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Teaching Clinical Reasoning 63
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Box 10.1 (continued)
Domain Areas of knowledge, skills, and behaviours
Shared decision-making Demonstrate the ability to make decisions with:
Clinical reasoning
concepts
Reproduced with permission from Taylor & Francis Journals, www.tandfonline.com Cooper N, Bartlett M, Gay S et al. (2021). Consensus statement on the
content of clinical reasoning curricula in undergraduate medical education, Medical Teacher; 43:2: 152–159.
• Patients and carers
•
Clinical teams
Guidelines, scores, and decision aids
•
•
Evidence-based medicine applied to the patient’s circumstances
Professional values and behaviours that support decision-making
•
Demonstrate an understanding of:
• Clinical reasoning theories (e.g., script, dual process)
•
How clinical reasoning ability develops
The role of clinical reasoning in safe and effective care for patients
•
•
Cognitive errors
Other factors that may impair the clinical reasoning process/outcome
•
Key Concepts in Teaching Clinical
Reasoning
In a review of the literature on teaching clinical reasoning,
Schmidt and Mamede found that educational approaches aimed
at teaching the general thinking processes involved in clinical
decision-making were largely ineffective, whereas teaching strategies aimed at building knowledge and understanding led to
improvements. They stated, ‘General reasoning strategies do not
exist separately from knowledge about a particular disease. It is
therefore pointless to teach them in isolation.’ [4] The exception
to this is reflection during decision-making, which has been
found to be the most consistent and precise cognitive intervention
for improving diagnostic decision-making [5]. The impact of
reflection is greatest when the case is more complex relative to the
learner. Most studies involved participants being instructed to
reflect. Examples included encouraging participants to ask themselves questions like, ‘What’s the evidence for this?’ and ‘What else
could it be?’ or listing findings that were compatible or not compatible with each differential diagnosis. Reflection during diagnostic decision-making not only appears to increase diagnostic
accuracy, but also fosters the learning of clinical knowledge [6].
Schmidt and Mamede’s findings explain why some strategies
are more effective than others in improving clinical reasoning
ability. But before describing teaching strategies in more detail,
it is important to understand three key concepts that are relevant to teaching clinical reasoning. These are 1) memory, 2) how
knowledge is organised in long-term memory, and 3) deliberate
practice.
Memory
Clinical reasoning ability is highly dependent on formal and
experiential knowledge, and this is highly dependent on memory
(see Figure 10.2). Understanding basic concepts about memory is
fundamental to teaching in general, informing how teaching
material and learning tasks can be designed in order to maximise
learning (i.e., remembering). For a full explanation and an excellent resource for teachers, see ‘Understanding how we learn: a
visual guide’ (see further resources).
Figure 10.2 Memory. Sensory memory stores information being processed
by the sense organs for less than a second, just enough to allow it to be
recognised and either discarded, or transferred into working memory.
Working memory stores and manipulates information for a brief period, and
is important in reasoning, comprehension, and learning. It can simultaneously
store and process visual and auditory information, but otherwise has limited
capacity. Long-term memory is thought to have infinite capacity.
Meaningful information is much easier to retain and recall, so
strategies that build understanding are effective in making
learning ‘stick’ and have also been shown to be effective in
teaching clinical reasoning. An example of such a strategy is elaboration, which we discuss in more detail later.
Retrieval practice (i.e., getting learners to bring information to
mind from memory) is another strategy that is not only powerful
in enhancing long-term retention and recall, but it also has a
direct effect on learning. When learners bring information to
mind from memory, they are changing that memory and making
the memory more durable and flexible for future use, including
easier retrieval of related information. Examples of strategies that
utilise retrieval practice include low-stakes quizzing, structured
reflection, and contrastive learning, which we discuss later.
Knowledge Organisation
We know that expertise develops as learners combine (or ‘chunk’)
simple ideas into more complex ones called schemas or scripts.
Consider the idea of sepsis, for example. In medicine, an ‘illness
script’ is a set of interconnected concepts, developed through
formal and experiential learning, that allows individuals to recognise patterns, check for consistencies or inconsistencies, and
64 ABC of Clinical Reasoning
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make predictions about how a particular disease or problem is
likely to progress. Humans have limited working memory when
it comes to handling new information. Working memory can
only hold around seven elements of information at any one time
and actively process two to four elements simultaneously. This
limitation does not apply, however, to knowledge that is already
stored in long-term memory as schemas. Even a highly complex
schema, such as an illness script, can be dealt with as one element
in working memory. Authors Lubarsky et al. point out that,
‘Studies of expertise development in medicine have consistently
shown that those considered to be experts are distinguished not
by their superior problem-solving skills, nor by their enhanced
capacity for memory retrieval, but by the content and organisation of their knowledge base – that is, by the set of individualised
scripts they have acquired through learning and experience’ [7]
(see Figure 10.3).
