think iterative steps that each
more analytically (Moulton et al., 2007; Moulton e al., 2010). It seems that the influence problem
combination of the nature of the problem and its difficulty, the context in which representation and
it is set (e.g. emergency, crisis situation), and the experience of the clinician may subsequent reasoning.
Analysing or assessing
create a signal, leading some experienced clinicians to slow down their usual
clinical reasoning at a single
way of handling problems (Norman et al., 2013). In summary, clinical reasoning moment, as a one-shot
is a dynamic process proceeding in iterative steps that each influence problem picture, has thus little
representation and subsequent reasoning. Analysing or assessing clinical potential to reflect the
reasoning at a single moment, as a one-shot picture, has thus little potential to whole process of an
reflect the whole process of an individual. individual.

These processes cannot be disconnected from their underlying knowledge base

and are not per se guarantees for successful diagnosis (Elstein et al., 1978;
Norman et al., 2014).

Problem representation Guide 117

Diagnosis and management of
Mental representation of the clinical problem is a key element for the clinical reasoning difficulties
understanding of the clinical problem, whether at the stage of its initial Part I. Clinical reasoning supervision
and educational diagnosis
assessment or later in the process, when additional information has been
retrieved (Chang et al., 1998; Nendaz & Bordage, 2002; Ericsson, 2006).
page | 5
This representation may take several shapes (anatomical representation,

... illness scripts are
specialised knowledge
structures that link clinically
relevant information about
general disease categories,
specific examples of
diseases, and conditions
that enable diseases to
flourish in living beings
According to script
theory, the organization of
knowledge plays a critical
role in clinical reasoning.
Hypothesis generation rests
on the ‘activation’ of scripts
by the available cues
... team reasoning is not
merely the result of
individual skills but involves
other key elements, such as
role identification and
perception, effective
communication, and shared
patient management
goals
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 6
pathophysiological scheme, etc.), including semantic abstraction (Bordage,
1994), i.e. transforming the information provided by the patient into more abstract,
medical concepts (e.g. pain and swelling of left knee at 2 a.m. becomes acute
mono-arthritis of a large joint). This allows clinicians to link the information with their
fund of medical knowledge, generate relevant hypotheses, and collect signifi-
cant data. (Chang et al., 1998).
Networks of knowledge
Health professionals rely on mental models to help them make sense of unfolding
situations. Among several models of knowledge organisation, illness scripts are
specialised knowledge structures that link clinically relevant information about
general disease categories, specific examples of diseases, and conditions that
enable diseases to flourish in living beings (Feltovich & Barrows, 1984). According
to theory, one or more relevant illness scripts are deployed from a clinician’s
mental database in response to early prompts, both verbal and nonverbal, that
he receives from the patient and the clinical setting (Charlin & Boshuizen, 2000).
This process, called script activation, generally occurs below the threshold of
conscious awareness using system 1 processes (Charlin et al., 2007). Hypothesis
testing may then proceed using system 2, to compare the expectations
embedded in the scripts and the actual features on the case at hand.
For example, the complaint of severe headache by a young female might first
activate the scripts of migraine, meningitis, and subarachnoid haemorrhage,
containing the attributes related (positive attributes) or not related (negative
attributes) to each disease, as well as the notion that an urgent condition might
be at stake. Additional information will lead a reevaluation of the fit of each
hypothesis until the most plausible diagnosis(es) is(are) retained. Scripts may
contain, not only attributes related to a diagnostic category, but also triage
components (“the patient must be referred to an emergency centre”) or
management decisions (“immediate antibiotics must be provided”). According
to script theory, the organization of knowledge plays a critical role in clinical
reasoning. Hypothesis generation rests on the ‘activation’ of scripts by the
available cues. Competing hypotheses can be ruled-in or out through additional
data collection based on the pieces of information deemed relevant within each
script. A learner’s ability to gather useful data and interpret them correctly
depends on the relevance of the links between clinical data and diagnostic
entities within their scripts (Lubarskyet al., 2015).
Clinical reasoning in context
In the real world of clinical practice, the cognitive dimensions described above
represent only one of the numerous factors that may influence problem solving.
Durning and al. explored how contextual factors, (patient, doctor, encounter)
may interact and influence clinical reasoning, and identified a number of
potentially modifiable influences on clinical reasoning (Durning et al., 2011).
Furthermore, there is growing interest in models of collaborative clinical reasoning,
i.e. problem-solving involving the provider and patient or several health care
professionals (Trede & Higgs, 2003; Coulter, 2005; Higgs & Jones, 2008). These
models are inspired by concepts linked to patient-centred practice and shared
decision making (Stewart, 2001). They align with current changes in clinical
practice in terms of the role of patients (increasingly viewed as partners) and of
interdisciplinary healthcare teams.
On-going studies seem to show that interprofessional team reasoning is not merely
the result of individual skills but involves other key elements, such as role identification
and perception, effective communication, and shared patient management
goals (Blondon et al.: paper submitted), (Muller-Juge et al., 2013, 2014).
As we will discuss later in the part II of this Guide, analysing reasoning difficulties
must therefore go beyond the cognitive processes themselves to take into
account several other dimensions.
Facilitating the development of clinical
reasoning and engaging in educational
diagnosis
In their AMEE Guide, Kilminster and colleagues highlighted the determinants of
effective supervision: direct observation, constructive feedback, structure and
quality of the supervisory relationship (Kilminster et al., 2007). Helpful supervisory
behaviours include giving direct guidance on clinical work; linking theory and
practice, engaging in joint problem-solving and offering feedback, reassurance
and providing role models. These recommendations are of course applicable
when supervision is specifically dedicated to clinical reasoning. We refer interested
readers to this publication for further information (Kilminster et al., 2007).

The findings of research on medical expertise have led to general suggestions to

foster the development of students’ clinical reasoning skills (Eva, 2004; Norman,
2005; Schmidt & Rikers, 2007). Students should, for instance, be exposed early to
a variety of examples that provide an accurate representation of the range of
ways in which diseases occur. They should engage actively in problem
solving, reflecting and elaborating on patients’ problems to gradually build up
their knowledge base (Chamberland et al., 2011).

As discussed above, a rich and well-organised knowledge base is central to ... a rich and
clinical reasoning; it evolves through stages during medical training as illness well-organised knowledge
scripts emerge as students are exposed to patients (Norman, 2005; Schmidt & base is central to clinical
reasoning; it evolves through
Rikers, 2007). Clinical experiences certainly accelerate changes in students’
stages during medical
knowledge structures, instigating a more rapid shift from causal networks to illness training as illness scripts
scripts (Schmidt et al., 1990; Schmidt & Rikers, 2007). Recent research suggest emerge as students are
that generating self-explanations during the process of reasoning through clinical exposed to patients
cases facilitates the construction of more coherent mental representations of
the diseases, possibly fostering the development of better organised and richer
illness scripts used for clinical reasoning, especially when dealing with less familiar
clinical contexts (Chamberland et al., 2011).

As suggested by several researchers (Schmidt et al., 1990; Norman et al., 1994;

Elstein, 1994), clinicians tend to use a non-analytical approach when they are
facing a case they are familiar with. As they observe their learner interacting with
a patient, or listen to students reporting on their interaction, supervisors need to
slow down their reasoning process and focus on the paths the learner took to
reach a diagnosis, which are often different from theirs. Furthermore, supervisors
should not just focus on the results of learners’ clinical reasoning, for example
the diagnosis, but also on the processes and the context at stake for a particular
case (Nendaz et al., 2005a; Nendaz et al., 2005b), as a correct diagnosis is not a
guarantee of proper reasoning. For example, a learner could use the prevalence
of a diagnosis to propose it, without being able to relate typical signs and
symptoms presented by the patient to support his/her hypothesis.

When they analyse the clinical reasoning of their learners, clinical supervisors may
refer to the conceptual framework of clinical reasoning (as illustrated in Figure 2)
as a reference to address specific steps (e.g. hypotheses generation and Experts can also provide
verification, data collection, context, etc.) by: explicit role modelling by
• asking the learners to articulate their own reasoning pathway, (what hypotheses explicitly unfolding their own
they verified, what data made them reject or retain a hypothesis, etc. ). reasoning to enable
learners’ development of
• interpreting indirect signs related to their learners’ clinical reasoning (e.g. focused
more effective reasoning
or unfocused history, identification of discriminating features, differential
diagnoses). Experts can also provide explicit role modelling by explicitly unfolding Guide 117
Diagnosis and management of
their own reasoning to enable learners’ development of more effective clinical reasoning difficulties
reasoning (Collins et al., 1989; Sternberg & Horvath, 1999; Stalmeijer et al., 2009). Part I. Clinical reasoning supervision
and educational diagnosis
This implies that they increase their awareness of their own reasoning process
and articulate it to learners, rather than just provide them with the correct solution
page | 7
(Côté & Leclère, 2000; Maudsley, 2001; Wright & Carrese, 2002; Cruess et al., 2008).
 PRACTICAL TIPS:
As an illustration, the following example (Box 1) highlights the differences
between a supervisor who focuses exclusively on solving the patient’s problem,
and another one who simultaneously seeks to understand the learners’ reasoning.

Box 1:
An 8 year-old boy is brought to the doctor by his parents. He has had a temperature and a cough for
three days:

Supervisor focused on managing the patient AND

Supervisor focused on managing the patient
on the learner’s clinical reasoning

Understanding the clinical problem Understanding both the clinical problem and the
learner’s ability to identify the key findings

- Did the parents actually measure the child’s temperature
or do they just think the child has a temperature?
- Does the child have a history of asthma? Of pneumonia?
- What were the findings on chest auscultation?
- What cues did you pick up on at the very beginning of the
encounter?
- What were your hypotheses when you began the history?
- How do you interpret your findings on chest auscultation?
- How do your findings affect your hypothesis of pneumonia?
- What makes you think it’s a viral rather than bacterial
infection?

Asking questions to further clarify the problem Asking questions to test the learner’s clinical reasoning

- Did the child look very unwell to you? - What do you make of the child’s general appearance?
- Did you think to check the oxygen saturation? - How does it fit within your reasoning process?
- What hypotheses did you come up with when the patient
mentioned he had chest pain? How did you test them?

Diagnosis and management Helping the learner develop his/her clinical reasoning

- What is your diagnosis?
- What tests were you planning to order?
- What are the results of the chest X-ray?
- What do you plan to prescribe?
- If the chest X-ray is normal, what will your diagnosis be?
- If you had seen this patient during a house call, would your
plan have been different?
- How does the oxygen saturation help you test or confirm
your hypothesis?
- How can you explain the diagnosis and reassure the parents
who are worried about their child having pneumonia?

The basic principles of educational diagnosis in the learner

In the hope of helping supervisors transfer competencies from their clinical role to
their teaching role, several authors have highlighted the similarities between a
health professional’s use of clinical reasoning, and a teacher’s use of educational
reasoning. Both are aimed at problem-solving (Vaughn et al., 1998), using similar
strategies (Evans et al., 2010), based on specialised knowledge which Irby, and
more recently Côté and Bordage posited, are organised in teaching scripts, using
the illness script analogy (Irby, 1992; Côté & Bordage, 2012; Irby, 2014).

Figure 3 illustrates the similarities between clinical reasoning and educational

reasoning, both of which lead to a diagnosis and management plan. The key
difference however is that supervisors must generally take the initiative in
detecting difficulties in learners as they are often unaware of their difficulties
(Ward et al., 2002; Hicks et al., 2005).

Guide 117
Diagnosis and management of
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Part I. Clinical reasoning supervision
and educational diagnosis

page | 8
Figure 3:
Comparison between clinical and pedagogical reasoning

Clinical Teacher

Trainee’s difficulty noticed

Patient’s complaint
by the the teacher

Data collection
Data collection Generating and testing
Generating and testing educational hypotheses
clinical hypotheses • Direct supervision
• History • Case discussion
• Physican exam • Discussion with the trainee
• Investigation • Sharing observations with
other teachers

Clinical diagnosis Educational diagnosis

Educational support or
Treatment plan remediation plan

During clinical supervision, supervisors mainly have access to the outputs of their
learners’ clinical reasoning: the data collected by the learner, their differential
diagnosis and their management plan. These are similar to the signs of an illness.
In order to evaluate the learners’ reasoning processes, supervisors must first make
them visible and try to develop a clear initial mental representation of the overall
pattern.

The following section describes specific strategies to gain access to learners’

thought process and to facilitate their thinking:

Box 2:
Rendering clinical reasoning explicit:

1. By clarifying the clinical situation and the learner’s ability to identify its key features
- “At the beginning of the encounter, what features of the problem did you think were significant?”
- “What makes you think of X?”
- “What were you looking for when you were performing this physical examination manoeuvre? Or asking this question?”
- “How do you interpret this finding in this context?”
- “Tell me about the patient’s problem in a couple of sentences”

2. By asking questions to assess the learner’s reasoning

- “What hypotheses did you have in mind when the patient mentioned that symptom? How did you test them?”
- “Do you see a link between A and B ?”
- “What information is consistent with your final hypothesis?”
- “What about this piece of information, how does it fit in with your thinking?”
- “Did you think of this diagnosis?”

3. By fostering the development of the learner’s clinical reasoning and his/hers ability to deal with uncertainty
- “How have you come to this final impression?”
- “What if you had found this sign, what would that have meant?”
- “What if you had seen this patient at home, would that have changed your management plan?”
- “How did you decide that you could rule this hypothesis out without any further investigations? “
- “How would this test help you verify or confirm your final hypothesis?”
- “How would you explain your diagnosis and reassure the patient who is worried about this disease?”
- “What if the problem evolved in this way, would that change your diagnostic hypothesis?”

... supervisors should
generate educational
hypotheses and collect
data purposefully to confirm
or eliminate competing
hypotheses, in an ongoing
educational reasoning
process.
Guide 117
Diagnosis and management of
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Part I. Clinical reasoning supervision
and educational diagnosis
page | 10
From the implications of Box 2 the supervisors then need to decode and interpret
what the learner said, did, and wrote, translating these findings about the various
steps of clinical reasoning into educational language (semantic transformation)
to make sense of them. For instance, a disorganised process of history taking
could be labelled “failure to direct data gathering on the basis of diagnostic
hypotheses” or alternatively “failure to generate and systematically test
hypotheses during history”.
Just as in clinical reasoning, the supervisor endeavours to delineate, characterize
and translate the learner’s strengths and weaknesses in a more abstract way,
which allows him/her to label the observed difficulty. This characterization enables
the supervisor to generate educational hypotheses, which s/he will then need to
test during subsequent supervised patient encounters.
Collecting educational data
We have often noticed that supervisors tend to collect extensive data about their
learners in an unfocused way, and wait until the moment of a learner’s evaluation
to try and make an educational diagnosis out of a series of examples, just like
novice clinical students collect data and try to formulate a diagnosis after the
patient encounter, while discussing the case with a supervisor. Instead, we
suggest supervisors should generate educational hypotheses and collect data
purposefully to confirm or eliminate competing hypotheses, in an ongoing
educational reasoning process.
Clinical supervisors must be pro-active (Kilminster & Jolly, 2000), and take
advantage of various modes of clinical supervision, e.g. direct observation, case
discussions, chart review, discussions with other supervisors etc. in order to collect
information to test and modify their educational hypotheses about the learner’s
clinical reasoning process and their mastery of related skills. Supervisors can also
use specifics techniques such as SNAPPS, (Wolpaw et al., 2009), “The one minute
preceptor” model (Neher et al.,1992; Ferenchick et al., teaching scripts from p 12,
the ‘Flipped supervision’ (Mehlman, 2003) or “the Aunt Minnie model” (Cunning-
ham et al., 1999) designed to teach, but also to assess clinical reasoning (see Box
3). These methods enable supervisors to have a structured approach leading to
a process of delineation of the difficulty and remediation (Kuhn, 2002).
Box 3:
SNAPPS: A six-step, learner-centred technique, for case presentations (Wolpaw et al., 2009).
Clinical learners conduct case presentations making each step explicit. This technique gives learners,
rather than teachers, the responsibility for expressing their clinical reasoning and uncertainties.

S - summarise the case

N - narrow the differential
A - analyze the differential
P - probe the preceptor
P - plan management
S - select an issue for self-directed learning

The One-Minute Preceptor method, (Neher et al., 1992).

This technique aims at revealing the clinical reasoning process of the learner and providing feedback
by reinforcing what is done well and correcting errors.

Step 1: Get a commitment (pushing the learner to make a decision)

Step 2: Probe for supporting evidence (uncovering the clinical reasoning process)
Step 3: Reinforce what was done well
Step 4: Give guidance about errors and omissions
Step 5: Teach a general principle

The 4 steps Flipped supervision: “ Tell Me The Story Backwards” (Mehlman, 2003).
This technique aims at routinely raising the cognitive level of clinical reasoning. It focuses on giving the
diagnosis first followed by relevant historic and physical examination information and exploration of
other diagnostic entities. The learner then goes on to recommend a plan of action.

Step 1: Ask the learner for his or her diagnosis (may be a provisional or working diagnosis)
Step 2: Ask the learner to offer specific historic and physical examination information that supports the
diagnosis
Step 3: Ask the learner to defend why the diagnosis is not one or more other possibilities
Step 4: Ask the learner to propose his or her plan of action (Sample questions: “Is additional work-up
indicated? If so, what? If not, what plan of action do you recommend?”)

This last clinical teaching technique stimulates higher cognitive levels: although popular and
challenging for experienced clinical learners, this technique can destabilise a less advanced
trainee who might feel the need to proceed step by step before reaching a diagnosis.

The Aunt Minnie Model (Cunningham et al., 1999)

This model is designed to promote rapid pattern recognition among learners; after seeing the patient,
the learner presents only the chief complaint and the presumptive diagnosis to his supervisor; discussion
of the case occurs only after the clinical teacher has independently seen the patient. The name of this
model is related to the adage “that if the woman across the street walks and dresses like your Aunt
Minnie then she probably is your Aunt Minnie, even if you can’t see her face” (Irby & Wilkerson, 2008).

Guide 117
Diagnosis and management of
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Part I. Clinical reasoning supervision
and educational diagnosis

page | 11
 Table 1:
Questions that supervisors should consider in order to identify strengths and weaknesses in the learner’s
clinical reasoning process
Clinical reasoning process
Problem representation
Hypotheses generation
Hypotheses generation and direction of
data gathering
Hypothesis generation adapted to the
data collected
Refinement of hypotheses and
hypotheses testing
Data interpretation
Final diagnosis
Development of a management plan
Similar to clinical
reasoning, generating
educational hypotheses
about a learner’s difficulties
is based on the activation
of teaching scripts that
integrate theoretical
educational concepts and
supervisors’ experiential
knowledge of dealing with
learners’ problems
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 12
Questions
Does the learner identify the critical features of the
problem? Has s/he grasped what the case is about?
Is the learner generating appropriate hypotheses?
Is s/he generating more than one?
Is the learner asking the key questions? Are the history
and physical directed at testing hypotheses?
When the patient provides clues, does the learner pick
them up and generate new hypotheses?
Is the learner keeping an open mind and pursuing several
relevant diagnostic hypotheses? Is the learner correctly
prioritising his/her hypotheses?
Does the learner recognize the key features of the case?
Does the learner attribute the appropriate
significance to the various features of the case?
Are the differential, the interpretation of data and the final
diagnoses consistent?
Does the case presentation allow you to get a clear
picture of the case?
How does the learner come to his/her management plan?
Can s/he justify his/her plan?
Is the management plan consistent with the specific
features of the case?
Teaching scripts
Irby described the specific and distinctive forms of knowledge that clinical
teachers must possess, i.e. knowledge of medicine and patients; knowledge of
context; knowledge of pedagogy and learners, and knowledge integrated into
teaching scripts (Irby, 2014).
Similar to clinical reasoning, generating educational hypotheses about a learner’s
difficulties is based on the activation of teaching scripts that integrate theoretical
educational concepts and supervisors’ experiential knowledge of dealing with
learners’ problems. By practicing educational reasoning and encountering
different types of difficulties, supervisors develop richer teaching scripts, and
become more effective (Irby, 2014).
Using different supervisory settings to assess clinical reasoning
To gain an overall picture of a learner’s clinical reasoning requires access to each
of the steps of the clinical reasoning process. In practice, clinical supervision is
often limited to case discussions based on the assumption that the learner
performed adequately beforehand. Our experience of supervision suggests that
supervisors should be wary of global impressions formed solely on the basis of case
discussions. Learners can sometimes be good at synthesising information and
presenting clinical cases in a logical way, yet they may have misinterpreted cues
presented by the patient and omitted them from the case presentation in good
faith, thus leading the supervisor astray. It is therefore essential that supervisors
assess each of the steps of clinical reasoning, in a variety of supervision settings,
such as direct observation, personal assessment of the patient, case discussions,
or chart review.
Some of these reasoning steps are more readily assessed through direct
observation, others through case discussions or chart review (Laurin et al., 2014).

Direct observation may be helpful for example to assess:

• The initial problem representation and the early generation of hypotheses
• Data collection efforts to test hypotheses
• The ability to take account of incoming cues to modify the problem
representation
• Whether the physical examination looks for signs that are consistent with
hypotheses

Case discussions may be helpful for example to assess:

• Problem representation, data synthesis and organisation of the information in a
logical way that allows the supervisor to follow his/her thinking
• Recognition and prioritisation of the features that were most significant in
developing a differential diagnosis
• Consideration of the specifics of the situation in the investigation and treatment
plan

Factors affecting the quality of

clinical reasoning
Understanding the root causes of different clinical reasoning difficulties is
important to guide remediation. The following section provides an overview of
the main causes.