Certain teaching strategies can facilitate script formation by
using script-based teaching techniques. Examples include elaboration, structured reflection, script-based questioning, and practice with as many cases as possible in as many different contexts
as possible.
Deliberate Practice
However, while practice (i.e., experience) is required to develop
expertise, Ericsson showed that even extensive experience in a
domain does not invariably lead to expert levels of achievement [8].
Something else is required – what he called ‘deliberate practice’.
Deliberate practice in clinical education settings means that
learners are engaged in difficult, goal-orientated work, supervised
by teachers, who provide feedback and correction, under conditions of high achievement expectations, with revision and
improvement [9]. Deliberate practice involves tasks that stretch,
getting outside of one’s comfort zone, repeated practice with
coaching and feedback, and the full co-operation and active
participation of the learner in the learning process. This requires
a safe learning environment, where mistakes are understood by
everyone as an important contributor to learning.
How to Teach
Teaching is making specific interventions to help people learn. It
is not the same as explaining things (although it may involve
that). Many of the strategies that have been shown to be effective
in developing clinical reasoning ability involve the learner doing a
lot of the work. This is because the cognitive effort involved is an
important factor in developing understanding, getting knowledge
into long-term memory, and building illness scripts.
Elaboration
Elaboration is one of the best ways to increase learning. It is
thought to encourage organisation, or the connecting and integrating of ideas. It aids deeper processing and therefore remembering. In education, there are three specific techniques used for
elaboration: self-explanation, using concrete examples to explain
abstract ideas, and dual coding.
Self-Explanation
Self-explanation involves learners explaining the steps they are
taking out loud while solving a problem. Generating self-explanations while diagnosing a set of clinical cases, even without
feedback, results in better diagnostic performance [10]. The
benefit of self-explanation increases when the case is more complex. ‘Prepare to teach’ is another method of self-explanation: in
order to teach a topic, you need to explain it to yourself first. Selfexplanation has been studied in education – it outperforms explanation by the teacher, probably because when effortfully retrieving
relevant previously learned information from memory and elaborating it with relevant new information, meaningful associations
are formed.
Figure 10.3 An example of illness scripts – which is the cat and which is the
dog? (Leunert/Pixabay). Imagine ‘cat’ and ‘dog’ are diagnoses. In fact, they
are very similar: both have fur, both have four legs, both have wet noses,
both have whiskers and pointy ears, and both spend a lot of time sleeping.
To a novice, telling the difference is difficult. They may pay attention to
irrelevant details, such as the dog’s collar. But to an expert the diagnosis is
easy. Years of formal study and experience has resulted in rich cat and dog
scripts – what they look like and how they behave – so one can easily be
distinguished from the other.
Concrete Examples
The problem is that humans are not very good at remembering
information about abstract concepts (e.g., ‘partial seizures’) and
are much better at remembering concrete examples. However, it is
important to use as many examples as possible, otherwise learners
will remember the surface details of the example, which is not as
important as remembering the abstract concept itself. If the
examples have different surface details, this is especially helpful.
Dual Coding
Dual coding is the third technique that can be used for elaboration. This involves combining visual and verbal information.
Information is processed in working memory via a visual channel
and an auditory channel. Simultaneously presenting related
information using both these channels leads to processing of
more information (see Figure 10.4). For a full explanation and an
excellent resource for teachers, see ‘Sweller’s cognitive load theory
in action’ (see further resources).
An example of dual coding is using concept maps, which can
be used in teaching or personal study. Concept maps are used
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Retrieval Practice
Retrieval practice is simple – it involves getting learners to
remember something before being told the answer. This could
involve low-stakes quizzing, being asked to solve a problem before
being told the answer, or any activity that involves recalling previously learned information from memory with little or no support.
Every time the information is retrieved, the memory is changed,
making it more durable and more flexible for future use. So
retrieval practice is not just about memorising information, it also
helps to promote meaningful learning.
Figure 10.4 Dual coding: presenting related information using both the
visual and auditory channel leads to processing of more information. For
example, a diagram of the heart is accompanied by a verbal explanation of
the cardiac cycle.
The problem is that many people do not understand the
difference between performance and learning. Performance is
what we observe during instruction or training. Learning is a more
or less permanent change in knowledge or understanding and is
the goal of instruction. The best Olympic figure skaters are the
ones who fall over the most during training. So when teaching
clinical reasoning, teachers may need to explain why they are
Seizure
Provoked
using certain strategies and why mistakes are not only okay, but are
in fact necessary and powerful for learning and improvement.
Due to acute
illness
Part of
epilepsy?
Script-based Teaching
As well the different forms of elaboration, structured reflection
and script-based questioning are examples of script-based teaching
[7]. In structured reflection, teachers can ask learners to list findings compatible or not compatible with each differential diagnosis.
Script-based questioning includes things like, ‘How would it
Generalised idiopathic
(young people with
normal brains)
Tonic-clonic
Absences
Myoclonic jerks
Focal/symptomatic
(all ages, most common)
Tonic-clonic
Focal (‘partial’) seizures
change your diagnosis if the patient had a history of fever with this
headache?’ This type of contrastive learning helps learners distinguish between similar presentations of different diseases.
Practice with Cases
Finally, learners need to practice with as many cases as possible in
Simple partial Complex partial
as many different contexts as possible to build illness scripts.
These could be paper cases, simulated scenarios, or using online
ANY seizure type can be in status
Figure 10.5 An example of a concept map (or tree) used in teaching, to
facilitate knowledge organisation in what can appear to be a complex
clinical topic.
case-based learning platforms, but ultimately must include real
exposure to real patients so that problems can be recognised and
represented by learners, not simply presented by the teacher (see
Chapter 4). There are two important caveats in case-based
learning: the first is that deliberate practice principles should be
utilised, as described above. The second is that a whole case
widely by high-performing medical students. In Figure 10.5, different types of seizures are explained. The teacher (or learner) can
elaborate using concrete examples by asking, ‘Can you give as
many examples as possible of how different partial seizures can
present?’
Using techniques such as concept maps relates to knowledge
organisation in another way. Learners struggle to apply knowledge
gained in one context to solving problems in another. Teaching
using a problem-orientated approach helps to overcome this. For
example, instead of teaching generally about syncope, teach an
approach to syncope using a diagram (see Figure 10.6), while
teaching the basic science and relevant clinical explanations
underpinning it, using lots of concrete examples. Then get
learners to use the same approach but with different types of
patients and different types of syncope, either using paper/online
or real cases, with corrective feedback.
approach is recommended for novices who have yet to establish
their illness scripts. A whole case approach is when all the
information related to the case is available to the learners – they
do not have to remember transient information that pops up on a
slide, or is verbalised, and then is no longer available to them.
Having all the information available decreases the load on
working memory, freeing it up to work on the problem, maximising learning. A simple example of a whole case approach is using
handouts or mock clerking documents instead of presenting a
case bit by bit using slides. Depending on the level of the learners
and the content being taught, a ‘whole case’ approach can mean
just the history in its entirety, not necessarily the history, physical
examination, and test results all together.
Feedback is a vital aspect of practicing with cases. For feedback
to be most effective for learning, the goals should be known to both
learners and teacher in advance. Feedback should then provide
66 ABC of Clinical Reasoning
If serious
obvious cause after the initial
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Initial evaluation
• History (including from an eyewitness whenever possible)
• Physical examination
• Lying and standing BP
• 12-lead ECG
Syncope
injury or
acute illness
present, or
not syncope
30-50% of cases will have an
Do not follow
the rest of this
flow chart
evaluation
UNEXPLAINED
SYNCOPE: RED FLAGS
ADMIT
Refer to Cardiology (for in-patient
or out-patient investigations)
Figure 10.6 A problem-oriented approach to syncope.
STRUCTURAL HEART DISEASE
DRIVING ADVICE REQUIRED FOR ALL PATIENTS
cues or reinforcements to learners relating to those goals. It is most
powerful when it addresses faulty interpretations, not a total lack of
understanding. Teachers should ensure they provide feedback on
the processes the learner used to perform the task and not just the
outcome (e.g., the right diagnosis). Process feedback is more powerful than outcome feedback. For a full explanation and an excellent resource for teachers, see Hattie and Timperley’s ‘The power of
feedback’ (see further resources).
A summary of the teaching strategies described here is listed in
Box 10.2.
Obvious diagnosis
(e.g., postural hypotension
due to medication or
vasovagal syncope)
TREAT
No further tests required
NO STRUCTURAL HEART DISEASE
Admission to hospital not
indicated
Single event –
no further
tests needed
Recurrent events
– refer to a
specialist
syncope service
of improving learner attainment are teachers’ content knowledge,
including their ability to understand how learners think about a
subject and identify common misconceptions, and the quality of
instruction, which includes using strategies like the ones described
here, and the use of assessment [11].