Stages of development
Clinical reasoning ability develops over the course of training. In the early stages
of medical school, students use causal reasoning to explain the consequences of
pathological agents on the body. When they first encounter patients, they find that
this mode of reasoning is slow and inefficient in the clinical setting which leads
them to use the processes described previously. Boshuizen and Schmidt
demonstrated that expert biomedical knowledge is gradually encapsulated and
integrated into clinical knowledge, enabling more efficient reasoning (Boshuizen
& Schmidt, 1992). This represents a significant transition, which some have referred
to as a cognitive revolution (Boshuizen, 1996). Lemieux and Bordage found a
relationship between the type of knowledge organization of learners and the quali-
ty of their reasoning, suggesting that some learners spontaneously reorganized their
knowledge to solve clinical problems effectively and efficiently (Lemieux & Bordage,
1986).

Various difficulties in clinical reasoning Between 5% and 15%

Between 5% and 15% of medical students suffer from academic difficulties, mostly of medical students suffer
due to cognitive factors and flaws in clinical reasoning (Hunt et al., 1989; Yates & from academic difficulties,
mostly due to cognitive
James, 2006; Audétat et al., 2015). Unfortunately, these difficulties are often
factors and flaws in clinical
recognised late in the learners’ course of study and training, usually when problems reasoning
arise in clinical rotations (Hauer et al., 2009a; Hauer et al., 2009b; Audetat et al., 2012).

Studies on diagnostic errors and difficulties, at undergraduate and postgraduate

levels, indicate that a majority of errors include a cognitive component (Bordage,
1999; Graber, 2005). According to Graber et al. (2005), the majority of cognitive
difficulties are not directly related to a lack of knowledge, but rather to a flaw
in data collection, data integration, and data verification (Graber et al., 2005).
Limiting a remediation process to the sole knowledge dimension may thus prove
insufficient to address reasoning difficulties.

Other factors as potential sources of clinical reasoning difficulties Guide 117

Diagnosis and management of
Several factors have been recognised as sources of reasoning and diagnostic clinical reasoning difficulties
Part I. Clinical reasoning supervision
difficulties (Graber, 2005; Higgs, 2008; Norman & Eva, 2010; Durning et al., 2011; and educational diagnosis
Audétat, 2011; Nendaz & Perrier, 2012; Audétat et al., 2012). According to
Durning’s ecological psychology and situated cognition perspective of page | 13
clinical reasoning, the following three contextual factors should be explored

Humans often use
reasoning shortcuts, called
heuristics, to make quick
decisions. These are mainly
unconscious strategies
allowing people to quickly
make decisions in everyday
life. Clinicians are no
exception and also use
them to make decisions
in a busy practice despite
uncertainty
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 14
when assessing reasoning difficulties of a learner in a given clinical situation
(S. Durning et al., 2011): clinician factors, patient factors, and setting factors (cf.
fig. 4). According to this perspective, separating components of the clinical
encounter into clinician, patient and setting factors may help reveal the
potentially complex interactions between these factors (S. Durning et al., 2011).
Figure 4:
Three factors as potential sources of clinical reasoning difficulties
Setting
factors
Clinical reasoning
difficulties
Clinician Patient
factors factors
In view of the educational focus of this Guide, we will stress factors related to learners.
Clinician factors: cognitive biases
Humans often use reasoning shortcuts, called heuristics, to make quick decisions
(Kahneman et al., 1982). These are mainly unconscious strategies allowing
people to quickly make decisions in everyday life. Clinicians are no exception
and also use them to make decisions in a busy practice despite uncertainty.
Heuristics are useful and necessary and their use is not to be blamed per se
(Norman & Eva, 2010). However, they may sometimes lead to reasoning and
decision errors or difficulties (Elstein, 1999; Gorini & Pravettoni, 2011; Nendaz &
Perrier, 2012; Croskerry, 2013), such as, for example, the frequent confirmation
and availability biases (van den Berge & Mamede, 2013). In the availability bias,
the clinician considers a diagnosis more likely because it readily comes to mind.
However, a recent and striking experience with a rare disease may make the
clinician overestimate the frequency of this disease for the next patient. This bias
seems to be associated with non-analytical reasoning and may be countered by
reflective reasoning (van den Berge & Mamede, 2013). Interested readers may
refer to published reviews on this topic (Croskerry, 2003).
To illustrate some of these biases, we will take an example described in an article
of one of the authors of this guide (Nendaz & Perrier, 2012) (Box 4):
 Box 4:
A 36 year-old man working in house construction consulted an emergency centre because of 10 days
of fatigue, occipital headaches, neck pain, and fever. Two months earlier, he wounded himself on
the left forearm and treated it himself. On physical examination, his pulse was 88/min, blood pressure
135/75 mm Hg, temperature 38.2 °C. There was an erythematous scar on the left forearm. He was alert
and presented no focal neurological deficits. His neck was stiff and painful, not only on flexion but also
on palpation of the spine.

Meningitis was suspected and a lumbar puncture was performed, showing: leucocytes 50/field, 94%
lymphocytes, normal glucose, proteins 0.65 g/l. Viral meningitis was considered the main diagnosis and
the patient was admitted to the ward for observation and analgesic therapy. This occurred on a Friday
afternoon.

During the following week-end, the neck pain remained intense. The resident on duty took the patient’s
history again and learned that the patient had already had some neck pain for the past 3 weeks, at-
tributed to his professional activities, with episodes of fever, chills, and occasional paresthesias of both
hands. On physical examination, temperature was 38.5 °C, and the neck was very stiff with a local,
intense pain at palpation. A cervical infectious process, potentially in relationship with the forearm
wound, was suspected and imagery was ordered. An MRI of the cervical spine and bacteriological
samples eventually confirmed the diagnosis of cervical S. aureus osteomyelitis and paracervical abscess.

The following fictitious scenario illustrates how some heuristics or biases may have been present in this
case: “Because the emergency physician who saw the patient first recently admitted a case of viral
meningitis, he considered this diagnosis more likely (availability bias) without including in his thinking
the spine pain, the previous forearm wound, and the duration of the symptoms (anchoring bias). He
only considered the results of the lumbar puncture to confirm his hypothesis, ignoring the other clinical
information (confirmation bias). Because he had already spent time and effort to manage this patient,
he was unwilling to consider any other diagnostic option (sunk costs bias), particularly more serious
diagnoses because he had the same age as this patient (visceral bias). Moreover, many other patients
in the emergency room were waiting and the chief of the department wanted a quick patient triage
and orientation (stress and external factors)”.

Although biases are not necessarily the sole culprits in diagnostic errors (Norman
et al., 2014), supervisors should be aware of their influence in learners with clinical
reasoning difficulties.

Clinician factors: Personal behaviour and attitudes

Several factors pertaining to personal characteristics of the learners may also
influence their ability to apprehend a clinical problem. Personal attitude towards Clinical reasoning relies
learning and deficiencies in aspects of self-regulated learning may impede on other clinical
reasoning acquisition (Artino et al., 2011). In their study, Artino et al. reported the competencies. Poor
interviewing and
following characteristics of students associated with lower performance in clinical
communication skills can
reasoning tasks: lower task value and self-efficacy beliefs, greater anxiety, lead to clinical reasoning
frustration, and boredom (Artino et al., 2011). Overconfidence in one’s own errors
capacities (Berner & Graber, 2008), a lack of self-reflection or of knowledge
about reasoning processes (Nendaz et al., 2011), as well as the inability to
recognise one’s own weaknesses through self-assessment (Eva & Norman, 2005)
represent additional factors associated with poorer outcomes in reasoning tasks.

Emotional factors regarding a specific case may distort the learner’s analysis of
the clinical situation (Artino et al., 2012). Finally, clinicians’ experience, beliefs,
and perspectives also influence their perception and interpretation of features
encountered in a case. Signs reinforcing a certain perspective may be
Guide 117
highlighted, while another line of thought may not receive appropriate attention Diagnosis and management of
(Malterud, 2002). clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
Clinician factors: additional necessary skills
Clinical reasoning relies on other clinical competencies. Poor interviewing and page | 15
communication skills can lead to clinical reasoning errors. For instance a learner

... supervisors should be
wary of premature closure in
their educational diagnosis
and should avoid forming
an opinion of learners’
performance too hastily
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 16
who asks unclear questions, who is unable to deal with a particularly talkative
patient, or who is uncomfortable talking about intimate health issues may lack
critical information to reach the correct diagnosis. Integrated teaching of
communication techniques in a clinical setting can significantly help the
development of the clinical reasoning processes in trainees having problems
conducting an efficient encounter with a patient (Evans et al., 1991; Windish et
al., 2005).
Patient factors
Some clinical situations may intrinsically be more complex than others, for
instance if a patient is uncooperative, stuporous, extremely emotive, voluble,
aggressive, or if there are language or cultural barriers (Maguire & Pitceathly,
2003). In the clinical setting, learners need to develop skills, as they progress
through training, to manage these more complex situations and to obtain the
necessary information.
Setting factors
Specific encounter factors, for example ambulatory or in-patient setting, may
influence the clinician’s clinical reasoning process (Durning et al., 2011).
Working conditions represent additional factors affecting clinical reasoning.
For example, stress or work overload represent potential sources of difficulties for
a particular case, impeding novice students or residents to correctly apply their
acquired knowledge and skills. More broadly, the supervisor must also be aware
of the potential influence of the culture of his/her own institution regarding
teaching and hierarchical relationships, which may, at times, influence the
learning attitudes of students and residents. For example, how physicians and
nurses perceive their mutual professions may influence how they work together
and solve problems together (Muller-Juge et al., 2013, 2014).
Diagnosing clinical reasoning difficulties
Clinical reasoning difficulties are often only a sign of delayed development,
which should not lead to consider learners as “problem learners”. Developing a
specific understanding of the difficulty at play is nevertheless important precisely
so that measures can be taken to avoid minor difficulties becoming serious.
Furthermore, educational diagnosis should also focus on identifying learners’
strengths and detailing the attributes of effective reasoning.
Issues related to educational reasoning about learners
Like clinical reasoning, educational reasoning develops through repeated
practice in authentic settings, by generating and testing educational hypotheses
during clinical supervision. This requires the development of specific knowledge
and competencies. By constructing teaching scripts regarding effective clinical
reasoning as well as the main clinical reasoning difficulties, supervisors should be
better able to identify the common manifestations of difficulties and reach and
educational diagnosis regarding their learners’ clinical reasoning (Côté &
Bordage, 2012; Irby, 2014).
Clinical supervisors should be aware that the same contextual factors that can
affect the quality of clinical reasoning, may impact educational reasoning, i.e.
factors related to setting, supervisor and learner. For instance, a supervisor who
is disorganised and finds it difficult to integrate his/her clinical and educational
tasks, or who is ill at ease in relation to the learner could negatively affect
educational reasoning.
During faculty development workshops, we have often observed that errors may
occur in educational reasoning and the types of difficulties described later in this
Guide can affect educational reasoning. In particular, supervisors should be wary
of premature closure in their educational diagnosis and should avoid forming an
opinion of learners’ performance too hastily. To avoid falling prey to premature
closure, supervisors should strive to generate alternative educational hypotheses
and test them in subsequent supervision sessions or discuss them with the learner.
Supervisors should also avoid over-diagnosing difficulties and should only consid-
er repeated difficulties as significant. Learners will make mistakes, which do not all
require an intervention.