However, there are challenges – in particular the challenge of
equipping every clinical teacher with the knowledge and skills
required to teach clinical reasoning. This can be overcome in part
by using a core group of experienced clinician-educators to teach
clinical reasoning concepts and provide training in teaching strategies for other clinical teachers.
Challenges
There is strong evidence that learners must have a deep foundation
of factual knowledge, but they also need to understand facts and
ideas in a conceptual framework, and organise their knowledge in
a way that facilitates retrieval and application. This is why we
need expert teachers. The two factors with the strongest evidence
Creating a Clinical Reasoning Curriculum
While there are several studies that describe the outcomes and challenges of teaching and assessing clinical reasoning, there are very
few descriptions of implementing a clinical reasoning curriculum
in either undergraduate or postgraduate medical education. In this
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Box 10.2 A summary of teaching strategies
Strategy Examples
Elaboration •
Problem-orientated
approach
Retrieval practice •
Script-based teaching •
Practise with cases and
feedback
Self-explanation
Use of concrete examples to explain
•
abstract concepts
• Dual coding
•
Teach basic science and clinical medicine
using a decision tree to organise knowledge
in a problem-orientated way; this increases
the ability to transfer the same knowledge
to different contexts
Any activity that involves effortful recall of
prior learning
• Low-stakes quizzes
Elaboration (all forms)
Structured reflection
•
•
Script-based questioning
Whole case approach is recommended for
•
novices
• Ensure goals are known in advance, and
feedback is given on process as well as
outcome
next section, we describe some of the steps taken by one medical
school to introduce an explicit, longitudinal clinical reasoning curriculum across a five-year undergraduate programme.
Defining Clinical Reasoning
There are several different definitions of clinical reasoning in the
literature, and its definitions continue to be debated [12], so it is
important for a curriculum development team to agree a definition
that is most appropriate for their local context. Is the course an
undergraduate or graduate programme? What are the professional
regulatory requirements? What is the overall purpose of the wider
curriculum? These three questions will help in deciding an agreed
definition that is important in creating a shared understanding
among the team, teachers, and learners (see Box 10.3).
Curriculum Design
In order to integrate a clinical reasoning curriculum into existing
programmes, it is important to apply the basic principles of curriculum design. The first part of this chapter described what
topics to teach (i.e., the syllabus), but a curriculum is everything
that happens in relation to an educational programme – this
includes the organisation of the programme, a description of the
expected methods of teaching and learning, feedback, and
Box 10.3 A definition of clinical reasoning
‘Clinical reasoning is the process by which clinicians collect cues,
process the information, come an understanding of a patient
problem or situation, plan and implement interventions, evaluate
outcomes, and reflect on and learn from the process.’
From Manchester Medical School, UK
assessment. For healthcare professions education, curricula are
also based on the needs of society and the required professional
characteristics of clinicians. A clinical reasoning curriculum
should therefore be created using established curriculum
development frameworks. Singh et al. [13] adapted Thomas’ curriculum development model for medical education [14] to
develop their clinical reasoning curriculum; however, several
models exist which can be condensed into five steps:
Complete a needs assessment
1.
Set goals and objectives
2.
Identify resources
3.
Determine key educational strategies
4.
Gather evaluation and feedback on the outcomes
5.
It is also important to get good engagement and support from
across all relevant organisations and departments (both academic
and clinical) with the formation of a dedicated group of carefully
selected people to oversee and drive implementation.
Teaching, Learning, and Assessment
If learners are to engage successfully in a clinical reasoning curriculum then intended learning outcomes related to the topics in a
clinical reasoning syllabus are required. Intended learning outcomes are what the learner will have acquired or be able to do by
the end of their studies. They are written from the learners’ perspective and should be measurable, achievable, and assessable – for
example, ‘Be able to produce an accurate problem representation
using semantic qualifiers and precise medical terms.’ Intended
learning outcomes not only make clear to learners what they need
to be able to achieve, but also guide teachers and learning activities
across the curriculum.
There are several theories that underpin the development of
clinical reasoning in learners. Examples include cognitive load
theory (see further resources), script theory [7], and deliberate
practice theory [8]. These can be integrated into the design of
teaching and learning activities, but it is vital to make them
explicit to learners so they understand why certain activities are
important. Concepts such as dual process theory are also useful
for teachers and learners to help both understand and explain
how experienced clinicians ‘get’ to a diagnosis. The clinical
reasoning cycle [15] is one model that can be adopted to help
learners break things down into manageable steps. The concept of
a cycle aligns with the idea of clinical reasoning as a process for
novices. The Manchester Clinical Reasoning Tool, illustrated in
Figure 10.7, is another.
Any clinical reasoning curriculum has to be spiral in nature,
that is, once topics have initially been learned, they are then continually revisited with increasing levels of difficulty throughout
training and clinical practice [16]. An effective spiral curriculum
thus ‘scaffolds’ learning from high instructional support on low
complexity, low fidelity (unrealistic) tasks through to minimal
support on high complexity, high fidelity (realistic) tasks.
Approaching graduation, students should work as part of a clinical
team and make decisions in real clinical environments, with
supervision and feedback, which is essential for developing their
clinical reasoning ability. An example spiral curriculum for
clinical reasoning is shown in Figure 10.8.
68 ABC of Clinical Reasoning
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Figure 10.7 The Manchester Clinical Reasoning Tool. Reproduced with permission from Manchester Medical School, UK.
clinical reasoning assessment methods, see further resources at the
end of this chapter.
Evolution or Revolution?
A distinct advantage of a clinical reasoning curriculum is the
ability to achieve its goals through realigning an existing syllabus and its teaching and learning materials. It does not require
additional curriculum time, nor a complete programme redesign, rather an approach to teaching and learning. Teaching
activities are adjusted to emphasise not just what needs to be
learned, but also why it is relevant to the patient in question and
how one’s decisions might change in different contexts. Similarly,
an assessment programme should be re-framed to assess more
than knowledge recall, with learners required to demonstrate
Figure 10.8 A spiral curriculum for clinical reasoning.
evidence of application of knowledge and justification of their
decisions.
Assessment methods should map against the intended learning
outcomes in any clinical reasoning curriculum. Assessments should
include both summative and formative ones, with workplace-based
assessments supporting the latter. For further information on
Finally, a clinical reasoning curriculum will not be successful
without a systematic faculty development plan that equips every
clinical teacher with the knowledge and skills required to teach
clinical reasoning. Addressing this challenge requires cross-
Teaching Clinical Reasoning 69
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organisational co-ordination and collaboration between academic
and healthcare organisations and dedicated time for faculty
development activities.
Summary
There is a growing consensus that medical schools and postgraduate training programmes should teach clinical reasoning in a
way that is explicitly integrated into courses throughout each year
of the programme, adopting a systematic approach consistent
with current evidence. A number of theories from diverse fields
have informed research on clinical reasoning, shedding light
on what should be taught and how. Effective teaching can be
achieved through curriculum re-design and a systematic faculty
development programme. Stand-alone modules designed to teach
clinical reasoning skills are unlikely to be successful because such
skills cannot be taught separately from content knowledge –
clinical reasoning should be explicitly integrated into courses
throughout undergraduate and postgraduate medical training in
a spiral fashion. Finally, assessment programmes should be reframed to support the emphasis on clinical reasoning ability
beyond knowledge recall.
References
1. Graber ML, Franklin N and Gordon R. (2005). Diagnostic error in
internal medicine. Archives of Internal Medicine; 165(13): 1493–1499.
2. Rencic J, Trowbridge RL, Fagan M et al. (2017). Clinical reasoning education at US medical schools: results from a national survey of internal
medicine clerkship directors. Journal of General Internal Medicine; 32(11):
1242–1246.
3.
Cooper N, Bartlett M, Gay S et al. On behalf of the UK Clinical Reasoning
in Medical Education (CReME) consensus statement group. (2021).
Consensus statement on the content of clinical reasoning curricula in
undergraduate medical education. Medical Teacher; 43(2): 152–159.
Schmidt HG and Mamede S. (2015). How to improve the teaching of
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clinical reasoning: a narrative review and a proposal. Medical Education;
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5. Prakash S, Sladek RM and Schuwirth L. (2019). Interventions to improve
diagnostic decision making: a systematic review and meta-analysis on
reflective strategies. Medical Education; 41(5): 517–524.
6. Mamede S, Van Gog T, Moura AS et al. (2012). Reflection as a strategy to
foster medical students’ acquisition of diagnostic competence. Medical
Education; 46(5): 464–472.
Lubarsky S, Dory V, Audetat V et al. (2015). Using script theory to culti-
7.
vate illness script formation and clinical reasoning in health professions
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8. Ericsson A. The influence of experience and deliberate practice on the
development of superior expert performance. In: Ericsson KA, Charness
N, Feltovich PJ, and Hoffman RR (Eds). The Cambridge Handbook of
Expertise and Expert Performance. Cambridge: Cambridge University
Press, 2006. pp 685–705.
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McGaghie W and Kristopaitis T. Deliberate practice and mastery learning:
origins of expert medical performance. In: Cleland J and Durning SJ
(Eds). Researching medical education. Oxford: Wiley-Blackwell, 2015.