A taxonomy of clinical reasoning difficulties

Reasoning difficulties may be classified according to the different steps of clinical
reasoning, as difficulties may occur at each one of these steps (Bordage, 1999;
Norman & Eva, 2010; Nendaz & Perrier, 2012).

Several authors have developed typologies of clinical reasoning difficulties

(Graber et al., 2005; Kassirer et al., 2009; Rencic, 2011; Audétat et al., 2013) or
have attempted to classify difficulties post-hoc, once errors have been
committed (Kassirer, 1989; Chimowitz et al., 1990; Kempainen et al., 2003).
In view of the educational perspective of the Guide, we have opted to use
Audétat et al.’s taxonomy. This taxonomy is the result of a participatory action
research project aiming to identify the most common clinical reasoning
difficulties as they present in learners’ patient encounters, case summaries, or
chart review (Audétat et al., 2013). The clinical reasoning process was divided in
discrete steps, as it unfolds in the clinical setting, to facilitate the identification of
difficulties (Kuhn, 2002).

Table 2 presents the main difficulties identified. The relevance of these results
was confirmed in our faculty development experience for use on a one-on-one
basis with learners and within educational teams from various specialties. Its use
appears useful in enabling supervisors to identify and categorise common
difficulties.

Table 2: Principal clinical reasoning steps, and potential difficulties (MC. Audétat et al., 2013).

Steps Main difficulties Definition of the difficulty

Problem representation Poor representation of
the nature of the
clinical problem
The learner:
1) does not transform the information provided by the patient into
abstract, medical concepts, or
2) fails to elaborate a mental representation of the presenting
problem.

Hypotheses generation Difficulties in generating The learner:

and direction of data hypotheses, identifying
gathering cues and directing data
gathering
1) fails to detect or appropriately select the key features or cues that
should allow him/her to generate diagnostic hypotheses, or
2) fails to generate a certain number of diagnostic hypotheses to
guide his/her reasoning
3) fails to direct and focus his/her data gathering.

Refinement of hypotheses Premature closure The learner quickly focuses on a single diagnostic hypothesis and
and hypotheses testing, conducts the interview superficially or directs it exclusively according
Data interpretation to that hypothesis.

Difficulties in prioritizing The learner:

1) prioritises inadequately the patient’s problems: difficulty in
focusing the interview on the cases most important aspects, e.g.
when there are several complaints.
2) has difficulty in appropriately choosing when to ascribe significance
to cues or data obtained in the course of the encounter.

Final diagnosis or Difficulties in painting an The learner fails to make connections between the different pieces
labelling of problem overall picture of the of information, fails to integrate the patient’s perspective and
and development of a clinical situation contextual factors to paint a picture of the clinical situation and
management plan adjust his/her investigation or management plan.

Difficulties in elaborating The integration and synthesis of the whole reasoning process is
a management plan unsatisfactory leading to the proposal of inadequate
management plans.

page | 17

Despite the challenges
posed by the clinical setting,
it is possible for supervisors
to identify the strengths and
weakness of learners’
clinical reasoning
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 18
What about other types of difficulties?
Other types of difficulties can coexist with clinical reasoning difficulties. Vaughn
et al. (Vaughn et al., 1998), for example, identified four classes of problems in
learners (affective, cognitive, structural, and interpersonal). In her AMEE Guide
on the subject, Steinert provides a useful framework for the overall management
of academic difficulties (Steinert, 2013). We would encourage supervisors to deal
with any difficulties in areas that are prerequisite to clinical reasoning, such as
problems concentrating due to personal issues, before attempting to implement
specific clinical reasoning remediation.
Remediation strategies: Part II of the Guide
Clinical supervision is a key process to help learners develop clinical reasoning.
The strategies used by supervisors to uncover learners’ clinical reasoning can
themselves be useful to foster its development. By asking learners to provide a
rationale for their decisions about a clinical case or to articulate the key
features that allowed them to reach a diagnosis or develop a management
plan, supervisors may help learners to become aware of their own reasoning
process and encourage them to organise their thinking process.
Furthermore, by supporting the development of communication skills or skills to
manage a clinical encounter, or by encouraging learners to develop illness scripts
through comparison and contrast of the various clinical situations encountered,
supervisors may contribute to their development of clinical reasoning.
For more complex clinical reasoning difficulties, we will outline specific and
targeted remediation strategies in Part II of this Guide.
Conclusions
Despite the challenges posed by the clinical setting, it is possible for supervisors
to identify the strengths and weakness of learners’ clinical reasoning.
The understanding of their own reasoning processes and their engagement in a
process of educational diagnosis in their learners should help supervisors select
appropriate supervision strategies to facilitate the development of their learners’
clinical reasoning.
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MANAGEMENT AND REMEDIATION OF CLINICAL PART II.
REASONING DIFFICULTIES

Abstract
Part II of this AMEE guide provides a detailed overview of the main difficulties in
clinical reasoning, including the cues to look out for in clinical supervision, the
root causes of each difficulty, and targeted remediation strategies.
Specific challenges and issues related to the management of clinical reasoning
difficulties will also be discussed.

Take Home Messages

• Difficulties in clinical reasoning should be identified early and appropriate Difficulties in clinical
support provided before learners run into major difficulties reasoning should be
identified early and
• Recent studies confirm that in most cases, remediation leads to appropriate support
academic success. provided before learners
run into major difficulties
• The cues available differ by type of supervision, , i.e. direct observation,
case discussions, or review of medical records

• Remediation strategies should be selected on the basis of the root causes

of the difficulty, the context’s affordances (time etc.) and learners’ needs.

• Organisational support is crucial for the remediation process given the

unpredictability of clinical contexts and locations in which supervisors
juggle multiple duties.

• Clinical teachers need to be supported by ongoing faculty development

to strengthen their pedagogical competencies with respect to clinical
reasoning, clinical supervision and the ability to recognize and remediate
reasoning difficulties

Introduction
Key elements mentioned in Part I and objectives of this part of the Guide
In Part I, we discussed clinical reasoning theory and the steps involved in clinical
reasoning, and how clinical teaching can foster the normal development of
clinical reasoning. We also described the general process of pedagogical
reasoning and how it is similar to that of clinical reasoning, thus providing a
framework enabling supervisors to proactively explore difficulties and provide
targeted support and/or remediation.

Part II of this Guide aims to help clinical teachers develop competencies to

diagnose and remediate clinical reasoning difficulties. We will describe the
difficulties in clinical reasoning as well as specific remediation strategies in more
detail. We will also focus on the specific challenges and issues related to the
management of clinical reasoning difficulties.

Effective remediation: Winning conditions

Remediation of clinical reasoning difficulties: is it effective?
There is no widely accepted framework for the remediation of clinical reasoning
difficulties. Moreover, there is controversy regarding strategies to reduce
reasoning errors in the health professions. Authors such as Croskerry, Graber or Guide 117
Diagnosis and management of
Kahneman suggest implementing strategies that are directed at a) clinical reasoning difficulties
increasing analytical processing, by slowing down, reducing distractions and Part I. Clinical reasoning supervision
and educational diagnosis
paying conscious attention and b) making individuals aware of the effect of
cognitive biases (Croskerry, 2003; Mamede, Schmidt, & Rikers, 2007; Kahneman,
page | 25
2011; Graber et al., 2012). On the other hand, there is some evidence suggesting

Early identification and
early support, before the
learner runs into major
difficulties, should be
regarded as “the gold
standard” for educational
supervision
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 26
that strategies to increase awareness of reasoning biases are neither necessary
nor sufficient for reducing errors in medicine (Sherbino et al., 2012; Ilgen et al.,
2013; Norman et al., 2014). According to Eva, applying knowledge, making
mistakes and learning from them is part and parcel of how novices become
experts (Eva, 2009). Conversely, reflection strategies that mobilize relevant
knowledge show some benefits (Monteiro & Norman, 2013). More research on
these aspects is needed. Nonetheless, we will draw from the existing evidence
on remediation of clinical reasoning difficulties to discuss practical strategies for
each difficulty.
Existing research highlights the key role of targeted exercises on clinical reasoning
as well as the potential benefits of reviewing videos for formative feedback
(Faustinella et al., 2004; Nendaz et al., 2011). All of these authors stress however,
that it is time consuming for the teachers involved (Hicks et al., 2005; Guerrasio et
al., 2014). A research conducted in family medicine in Québec aimed to
evaluate the academic issues of residents related to the use of remediation plans
by Faculty members, considering that academic problems were mainly cognitive,
and more specifically clinical reasoning problems (Audétat et al., 2015). The study
of residents’ post-remediation rotation evaluations revealed significant
improvement for nearly 70 % of them. Similarly, the University of Colorado School
Of Medicine developed a ten-step remediation plan which proved to be
successful for learners struggling with clinical reasoning. The majority (96 %)
passed the reassessment and 91 % were deemed competent for graduation and
continued practice (Guerrasio et al., 2014).These results are consistent with other
studies also showing that most remediation programs led to academic success;
Zbieranowski et al., 2013). Nevertheless, a minority of cases are not amenable
to remediation (Katz et al.,2010). In these cases, the remediation process can at
least provide reassurance to supervisors that fail decisions were the only option
after all others had been attempted.
General remediation strategies
According to the literature, effective remediation strategies share the following
critical elements: 1) an assessment of the learner’s competence 2) an established
educational? (si on suit la recommandation de Valérie) diagnosis, 3) a well-defined
and individual remediation plan or educational prescription, 4) the use of various
methods to better structure clinical reasoning, based on video recorded cases, role
playing, standardized patients and targeted and directed supervision on clinical
reasoning, and finally 5) a focused reassessment (Hauer et al., 2009; Katz et al.,
2010; Audétat et al., 2013; Steinert, 2013).
Early identification and early support, before the learner runs into major difficulties,
should be regarded as “the gold standard” for educational supervision (Evans et
al., 2010; Steinert, 2013). Many struggling learners exhibit a problematic cycle of
underperformance and early remediation interventions can stop this dynamic
(Cleland et al., 2013).
Based on the existing literature and our experience of supervision, we propose
the use of the global and concrete strategies described below. They can help
clinical teachers manage difficulties by enabling them to act quickly and
purposefully.
 Box 1: General principles to diagnose and remediate clinical reasoning problems
A. Adopt a educational reasoning process
• Observe learners, (even for parts of the task)
• Document observed difficulties and check in what context they occur
• Share and discuss your observations and educational hypotheses with colleagues to help formulate
a well-documented educational diagnosis.
• Work with colleagues to design a targeted plan of supervision

B. Develop educational skills

• Develop your knowledge and understanding of the clinical reasoning processes.
• Develop your ability to give explicit feedback to learners about their potential difficulties.
• Develop your supervisory skills and your educational diagnosis ability.