Chamberland M, St-Onge C, Setrakian J et al. (2011). The influence of
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medical students’ self-explanations on diagnostic performance. Medical
Education; 45(7): 688–695.
Sutton Trust. What makes great teaching? Review of the underpinning
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research, 2014. https://www.suttontrust.com/our-research/great-teaching
(accessed April 2022).
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Young M, Thomas A, Lubarsky S et al. (2018). Drawing boundaries: the
difficulty in defining clinical reasoning. Academic Medicine; 93(7):
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Singh M, Collins L, Farrington R et al. (2022). From principles to
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practice: embedding clinical reasoning as a longitudinal curriculum
theme in a medical school programme. Diagnosis; 9(2): 184–194.
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Further Resources
1. Gooding HC, Mann K and Armstrong E. (2017). Twelve tips for applying
the science of learning to health professions education. Medical Teacher;
39(1): 26–31.
2. Trowbridge RL, Rencic JJ and Durning SJ (Eds). Teaching clinical reasoning.
Philadelphia: American College of Physicians, 2015.
3. Weinstein Y and Sumeracki M. Understanding how we learn: a visual guide.
Oxford: Routledge, 2018.
Lovell O. Sweller’s cognitive load theory in action. Melton: John Catt
4.
Educational, 2020.
5.
Hattie J and Timperley H. (2007). The power of feedback. Review of
Educational Research; 77(1): 81–112.
Daniel M, Rencic J and Durning SJ. (2019). Clinical reasoning assessment
6.
methods: a scoping review and practical guidance. Academic Medicine;
94(6): 902–912.
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Index
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Note: Page numbers for figures are in italics, tables are in bold.
abductive reasoning
absolute risk 31–32, 32
accidents, Swiss cheese model
active consciousness
affective biases
alcohol dependence/intoxication
algorithms
analytic decision-making
anchoring
APGAR Score
ascertainment bias
associated symptoms
attribution errors
Augenblick diagnosis
automating/automation of knowledge
availability biases
30, 38
42–44, 44, 55, 55, 57
36
49, 49
54
55, 57–58, 58
30, 50
35–39, 42–43
56, 56
44, 55, 57
9–11
44
55, 55
43, 44, 55
base rate neglect 44
Bayes’ Theorem 20–21, 20
belief/probability biases
41–46
bias
affective
55, 57–58, 58
ascertainment
availability
belief/probability
blind spot
case histories
cognitive
commission
confirmation
debiasing
decision-making
heuristics
judgement and decision-making
memory
metacognition
outcome
overconfidence
situational vulnerability to
social
status quo
Bird’s triangle
blind spot bias
body position, effects on test results
brutish automatism
44
57
37, 41–46, 53–59
53–58, 54
41, 41, 45
43
44, 48–49, 55, 56
43
54, 56–57
43
44, 55, 57
43
42
44
43, 44, 53, 55, 57
41–46, 53, 55, 57–58
53, 55, 57–58
41–46, 45, 53–59
43, 44, 57
57
49, 49
57
18
54, 54
CAGE Questionnaire 30
Calgary-Cambridge model 8, 8
case-based teaching/training in clinical
reasoning 65–66, 67
caveats
55, 56
55, 56
checklists
chest pain history
chunking of knowledge
clinical assessments
clinical guidelines
8–11, 8, 11
4, 63–64
30, 33
29–33, 29
4
clinical prediction rules
clinical reasoning
definitions 1–2, 67, 67
expertise development
history and examination
importance of
models
perspectives
coaching
cognition, situated
cognitive apprenticeship
cognitive biases
case histories
expert intuition and
types
cognitive debiasing
characteristics of
newly evolving strategies
overall challenges of
situational vulnerability
cognitive dispositions to respond see
cognitive errors
cognitive forcing strategies
cognitive miser functions
cognitive overload
cognitive psychology
cognitive skills, failures in
cohort studies
commission bias
communication skills
decision-making
team work
computed tomography (CT)
concept maps (trees)
conditional probability