Developing competencies to diagnose clinical reasoning difficulties

As discussed in Part I of this Guide, teaching in the clinical environment is a
demanding, complex and often frustrating task that many clinicians take on
without adequate preparation (Ramani & Leinster, 2008). Indeed, though
clinicians are usually well prepared for their clinical roles, few are trained for their
teaching roles (Steinert, 2005). While clinical teachers usually carry out their role
with enthusiasm and genuinely want to help their clinical learners, their lack of
educational knowledge can make them less effective (Wilkerson & Irby, 1998).
Supervisors today are required to have an expanded toolkit of teaching skills
and clinical expertise (Harden & Crosby, 2000; Searle et al., 2006; Irby, 2014).
The strategies presented in this Guide aim to help clinical teachers develop
competencies to diagnose and remediate clinical reasoning difficulties.

Frequent clinical reasoning difficulties

and targeted remediation strategies
“Go and read!” This is probably the most frequent recommendation clinical
supervisors provide their trainees with, based on the assumption that a mere lack
of knowledge is responsible for most reasoning problems. But is this truly the case?
Our qualitative research with clinical teachers in different countries show that
supervisors’ perception of clinical reasoning difficulties is often not supported by
an in-depth, explicit understanding of how clinical reasoning develops resulting in a
risk of confusion between lack of knowledge, ability to apply knowledge in clinical
settings, and clinical reasoning problems (Audétat et al., 2011; Audetat et al., 2012).

These findings confirm those of Scott, who stresses that, while reasoning errors can
co-exist with medical knowledge problems, there seems to exist a misconception
that clinical reasoning errors are driven by a lack of medical knowledge rather
an inability to apply that knowledge in clinical practice (Scott, 2009).

A taxonomy of clinical reasoning difficulties for each step of the clinical

reasoning process
Difficulties can occur at any step of the clinical reasoning process and the
clinical teacher needs to first identify and label difficulties before designing
remediation. The taxonomy we propose is the result of a participatory action
research (Kemmis & Mc Taggart, 2005), which was carried out with senior clinical
teachers who have been involved in clinical supervision and remediation of
clinical reasoning difficulties for a number of years (Audétat et al., 2013). It does
not claim to be exhaustive, but illustrates the main prototypical difficulties
regularly observed and diagnosed in supervision. Guide 117
Diagnosis and management of
clinical reasoning difficulties
Figure 1 illustrates these main difficulties by placing them in a contextualised Part I. Clinical reasoning supervision
and educational diagnosis
perspective (a patient, an encounter, a particular clinician) in light of the dual
process theory explained in the first part of this Guide as well as key stages of page | 27
clinical reasoning.
Figure 1: Main clinical reasoning difficulties as they usually present in clinical settings
(Audétat et al., 2013)

DIFFICULTIES IN GENERATING POOR REPRESENTATTION

HYPOTHESIS, IDENTIFYING CUES OF THE NATURE OF
AND DIRECTING DATA GATHERING THE PRESENTING PROBLEM

Contextual factors related to physician, setting/encounter and patient

Analytical Process Non analytical Process

Problem representation
Immediate recognition
of clinical picture:
PREMATURE CLOSURE

Both processes involved

Hypothesis generation

specific features
of a case
Data interpretation
or

DIFFICULTIES IN
Hypothesis verification
similar cases
PRIORITIZING previously
encountered
Additional data collection

Working diagnosis Management decisions

DIFFICULTIES IN PAINTING
AN OVERALL PICTURE OF THE DIFFICULTIES ELABORATING
CLINICAL SITUATION A MANAGEMENT PLAN

In order to identify clinical reasoning difficulties, clinical teachers first need to

recognise and interpret cues or indicators of the difficulties as they present in
clinical supervision. These indicators may differ depending on the type of
supervision provided, i.e. direct observation, case discussions, or review of
medical records (Audétat et al., 2013).

Difficulty in elaborating a problem representation

Poor representation of the nature of the problem may happen, for example,
when there is insufficient characterization of the presenting symptoms.
Being unable to build a correct mental representation about the initial
problem may prevent the clinician from immediately recognising the clinical
picture (non-analytical process) or from entering a relevant analytical process.
Another obstacle to problem representation is staying too close to each piece of
information, without being able to step back and make a more global and
abstract “picture” of the problem (for example by using semantic qualifiers)
(Chang et al.,1998; Bordage, 1999) or to include the patient’s psycho-social
context (see Table 1).
Guide 117
Diagnosis and management of
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Part I. Clinical reasoning supervision
and educational diagnosis

page | 28
 Table 1: Poor representation of the nature of the problem

Difficulty : Poor representation of the nature of the problem

CUES available in direct supervision
• Learner starts asking questions as soon as the patient has expressed his main complaint.
• Learner doesn’t take into account the complexity of the situation.
• Learner asks about each symptom in isolation.
• Learner fails to investigate the patient’s psycho-social context.

CUES available in indirect supervision or case discussions

• Learner fails to present an initial global and/or abstract representation of the problem.
• Learner rapidly suggests diagnostic hypotheses or tests in an emergency context.
• Learner is unable to summarize the case using key information.
• Learner doesn’t integrate the patient’s context in his/her presentation of the case.
• The clinical teacher is unable to elaborate a clear representation of the problem after
the case presentation.

CUES available in medical records

• The summary of the case is narrative and doesn’t describe the situation as a ‘medical
problem’.
• The list of the patient problems is long and chunked in small pieces.

Difficulty in hypotheses generation and direction of data gathering

At this phase of the clinical reasoning process, the learner either fails to consider
one or many diagnostic hypotheses, considers irrelevant hypotheses or doesn’t
take into account the features of the problem to adapt his/her data collection.

Using relevant diagnostic hypotheses to frame data collection has been shown Using relevant diagnostic
to increase the relevance of the data collected and diagnostic competence hypotheses to frame data
collection has been shown
(Barrows, et al., 1982; Nendaz et al., 2006). A learner may present difficulties at
to increase the relevance
this stage, because he/she simply mechanically follows lists of questions to ask a of the data collected and
patient rather than purposefully testing specific hypotheses, or he/she needs to diagnostic competence
verify hypotheses systematically to make sure nothing is left out (see Table 2).

Table 2: Difficulties in generating hypotheses, identifying cues and directing data gathering

Difficulties in generating hypotheses, identifying cues and directing data gathering

CUES available in direct supervision
• Learner fails to select the key features.
• Learner fails to ask key questions early.
• Interview can be unduly exhaustive, stereotypical and unconnected to the patient’s complaint.
• Physical examination can be unduly exhaustive, stereotypical and unconnected to the patient’s complaint.
• Consultation is conducted in a rigid way, failing to take account of new cues or information provided by the patient.
• Interview is disorganized, with no clear direction, occasionally excessively brief but more typically unduly long.
• Learner asks questions with no obvious relevance to the case or persists in an irrelevant line of inquiry.

CUES available in indirect supervision or case discussions

• Case summary is unduly long or brief and fails to bring out the case’s key features.
• Case summary is disorganized with no clear direction.
• Learner shows difficulty in formulating and justifying the hypotheses governing his/her line of inquiry.
• Learner shows difficulty in performing a semantic transformation.

CUES available in medical records

• Key features are mentioned but not in an organized fashion.
• Lack of key features that serve to exclude alternative hypotheses (relevant negatives).
• Profusion of irrelevant details.

Refinement of hypotheses and hypotheses testing and data interpretation: Guide 117
Diagnosis and management of
Premature closure clinical reasoning difficulties
Data interpretation is a major step in the reasoning process and gives meaning to Part I. Clinical reasoning supervision
and educational diagnosis
the information at hand. Premature closure happens when the clinician accepts
a diagnosis before it has been completely verified (J Higgs, 2008). (See Table 3).
page | 29
 Table 3: Premature closure

Difficulty : Premature closure

CUES available in direct supervision
• Learner seeks only those data that confirm his/her single hypothesis.
• Learner fails to explore cues or information that could lead to other diagnostic hypotheses.
• Learner fails to notice new cues.
• Learner fails to clarify or check the patient’s complaints.

CUES available in indirect supervision or case discussions

• Scarce elaboration of alternative hypotheses.
• Failure to retain or to identify certain pieces of information that could have evoked other hypotheses.

CUES available in medical records

• No key information serving to exclude alternative hypotheses (relevant negatives).
• No information that could cast doubt upon the main hypothesis.
• No differential diagnosis.

Refinement of hypotheses and hypotheses testing and data interpretation:

Difficulties in prioritising
The meaning of the data will depend on their relevance to solving the case.
There may be misinterpretations about the value attributed to an information
collected thus supporting a specific hypothesis (e.g. giving too much value to
orthopnea and considering it is linked to heart failure, while this symptom may
also be present in chronic obstructive pulmonary disease), or resulting in the
elimination of a relevant hypothesis (e.g. giving insufficient value to a dull
abdominal pain in a pregnant patient and rejecting the hypothesis of ectopic
pregnancy).

Another form of difficulty of prioritisation is when a learner fails, with a patient with
multiple complaints, to focus on the main problem with regard to the patient’s or
the clinician’s perspective. (See Table 4).

Table 4: Difficulties in prioritising

Difficulties in prioritising
CUES available in direct supervision
• Interview follows a set or inappropriate structure.
• Learner fails to identify which of the patient’s complaints is the chief or most serious complaint and to direct the interview
accordingly.
• Learner spends far too much time exploring a minor point.
• Learner doesn’t elicit a detailed picture of the chief complaint elicited.
• Encounter “doesn’t go well”, poor management, patient dissatisfaction, communication problems.
• Supervisor needs to intervene to shift the focus of the encounter.

CUES available in indirect supervision or case discussions

• Conclusions, diagnosis or management plan that don’t match the expectations of the teacher (too much or not enough).
• Sense of losing the thread of what the learner is saying, difficult for the supervisor to picture the situation (resident is
unable to integrate or synthesize the data collected).
• The supervisor is impatient to take charge, go back to see the patient etc, in order to get a better picture of the clinical
situation.

CUES available in medical records

• The learner reproduces a theoretical textbook table of hypotheses without adjusting and ranking them to the patient case.
• Lack of details delineating the chief complaint and/or too many details regarding minor issues.
• The ranking of the hypotheses is not adjusted to the patient case.

Final diagnosis or labelling of problem and development of a management plan

Guide 117
Diagnosis and management of
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Part I. Clinical reasoning supervision
and educational diagnosis
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At the stage of synthesizing the problem and making decisions, the learner may
have difficulties elaborating a global, final representation of the patient’s problem,
recognising important features, and prioritising diagnostic hypotheses. This results
in forgetting important hypotheses, in promoting irrelevant ones, and in elaborating
a patient’s problem list that is incomplete, or too complex, with isolated data that
should have been seen as a constellation or pattern. (See Table 5).
 Table 5: Difficulties in painting an overall picture of the clinical situation

Difficulties in painting an overall picture of the clinical situation

CUES available in direct supervision
• Each issue and its management are addressed in isolation.
• Learner uses a set structure of reasoning which leaves little room for the specificities of the patient.
• Treatment or investigation plan becomes unrealistic when the patient’s characteristics are taken into account.
• Learner applies guidelines in an unduly rigid manner.

CUES available in indirect supervision or case discussions

• Stereotypical or simplistic view of the situation.
• Failure to appreciate the patient’s situation comprehensively in all of its biopsychosocial complexity.
• Lack of a longitudinal perspective in his/her understanding of the clinical situation.

CUES available in medical records

• No mention of patient’s status and perceptions. The notes fail to convey “who” the patient is.

If the reasoning process is flawed for any reason described above, the risk of
imperfect subsequent decisions will, of course, be increased. However, some
learners, especially those more advanced in their training, may be able to
provide a satisfactory reasoning approach, but still have difficulties relating their
working hypotheses to the different actions required, such as the elaboration of a
management plan, or proposals for tests, treatments, or orientation of the
patient. (See Table 6).

Table 6: Difficulties elaborating a management plan

Difficulties elaborating a management plan

CUES available in direct supervision
• Management plan is missing or defective: too extensive, stereotypical, ambiguous, vague, doesn’t solve anything or
repeatedly defers decisions.
• Management plan is unsatisfactory and inappropriate considering the situation or fails to address the patient’s issues.
• Learner fails to discuss with the patient how the management plan might be altered depending on the course of the
disease or treatment.
• Learner finds it difficult to explain the management plan to the patient.
• Follow-up is inappropriate.

CUES available in indirect supervision or in case discussions

• Inability or difficulty to integrate or synthesize the information gathered.
• Inability to justify his/her management plan.
• Failure to consider availability or cost of resources, prevalence or urgency of problems, or the constraints posed by the
patient’s issues in his/her management plan.
• Defective management plan: too extensive, stereotypical, ambiguous, vague, doesn’t solve anything or repeatedly
defers decision.
• Management plan that doesn’t include expectations regarding the course of the clinical problem (e.g. restricted to one
step at a time).
• Unsatisfactory management plan that is inappropriate considering the situation.
• Inappropriate follow-up.

CUES available in medical records

• Management plan is missing
• Defective management plan: too extensive, stereotypical, ambiguous, vague, doesn’t solve anything or repeatedly
defers decision.
• Lack of consistency between the process of diagnostic reasoning and the proposed management plan.
• Management plan that fails to mention conceivable next steps according to the course of the illness.
• Unsatisfactory management plan that is inappropriate considering the situation.
• Inappropriate follow-up.

The example below (Box 2), although non-exhaustive and slightly stereotyped
with regard to the demonstration, illustrates what some of the difficulties that we
have mentioned could look like in a given clinical situation. Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis

page | 31
 Box 2: An example of the potential clinical reasoning difficulties of a learner in a
contextualised clinical situation
Mrs Smith, a young woman of 23 years of age, presents to her family doctor’s office complaining of an
intense headache that she has had for 3 days. Mrs Smith has not had any relief from acetaminophen which
she normally finds effective. Her headache is characterised as pulsating accompanied by nausea and pho-
tophobia. She slept badly the night before, although headaches in the past have not kept her from sleeping.
Her headache resembles the ones she usually has. It is simply lasting longer, because normally a good night’s
sleep makes the pain go away.

She is really worried because she has a job interview the next day and she has been unemployed for several
months. She is mainly asking for some relief, with the perspective of the upcoming interview. She has been
sleeping badly for several days, worried about her professional prospects. The headache was present during
the night, but she is far from certain that that is what has kept her from sleeping.

If he/she had difficulties with the initial representation: the learner would, for example, hurry into following
a questionnaire to check for the different degrees of headaches in a woman of the patient’s age, he/she
would find a certain severity/degree of migraine status or worry about an intracranial bleeding and suggest
strong painkillers or even refer her to the emergency department. The learner would probably have
difficulties to describe the problem in its entirety to the patient and in the direct supervision, it would probably
be possible to see that the patient is being pushed to respond to closed questions instead of being
encouraged to describe her problem.

If he/she had difficulties to generate hypotheses: the learner would for example, start to ask questions about
the different degrees of headaches, without any discrimination, by making Mrs Smith detail all the different
headache episodes of the past year, what medications she took and having her rate the headaches in
terms of degree of pain for each episode, etc. However, this kind of excessive documentation does not help
select one hypothesis over another.
The learner would also ask questions in an illogical order, bringing together symptoms that go with a
particular degree of headache and thereby lose him/herself in a disorganised and random questionnaire.

If he/she had a tendency to close prematurely: the learner would for example put the headache down to
stress without checking whether there are signs of severity or for example, worry, without checking about the
fact that the patient had been woken up during the night by the pain and conclude that there was a risk
of an intracranial problem and refer the patient directly to the emergency department, meaning that she
would miss her interview.
A perfect, classic presentation of the clinical situation without any nuances could help make the supervisor
attentive to this risk.

If he/she had difficulties to prioritise: the learner would for example do a rather complete and relevant
history-taking but not identify the key elements of the clinical situation in order to make a decision. He/she
would present multiple options to the supervisor without suggesting a clear line of action and thereby
contributing to give the supervisor a sense of confusion. Faced with this kind of presentation, the supervisor
would want to intervene and go and see the patient and ask her questions to get an idea…

If he/she had difficulties to grasp a global representation of the situation: the learner would for example
question the patient, question her personal situation, but from a factual point of view, without interpreting
the information and without making any links. The learner would then present the fact that the patient was
without work and that she had an upcoming interview as elements among others, without taking them into
sufficient account neither in his/her evaluation of the degree of headache, nor in his/her intervention plan.

If he/she had difficulties in coming up with an intervention plan: the learner would for example prescribe a
very costly medication, without letting the patient know, with the risk that she would not take the medication
because it isn’t within her financial means to do so (no insurance, adequate coverage) or that the learner
would give her sleeping tablets with the risk that she would not be able to do her interview.

page | 32
Targeted strategies to support the development of organised knowledge
Lack of knowledge or poor organisation of knowledge contribute to difficulties at Lack of knowledge or
all steps of the clinical reasoning process. If deficits in knowledge and clinical poor organisation of
reasoning coexist, Guerrasio et al. highlight the importance of remediating knowledge contribute to
difficulties at all steps of the
knowledge first, in order to provide the foundation to develop clinical reasoning
clinical reasoning process
skills (Guerrasio et al., 2014).

On the basis of the concept of knowledge organisation and illness scripts

discussed in Part I of this Guide, supervisors should encourage learners to build
strong and useful knowledge structures and representations (Bordage, 1994;
Norman, 2005; Schmidt & Rikers, 2007; Charlin et al.,2007) by asking them not only
to read about diseases, but to read to meet clinical objectives such as identifying
the key symptoms and signs, the usual course and the key symptoms and signs of
resolution or complication of a disease, etc. The practical tips highlighted in Box
3 explain some useful strategies.

Box 3: Strategies aimed at developing learners’ illness scripts

(Laurin et al., 2015; Lubarsky et al., 2015)

Ask the learner to read about:

• a disease and relate elements of physiopathology and clinical signs (e.g. to understand why the mouth
and forehead are affected in Bell’s palsy),
• diseases that share a key symptom and compare and contrast them. (e.g. Osteoarthritis vs arthritis,
hepatitis vs gallstones),
• the usual course of a disease and the key symptoms and signs to monitor to detect a complication (e.g.
Predicted delay before the resolution of symptoms of pneumonia with antibiotic treatment),
• a disease and the most appropriate diagnostic tests to order in terms of availability, cost, relevance, etc.
(e.g. X-Ray vs Scan vs MRI in mechanical low back pain),
• discuss their readings with them and encourage them to group the key features of each script together.

During supervision:
Ask the learners to identify the key features of the clinical situation they just encountered and:
• ask what cluster of signs and symptoms back their main hypothesis,
• ask what signs and symptoms are atypical of their main hypothesis,
• encourage them to present the case according to the hypotheses they envisaged, with the cluster of
features present for each.

During case discussions,

• ask learners to articulate which scripts they activate for a given symptom, and discuss the additional signs
or symptoms they should look for, for each activated script,
• work on helping the learners to identify and weigh the key features of a case.

During case discussions, enrich learners’ scripts:

• by getting a sense of the learner’s script and the elements it contains, and by sharing the
knowledge/experiences/competences that are part of your own scripts,
• by articulating the links between signs and symptoms, and between the different elements of your own
scripts,
• by comparing the main presenting symptoms and signs depending on the stage of a disease or the
clinical context (eg. early symptoms and signs in an out- patient vs severe symptoms in an emergency
setting),
• by discussing the clinical rationale of your choice of diagnostic tests,
• by explaining what symptoms and signs you would monitor in order to detect a complication.

Specific remediation strategies for clinical reasoning difficulties

Once the clinical teacher has identified and labelled the learner’s difficulty, Guide 117
he/she has to look for the potential root causes of each difficulty, the context’s Diagnosis and management of
clinical reasoning difficulties
affordances (time etc.) and the learners’ needs and determine what Part I. Clinical reasoning supervision
and educational diagnosis
remediation strategies are best suited.

page | 33
 It can be difficult to distinguish between a minor mistake, which one would
expect from novices, and a difficulty requiring remediation. Nevertheless, it is
worthwhile to identify errors early on and apply tailored educational strategies
so that minor challenges do not crystallise into serious problems that are more
difficult to deal with later on.

Strategies should be adjusted to the severity of the issue (whether it represents a

relatively normal stage in the transition from novice to expert or whether it
constitutes an actual problem) as well as to the type of difficulty.

The strategies we propose aim at providing very concrete tools for clinical
teachers and address the different causes of difficulties. Some of these measures
can be used during supervision, and others once the clinical encounter has
ended in order to avoid holding up patients or delaying treatment. These
educational strategies will be all the more effective if they are repeated and
integrated into a remediation plan.

Remediation of complex difficulties (e.g. combination of reasoning and

attitudinal issues) requires a structured remediation plan using several methods
and approaches, as well as a follow-up schedule. This Guide purposefully
focuses on strategies to facilitate the normal development of clinical reasoning
and to correct clinical reasoning difficulties specifically. It does not include plans
to address complex multifactorial issues beyond clinical reasoning, such as
mental illness or other personal difficulties of the learner revealed by difficulties in
reasoning but requiring another type of support.

Table 7 provides potential causal or enabling conditions and remediation

strategies for each clinical reasoning difficulty (Audétat et al., 2013; Laurin et
al.,2014).