confirmation bias
confirmation of hypothesis
confusion matrices
controlled trials
critical differences (CD)
critical thinking
CT (computed tomography)
debiasing strategies 53–58, 54
decision aids 29–33, 33
decision fatigue
decision-making
biases 41–46, 53, 55, 57–58
clinical guidelines
clinical reasoning models
errors in
evidence-based medicine
intuition
problem-solving
scores
55, 56
3–4, 39
2–3
35–40
35–36, 36
3, 27, 40, 46, 61, 64
32–33, 47–48
45
37, 41–46, 53–59
42
45–46, 45
43–46, 43, 44
53–58, 54
58
57–58
cognitive biases
2, 2, 53, 63
37–38
38, 50, 57, 57
1, 35
38–39
30
44
31–32, 31
50–51, 51
64–65, 65
20–21, 20
43, 44, 53, 55, 57
21–22, 21–22
30
18–19, 19
35–36, 43, 45–46
4, 38, 43, 50, 57
29–33
29–30, 36–39, 41–46, 53–58
36–39, 41, 45–46, 53
23, 25–27, 27
29–33
1–5, 5
56–57
57
55–57, 55–56
19, 21, 42, 50
43, 44, 57
19, 21, 42, 50
35–40
30–31, 31
shared
27, 29–33
situated cognition
deliberate practice
diagnostic errors
46–47, 47, 61–62
diagnostic momentum 42–44, 42, 44
diagnostic reasoning
diagnostic tests
Bayes’ Theorem
conditional probability
disease prevalence in a population
21–22
influences on results 17–19, 17, 19
misinterpretation
normal values
operating characteristics
predictive analytics
probability and
sensitivity and specificity
thresholds
differential diagnosis
D-dimer tests
disconfirmation of hypothesis
disease prevalence in a population
distributed cognition
dual coding
dual process theories
46–48, 50, 53–58
32–33
64
2–7, 27, 35–38, 36, 41–42,
27, 36, 36, 38
17–22
20–21, 20
20–21, 20
17, 21–22,
18–19
17–21, 17, 20
17, 19–20, 20
17, 21–22, 21–22
20–21, 20
17, 19–21, 19, 20
22
5, 55, 55
18, 21, 30
43, 44, 57
17, 21–22, 21
47, 48
64–65, 65
36–39, 36, 37, 38, 41–43,
echocardiography 11, 11
ecological psychology 47, 48
electrocardiography
EMB (evidence-based medicine)
55–56, 55
embodied cognition
ergonomics
error chains
errors
attribution 44
cognitive
in decision-making
diagnostic
in healthcare
misinterpretation in diagnostic tests
misunderstandings in
no fault
posterior probability
situativity theories
systematic
in thinking
2
types
evidence-based history and examination
7–15, 55
cardiovascular pain 8–9, 9
combining process and content
diagnosis from
12, 18–19, 25, 30, 42
30–31, 31,
47–48, 47
47–52, 61
49, 51
2, 2, 53, 63
29–30, 36–39, 41–46, 53–58
2–7, 27, 35–38, 36, 41–42, 47, 61–62
48–50
37
2
44
48–49
2, 41–46
38–40
7–12
1–5, 5, 7–15
18–19
1–5, 5,
ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
72 Index
https://t.me/medicina_free
future of 14
interpreting features
key symptoms
likelihood ratios
limitations of
natural history and context
physical examinations
7, 8, 11, 14–15
reflection
skill development in teaching
evidence-based medicine (EBM)
55–56, 55
examination see evidence-based history and
examination
executive override
experience
expert intuition
expertise development
experts vs novices, problem solving
26–27, 37–40
9–12
7–12, 8
13–14, 13
14
10–12
12
14–15, 15
30–31, 31,
54
45–46, 45
3–4, 39
25
false positives and negatives 17, 19–21, 20, 39
fatigue, adverse effects of 4, 38, 43, 50, 57
27, 46, 61, 64–68
feedback
fire safety training
forcing strategies
forward thinking
framing effect
51–52
55–57, 55–56
25, 25
44
gambler’s fallacy 44
guidelines, clinical 29–33
heuristics 37–38, 41, 41, 45, 53, 56
hindsight bias 44
human factors
embedding in healthcare 51–52, 51
performance limitations
situativity/training
hypothesis
confirmation/disconfirmation of 43, 44, 57
generation
1
49–50, 50
47–52, 61
I-PASS mnemonic 56
illness, adverse effects of 50
illness scripts
imaging stress tests
inductive reasoning
integrated case learing
Interheart study
intuitive decision-making
iterative diagnosis
judgement and decision-making (JDM)
24, 37–38, 63–65, 64, 67
21–22, 22
36
11
26
53, 55, 57–58
bias
5, 61, 67, 69
36–39, 41, 45–46, 53
knowledge chunking 4, 63–64
language, problem representation
latent conditions 49, 49
likelihood ratios (LR)
limitations of human performance
7, 9–10, 13–15, 13, 45, 62
24, 24
49–50, 50
management plan formulation 24, 26–27, 31, 62