Guide 117
Diagnosis and management of
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Part I. Clinical reasoning supervision
and educational diagnosis

page | 34
Potential causal or enabling conditions and remediation
strategies for each clinical reasoning difficulty
Main Main causal or
difficulties enabling conditions
Poor • Relies only on own first
representation impression
of the nature of
the presenting • Too much haste in
problem or of generating hypotheses
its evolution
• Poor semantic
transformation
• Incapacity to summarize
the features of the patient
in one or two sentences
• Lack of interviewing
skills
• Relational complexity
with patient or family
Difficulties in • Inexperience or
generating insecurity: needs to
hypotheses, ask questions in a set
identifying cues in order to feel more
and directing secure or to avoid
data gathering getting muddled up
• Unfamiliarity with the
hypothetic-deductive
model or application
of the ‘systematic
interview’ model
learned at earlier
stages of training
• Poor semantic
transformation
• Cognitive biases:
(availability –
representativeness)
Premature • Influencing factors such
closure as a lack of time, feeling
awkward or unsure about
how to go about things
• Erroneous belief that the
patient will spontaneously
volunteer all of his/her
symptoms without the
need for specific enquiry.
• Cognitive biases:
Confirmation, Anchoring,
Overconfidence
Table 7
Examples of remediation strategies
Ask the learner to first ask about the symptom itself and the context in which it ]
appears before initiating an analytic process
Take time to discuss this first stage of the consultation with the learner during supervision:
(e.g. what elements of the presenting complaints would you value? What if we put
together this and this pieces of information?)
Explicitly demonstrate and illustrate semantic transformation of the problem: (e.g.
young woman with acute pain in the lower left abdominal quadrant)
In the case of a known patient for example, discuss the clinical situation with the
learner before the encounter bringing up key points and explaining them in a way that
illustrates the representation of the problem: (e.g. old man under analgesic therapy
presenting delirium after increase of dosage at home)
Use role play or suggest useful questions to ask at this stage
Suggest tips to overcome the relational or context difficulties or discuss
with the learner how he/she could have managed the situation.
Foster the systematic and early generation of hypotheses:
• If the main complaint of the patient is known before the learner meets the patient,
ask him/her to already generate a few (three, for example) hypotheses based on
data at hand (age, sex, complaint, context, etc.)
• Present a few fictitious patients along with the initial information. For each case, the
learner is asked to provide the most likely hypothesis together with plausible
alternative diagnoses. (For use outside the context of patient care).
Give tips to keep track of the process (taking notes, making a list before the encounter,
etc.) to help direct a more flexible interview
Explicitly describe the overall process of clinical reasoning using the case content:
(“Let’s go through the different steps of this case together”).
Explicitly discussing each step in turn.
Verbalize and explicitly demonstrate clinical reasoning: (“When I hear (symptom),
I think of (diagnoses), because …”)
Foster the early recognition of discriminating cues: (“Have you already seen a
patient with disease x, if so in what way is this case similar, in what way is it
different?”) Or while watching a video recording of the encounter, stop the recording
repeatedly during the early stages of the consultation as key cues crop up and ask
the resident: “What important cues can you identify?” “What should you be thinking of
when the patient tells you that?” “What if the patient would be younger, or female?”
Explicitly demonstrate and illustrate semantic transformation: (“From what you’re
describing, I’d say that it’s a case of postprandial epigastric pain relieved by antacids.
This would be the starting point for my working hypotheses and questions to the patient.”)
Verbalize and explicitly demonstrate clinical reasoning: (“When I hear (symptom),
I think of (diagnoses), because …”)
Encourage the learner to articulate their clinical reasoning
Adapt the learner’s schedule, allow more time for each consultation, teach
communication skills, give tips on how to address sensitive issues with patients, etc.
Foster the systematic generation of a differential diagnosis: systematically ask the learner
to generate and verify a number (three, for example) hypotheses for each situation
Encourage the learner to proceed methodically by focusing on the justification of the
main hypotheses and the generation of alternative hypotheses: ask the learner to justify
the most likely diagnosis with positive and negative relevant data as well as a less likely
but potentially serious one (red flag). (“Is this hypothesis supported by the findings?
Are all findings explained by this hypothesis?”)
Encourage the learner to reflect on why s/he failed to retain other hypotheses.
page | 35
Table 7 ... Cont’d

Main Main causal or

difficulties enabling conditions
Difficulties in • Influence of factors linked
prioritizing to the patient
(psychosocial issues,
personality, etc.), the
context and the learner.
• Influence of factors linked
to the learner him/herself
(experience, values and
prejudices,
preoccupations,
counter-transfer, etc.).
• Biases: Representativeness
- Anchoring.
• Competencies still in
need of practice such as
techniques of consultation
management,
assertiveness, etc.
Examples of remediation strategies
Explicitly demonstrate the reasoning involved in prioritizing (explicit role modelling): the
supervisor explains why s/he thinks that this issue is the most important one.
Encourage the learner to consider an alternative priority: “If you prioritized the issues
in a different way, how would that change your perspective, your treatment or your
management?”
Work on eliciting and weighing the different issues and factors and their influence on
the decision: confront the learner to trigger reflection and make the impact of these
factors explicit during discussions.
Ask the learner to tell the patient’s story in a narrative format: “Imagine that you had
to present this patient’s situation to a consultant, what would you say?” “Who is this
patient?” and ask him/her to determine priorities.
Manage the clinical problem and explain the situation afterwards (role modeling of
process).
Give tips on how to select the problems to address when a patient has many
complaints and teach communication skills to negotiate the selection with patients.

Difficulties in • Lack of clinical
painting an experience, lack of
overall picture appreciation of the
of the clinical importance of contextual
situation factors.
Difficulties • Lack of interest, insensitive
elaborating a or overly sensitive
management (protection mechanisms).
plan • Poor grasp of
patient-centered care.
• Difficulty dealing with
uncertainty
• Difficulty integrating the
patient’s perspective
and/or biopsychosocial
context.
• Difficulty developing a
longitudinal perspective
of the patient’s history.
• Difficulty integrating new
cues (response to
treatment, test results etc.)
in his/her reasoning
process.
Prompt the learner to think about the connections between different aspects of the
clinical situation: (“Does your patient’s personality, context, values…. affect the
management plan?” “Does problem X have an impact on the management of
problem Y? In what way?”)
Encourage the learner to think about the patient with a longitudinal perspective:
before the clinical encounter, the learner should read the patient’s notes, summarize
them and discuss them with his/her supervisor.
Ask the learner to draw a diagram or a concept map of the clinical situation and
discuss it with him/her.
Demonstrate proper clinical reasoning (explicit role modeling): the supervisor explains
why s/he favours plan X considering various pieces of clinical information
Go over clinical reasoning and focus on the specifics of the clinical situation which
require a departure from the guidelines: supervisor explains how s/he takes the
specificities of the patient into account to modulate his/her application of clinical
guidelines in a rational manner.
Ask the learner to read up on the different investigative and management options
available and compare and contrast their advantages and disadvantages.
Prompt learner to conclude and settle on a plan: supervisor pushes the learner’s
thinking a little further and, if necessary, offers possible test results or outcomes to
encourage the learner to develop a complete and integrated management plan.
(“What would be the consequences of your test proposals?”).

Examples to develop teaching scripts

As developed in Part I of this Guide, we highlighted the parallels between clinical
reasoning and pedagogical reasoning.

Let us take a look at the following frequent symptom that arises in supervision: -
too much time spent in consultation.

Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
The clinical teacher notes that the learner regularly takes far too long to get to
the end of his/her consultations. The clinical teacher then puts in place a
pedagogical reasoning process, such as presented in Table 8, which is aimed
at getting the learner to consider and check pedagogical hypotheses, and to
suggest a targeted remediation strategy.

page | 36
 1 Symptoms : Too much time spent in consultation Table 8
Example of an
educational diagnosis
• Communication problem with the patient?
2 • Clinical reasoning problem? associated with a
Initial educational hypotheses : • … targeted remediation

• Interview is stereotypical or exhaustive.

3 • The learner fails to select the key features,
Acquisition of additional data : and fails to direct and focus his data gathering.
the supervisor conducts direct
supervision and notes that :

Difficulties in generating hypothesis

4
Data interpretation

Difficulties in generating hypothesis

5
Hypothesis verification and Causes: Inexperience or insecurity, needs to ask
validation with the learner, and discussion questions in a set order to feel more secure or to
of causes and educational diagnosis avoid getting muddled up.

Chosen remediation strategy : ... generating

6 Explicitly describes the overall process of clinical educational hypotheses
reasoning: “Let’s go through the different steps about a learner’s difficulties
Choice of a targeted support strategy together” (explicitly discussing each step in turn) is based on the activation
of teaching scripts that
As we noted it in Part I. of this Guide, generating educational hypotheses about integrate theoretical
a learner’s difficulties is based on the activation of teaching scripts that integrate educational concepts,
knowledge about clinical
theoretical educational concepts, knowledge about clinical reasoning difficulties
reasoning difficulties and
and remediation, and supervisors’ experience of dealing with learners’ problems. remediation, and
By practicing educational reasoning and encountering different types of supervisors’ experience
difficulties, supervisors develop richer teaching scripts, and become more of dealing with learners’
effective. Figure 2 illustrates what these kinds of teaching scripts, sharing a same problems
“symptom”, could include.

Example of the content of teaching scripts about two different types of Figure 2
difficulties revealed by the same learner’s difficulty

DIFFICULTIES
Clue:
Theoretical Knowledge Clue: GENERATING
fails to
educational about clinical fails to HYPOTHESIS
generate a
concepts reasoning direct and SCRIPT
certain number
focus his data
Clue: of diagnostic Clue:
gathering
Interview is hypothesis fails to
Targeted Supervisor’s
stereotypical select the
remediation experiential
or exhaustive key
strategies knowledge
features

Interview unduly long

Targeted Clue: has

Knowledge and remediation difficulty Knowledge and
experience about strategies structuring experience about
communication’s Clue: the different Clue: seems doctor-patient
skills does not stages of the uncomfortable relationship Guide 117
Theoretical control the interview or awkward Diagnosis and management of
DIFFICULTIES
clinical IN
reasoning difficulties
educational flow of the in the
interview COMMUNICATION
Part I. Clinical reasoning supervision
concepts relationship and educational diagnosis
SKILL SCRIPT