Manchester Clinical Reasoning Tool 67, 68
medicalising of patients problems
memory
63
memory biases
metacognition
mindware
mnemonics
models of clinical reasoning
43
3–4, 35, 38–46, 45, 53–59
37–39, 38, 53–54, 54, 57–58, 58
55, 56, 56
2
35–40
MUDPILES mnemonics
multiple alternative bias
56, 56
44
natural history of disease 10–12
New York Heart Association Functional
Classification of Heart Failure
night work, adverse effects of
no fault errors
nudging strategies
2
57
11, 11
50
omission bias 44
order effects 44
Ottawa ankle rules
outcome bias
overconfidence biases
overdiagnosis
56
44, 48–49, 55, 56
43, 44, 57
2–3, 2
passive consciousness 54
patient-centred differential diagnosis 5
Patient Decision Aids (PDA)
peritonsillar abscess (quinsy)
55, 56
pitfalls
posterior probability errors
predictive analytics
pregnancy, effect of, on test results
premature closure
probabilistic reasoning
probability
conditional 20–21, 20
pre-test (clinical)
problem representation
problem-solving
classroom vs clinical environments
cycles
decision-making
experts vs novices
management reasoning
reflection
role-modelling
syncope
teaching/training in clinical reasoning
67
uncertainty management 25–27
prolongation of life
psych-out error
44
23–27
23–27
26–27
26–27, 27
65–66, 66
44
32–33, 33
11–12, 12
20, 44
17, 21–22, 21, 55, 56
18
3, 20–22, 22, 37
11–13, 12, 13–14, 20–22, 20, 22
3, 23–26, 43, 67
25
23, 25–27, 27
25, 25
27
65–67, 66,
32, 32
receiver operating characteristics (ROC) 19–20, 20
red flags 12, 51, 55, 56, 66
reflection
evidence-based history and examination 7, 8, 11,
14–15
metacognition
models of clinical reasoning
problem-solving
teaching/training in clinical reasoning
representativeness
retrieval practice
risk
absolute
hormone replacement therapy
ROC (receiver operating characteristics)
role-modelling
Rome 4 Criteria for irritable bowel syndrome
root causes
rules out the worst-case scenario (ROWS)
SBAR (situation, background, assessment,
recommendation) communication system
51, 51
53–57
35–38
26–27
63–65, 67
44
65, 67
31–32, 32
32, 32
19–20, 20
26–27, 27
30
49, 49
55, 56
27, 29–33, 51, 56, 63
scores
screening tools
script-based teaching
search satisficing
self-explanation
semantic competence
semantic qualifiers
sensitivity and specificity
shared decision-making
situated cognition
situational vulnerability to bias
situation awareness
situativity
sleep deprivation
social biases
spiral curriculum
spot diagnosis
STARD criteria
status quo biases
stereotyping
stress, adverse effects of
Sutton’s slip
Swiss cheese model of accident causation
systematic errors
systematic reviews
30
63–65, 64, 67
42, 44
64
24
24–26, 24
17, 19–21, 19, 20
27, 29–33
32–33, 47–48, 47
57
49–50, 49
47–52, 47
4, 38, 43, 50, 57
43
67–68, 68
55
14
54, 56–57
37, 57
50, 55
44
49, 49
2, 41–46
2, 5, 7–9, 17, 29, 37–39, 55, 61
teaching/training in clinical reasoning 61–69
case-based 65–66, 67
challenges in
curriculum creation/design
educational theories
elaboration
illness scripts
key concepts
knowledge organisation
memory
problem solving
reflection
retrieval practice
spiral curriculum
syllabus
techniques in
team work, communication skills
therapeutic thresholds
thresholds
time outs
triage-cueing
tri-process theories
two-minds hypothesis/dual process theories
36, 37, 38, 41–43, 46–48, 50, 53–58
type 1 thinking
type 2 thinking
66
66–69
63–64
64–65, 65, 67
63–65, 64, 67
63–64
63–64
63
65–67, 66, 67
63–65, 67
65, 67
67–68, 68
61–63, 62–63
64–66
50–51, 51
22
22
51
44
37–39, 38
36–39,
36–39, 36, 37, 38, 41, 46–48, 53–58
36–39, 36, 37, 38, 41, 43, 50, 53–54
ultrasound 14, 18–19, 30, 62
uncertainty management 25–27
universal model of diagnostic reasoning
unpacking principle
44
36, 36
values based practice 17–22, 29, 32–33, 36
visceral bias 44
Wells’ criteria for pulmonary embolus 56
Wells’ Score for DVT 30
whole person care
WHO safe surgery checklists
working diagnosis
working memory
workloads, adverse effects of
worst-case scenarios
5
49, 51
1, 38
63–64
2, 4, 50
55, 56
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