... most remediation
interventions lack
theoretical foundations and
tend to be implemented in
the final stages of medical
training
... supervisors may fall
prey to pedagogical
“premature closure” and
focus only on his/her first
hypothesis without
validating it through closer
supervision. To avoid this,
clinical teachers should
strive to generate
alternative educational
hypotheses and test them
in subsequent supervision
sessions or discuss them with
the learner.
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 38
Challenges and issues related to the
diagnosis and management of clinical
reasoning difficulties
There are many challenges related to the identification of academic difficulties
of learners and their management. Dudek et al found that supervisors lacked
documentation, practical tools, and knowledge, leading to a lack of
confidence in their educational action (Dudek et al., 2005). In a review of the
literature, Cleland et al reported that most remediation interventions lack
theoretical foundations and tend to be implemented in the final stages of
medical training (Cleland et al., 2013). These authors also found that more often
than not, remediation strategies tended to represent ‘more of the same’, such as
additional or intensive knowledge or skills teaching (Cleland et al., 2013).
Furthermore, Hauer et al noted that assessment and remediation processes are
seldom matched by official institutional procedures (Hauer et al., 2008).
In the following section, we will highlight specific challenges and issues related to
the management of clinical reasoning difficulties in particular.
Issues related to clinical teachers:
An exploratory study in residency in Québec found that supervisors tend to focus
on organizational factors (for example, reducing the number of patients seen by
residents, increasing the time scheduled for each consultation) rather than on
clinical reasoning itself. Supervisors tended to seek immediate solutions and were
generally unaware of the reflective and longitudinal aspects of educational
processes. Their diagnoses and remediation plans were not sufficiently grounded
in data collected through specific tools or using structured educational
processes, making them less targeted than they could be (Audétat et al., 2011).
Just as in clinical reasoning (Durning et al., 2011), a variety of factors (related to
the learner, supervisor, and setting) may be at play. During training sessions with
clinical teachers, errors may often occur in educational reasoning. For instance,
a supervisor who is disorganised and finds it difficult to integrate his/her own
clinical and educational tasks, or who is ill at ease with the learner could have
trouble making an accurate educational reasoning. In particular, supervisors may
fall prey to educational “premature closure” and focus only on their hypothesis
without validating it through closer supervision. To avoid this, clinical teachers
should strive to generate alternative educational hypotheses and test them in
subsequent supervision sessions or discuss them with the learner.
Like clinical reasoning, educational reasoning develops through repeated
practice in authentic settings, by generating and testing educational hypotheses
during clinical supervision. By constructing teaching scripts addressing effective
clinical reasoning and the main clinical reasoning difficulties, supervisors should
be better able to identify the common manifestations of difficulties and reach an
educational diagnosis regarding their learners’ clinical reasoning (Côté &
Bordage, 2012; Irby, 2014).
Issues related to the supervisor-learner relationship:
There are issues related to the relationship between clinical teachers, who need
to accept their role as supervisors, and learners, who need to accept
constructive feedback while developing as self-directed learners. Furthermore,
supervisors hold a variety of beliefs about their relationship with learners, many
of which are largely subconscious, and that can affect their behaviour and the
educational relationship they develop with their learners (Dory & Audétat, 2013).
In a qualitative research carried out with clinical teachers in various medical
specialties in Switzerland and Belgium, the authors uncovered supervisors’
beliefs and their potential influence on practice, as they emerge through
metaphors used when speaking about their current practice regarding residents
with clinical reasoning difficulties. Many of the metaphors revealed an ideal
vision of “normal” residency as a natural, spontaneous, smooth process with
minimal need for input on their part. One key difference between the metaphors
they found concerned the level of detachment/attachment expressed by the
supervisors. Most of the metaphors revealed varying amounts of detachment
towards residents. This was exemplified by the quality control metaphor where
residents are merely objects to be evaluated. At the other end of the spectrum,
the child-rearing and abusive relationship metaphors represented a deep
affective commitment. Only one metaphor, i.e. the sports coach metaphor, lay
at the centre of the scale, symbolizing a balanced, appropriate, level of
involvement with residents. Metaphors on one side were associated with a
degree of listlessness in their dealings with struggling residents, whereas
metaphors on the other side were linked to strong emotions of anger and
frustration (Dory & Audétat, 2013). Neither extreme seems to represent an
appropriate educational relationship where supervisors can act appropriately
both when residents do well and when they do not: too little involvement and
struggling residents may suffer, too much and supervisors are at risk of burn-out
when learners present difficulties and both may end up losing out.

Issues related to institutional procedures and teaching paradigms

The work of Hauer et al. has revealed how little there is in the literature in terms
of best practices with regard to remediation in medical education (Hauer et al.,
2008). It has also shown that the material that does exist is still very much
localised and not explicitly implemented as faculty processes (Hauer et al., 2008).
The remediation work is indeed carried out locally, within the clinical teaching
teams. The consequences of this local responsibility are that the entire
educational process remains highly dependent on the capacities and willingness
of teaching staff or the unit which the learner is attached to. We find it necessary
to highlight the importance of developing practices related to diagnosis and
remediation of clinical reasoning difficulties within a more organised and more
structured framework, emanating from the Faculties and Departments
themselves. Kalet and colleagues have just published a “12 tips paper”
derived from a decade of remediation experience. These authors hope to guide
program leaders to build better remediation systems in their institutions (Kalet et
al.,2016). Enhanced
professionalism in clinical
It is also useful to clarify or render explicit the paradigm in which the clinical education requires ongoing
teachers find themselves within their faculties. Implicit norms conveyed by faculty development
peers and institutions often remain steeped in the traditional “teabag” model programs to provide a
formal body of knowledge
of education, where clinical educators are expected to acquire educational
and skills but also to foster
skills by osmosis (Hodges, 2010). However, this traditional approach is now being the development of a
challenged by the advent of outcome-based medical education (Dath & Lobst, distinct identity as educator
2010). Enhanced professionalism in clinical education requires ongoing faculty by instilling new attitudes
development programs to provide a formal body of knowledge and skills but and values
also to foster the development of a distinct identity as educator by instilling new
attitudes and values (Young, 1987; Brott & Kajs, 2001; Dowling, 2001; J. Higgs &
Mc Allister, 2006; Steinert & Mann, 2006a, 2006b; Ramani & Leinster, 2008; Sutkin et
al.,2008; Irby, 2014)

However, this cannot occur without a wider collective transition into a new
learning paradigm (Audétat et al., 2012) in which the supervisor is a skilled clinical
teacher, pedagogically speaking, with the responsibility to identify the strengths
and difficulties of his/her learner, to support and correct his or her clinical
reasoning. In addition, the clinical learner is a learner who develops his/her
reasoning during supervised clinical activities. He/she “accepts” to be
supervised and to receive feedback. He/she recognises his/her difficulties, trusts Guide 117
Diagnosis and management of
the supervisor and commits to a learning process. His or her collaboration and clinical reasoning difficulties
active participation are also essential to the success of an educational plan Part I. Clinical reasoning supervision
and educational diagnosis
(Laurin et al., 2012).
page | 39

Faculty development
aims to help teachers
develop the requisite
knowledge, skills and
attitudes to perform their
tasks. Many of those
required to manage
learners with clinical
reasoning difficulties belong
to the general repertoire
of clinical teachers such as
basic pedagogical
principles and skills in
providing constructive
feedback.
Just as novice clinicians
must learn about different
disease categories and how
to match patients’ signs and
symptoms with a category
or diagnosis, so too must
teachers learn about
different types of difficulties
and how to recognize
them
although supervisor
training is important and
necessary, it is equally
crucial to offer
organizational support for
the remediation process
given the unpredictability of
clinical contexts and
locations in which
supervisors juggle multiple
duties
Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 40
What kind of faculty development for the management of learners with
difficulties in clinical reasoning?
Faculty development aims to help teachers develop the requisite knowledge,
skills and attitudes to perform their tasks. Many of the skills required to manage
learners with clinical reasoning difficulties belong to the general repertoire of
clinical teachers such as basic educational principles and skills in providing
constructive feedback. However some aspects require specific development.
In the beginning of Part I. of this Guide we mentioned how difficult it is for
experienced clinicians to explain how they solve clinical problems due to the
organisation of their knowledge which is compiled (G Bordage, 2007) or
encapsulated (Schmidt & Boshuizen, 1992). As the evidence regarding clinical
reasoning has accrued over four decades, so too have papers addressing
empirical findings and conceptual models of clinical reasoning. Some of these
papers have specifically targeted clinical teachers (Eva, 2004; Nendaz et al.,
2005; Bowen, 2006; Audétat & Laurin, 2010a, 2010b; Atkinson et al.,2011; Rencic,
2011). In fact there is now some evidence that these efforts to disseminate
knowledge about clinical reasoning are beginning to pay off: Côté and
colleagues have found that clinical teachers referred to a variety of conceptual
frameworks, including ones for clinical reasoning, when solving paper-based
educational cases (Côté & Bordage, 2012; Côté & Laughrea, 2014).
Workshops to train clinical teachers in specific techniques such as the One
Minute Preceptor have been developed, using role play and fictional
educational cases (Bowen, 2006). Bowen et al. enhanced workshops by
including standardised learners and more scripted cases which increased the
realism of the role play experience. Standardized learners also provided
feedback and coaching which participants appreciated, and teaching scripts
helped teachers focus on diagnosing the learner rather than the patient (Bowen,
2006).
Others have developed broader workshops on managing struggling or
“problem” learners (Steinert et al., 2001). The workshops centre around a
problem-solving approach which includes a diagnosis phase, where the problem
is clearly defined, and a management phase. This points to the fact that
managing learners with clinical reasoning difficulties is similar to managing
patients (Evans et al., 2010). Just as novice clinicians must learn about different
disease categories and how to match patients’ signs and symptoms with a
category or diagnosis, so too must teachers learn about different types of
difficulties and how to recognize them (Irby, 2014). There is some evidence that
experienced clinical teachers develop teaching scripts through experiential
learning (Irby, 1992; Govaerts et al.,2012). This process could be facilitated
through the provision of formal knowledge about educational diagnoses,
together with opportunities for practice and reflection. Techniques such as
role-playing and small group reflection have previously been used in faculty
development initiatives. Coaching for on-site supervisors might be another good
way to progressively enrich teaching scripts. Other methods such as the use of
student evaluations (Boerboom et al., 2011) or the Objective Structured Teacher
Encounter (OSTE) (Trowbridge et al., 2011) could be used as a trigger for
reflection.
Finally, we would like to stress that, although supervisor training is important and
necessary, it is equally crucial to offer organizational support for the remediation
process given the unpredictability of clinical contexts and locations in which
supervisors juggle multiple duties (Audétat et al., 2015).
Conclusions
Even though the clinical
Even though the clinical context holds a set of important challenges for teachers context holds a set of
and learners, it represents the most suited environment for the development of important challenges for
clinical reasoning skills. By engaging in an educational reasoning process, teachers and learners, it
clinical teachers can identify their learners’ strengths and difficulties and represents the most suited
implement remediation strategies in the course of daily supervisions. environment for the
development of clinical
reasoning skills
Becoming an effective clinical supervisor is a developmental process (Higgs &
Mc Allister, 2006); clinical teachers need to be supported by ongoing faculty
development to strengthen their educational competencies with respect to
clinical reasoning characteristics, clinical supervision, as well as the pedagogical
diagnosis and remediation development processes. That would help them feel
more confident and experience more satisfaction in their teaching role.

We hope this Guide will help clinical supervisors in their task as teachers and
contribute to their educational involvement with clinical learners, especially
those experiencing clinical reasoning difficulties.

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Guide 117
Diagnosis and management of
clinical reasoning difficulties
Part I. Clinical reasoning supervision
and educational diagnosis
page | 43
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