This reflection has demonstrated how clinical reasoning was taught and learned through bedside demonstration, case presentation with reflected discussion, and case selection for case report writing. The ultimate goals of this reflection will include improving students’ clinical competency, reducing theory-practice gap, consolidating the learning of clinical reasoning, and understanding the essential preparations to become a qualified intern.
Bedside clinical skill demonstration
Bedside clinical teaching is known to be difficult to implement because it is obviously resource intensive with many factors including increasing workload and need for efficiency in clinical departments, service provision, and patient care, which may take priority over teaching when resources are limited. 6 There may be factors specific to the learner, teacher, patient, environment, and ethical issues. However, bedside teaching has been well documented to provide benefits in terms of role modelling, staff recruitment and retention, formative assessment of learner’s performance, continuing professional development of the teacher and quality improvement, both clinically and educationally. The elective students had been provided with formal bedside teaching including pre-selected cases, two dedicated tutors, and inpatient availability of all departments. Recent evidence has demonstrated that formal bedside teaching is effective if organised with adequate staffing to quarantine the teachers or tutors, and concentrating on case presentation, case selection and clinical reasoning discussion.6 Clinical reasoning and knowledge were perceived to be most important, exerting good patient outcome through comprehensive assessment with “SNAPPS” and “PICO” frameworks leading to prompt decision making. Bedside demonstration has laid the foundation for the eventual case presentation and selection for writing case report and integrate the clinical reasoning into the learning objectives. Bedside demonstrations have also been shown to be useful for providing an overview of the complete set of clinical skills to be learned, especially when an overview is provided early in the learning process of preclinical and transitional clinical years, as evident in this elective of how clinical reasoning skills were taught and learned.7,8,9
Another salient point from the reflection is case presentation and selection for case report writing for journal submission. It has been proven to be an expected outcome of this elective in enhancing clinical reasoning skill. Case presentation has always been one of the most valuable and evidence-based tools of medical education for presenting challenging medical cases to medical students, junior doctors and even consultant physicians.10 Clinical learning during medical school is mainly case-based.11 Most of the important educational objectives that case reports introduce include enhancing awareness of rare disorders to facilitate diagnosis, clarifying new aspects on disease’s aetiology, clarifying misunderstood treatment response, and describing how to avoid future mistakes.12 During this elective, students have been able to select the cases from their many bedside demonstrations and recognize the answerable clinical question, and then to find current best evidence to answer this question by performing a thorough and effective literature review. During the literature review, students critically analysed the medical literature and chose the appropriate reference to support the case. By writing a case report, students gain experience in literature review and medical writing as well as experiencing the steps of evidence-based medicine, which consists of formulating a clinical question, finding the best evidence, critically appraising the evidence, and applying the evidence to the patient. Each of the six students has already had one case report published/accepted for publication in Australian Doctor, which is the most read clinical journals among clinicians. Another case for each student is either published or editorial review in BMJ Case Report. Even if the manuscript does not ultimately get published, the review of the case literature carries educational value. A case report including evaluating a patient’s medical history, performing a physical examination, considering various differential diagnosis, selecting a treatment plan, and considering various side effects and outcomes of treatments provide an educational platform for students’ clinical reasoning learning, albeit will not have as much potential impact on clinical practice as randomized controlled trials or other research.13 However, well-written and appropriately structured case reports with meticulous attention to the very minute details will contribute to the medical literature and can still enrich our knowledge in today’s evidence-based medical education. The case reports written by the students from this elective certainly reflect this important educational message despite the fact that they are inexperienced and novice authors.
In line with the students’ reflection, case reports provide the opportunity to engage in simpler scientific writing before pursuing more advanced forms of medical writing. Case reports provide an early opportunity to publish outside formal scientific research projects.14,15 They engage a pertinent clinical question, and give students practice in research and assessment skills that forge competent clinicians.16 Another recent study identified five educational benefits of case reports for medical students including developing observation and pattern recognition skills, developing hypothesis-generating skills, understanding patient-centered care, writing skills and rhetorical versatility, and the case report as a “mini-thesis”.17 Such benefits have been observed in the clinical placement after the elective, when students learn self-criticism, hone hypothesis-generating skills through case report writing and answer editors’ arguments and criticisms by analysing how to implement the most up-to-date research evidence into clinical practice. Implementing updated research evidence into clinical practice is the fundamental element of ongoing training for a competent clinician, as evidenced by a recent study.18 In this study, graduate trainees stated that they acquired most of their competences of implementing research into practice by on-the-job experience of clinical case management, self-study and ongoing professional education. Case reporting writing with this elective has certainly laid the foundation of ongoing training for medical students in terms of evidence-implementation skills in clinical practice, consequently fostering the lifelong learning of a competent clinician.
This elective highlighted two other educational points including students’ longitudinal follow-up reflections at different time-points and the integration of bedside demonstration and case report writing into clinical reasoning. Clinical reasoning has been defined as a way of critical thinking and decision making in clinical practice19, requiring clinicians to analyse a cluster of clinical presentations, create a list of differential diagnosis and develop a management strategy.20 The process of clinical reasoning is undertaken by all clinicians, usually automatically, similar to the “SNAPPS” and “PICO” approaches used in this elective, and is the cognitive process that underlies differential diagnosis and management of clinical presentations.21 The dual cognitive process from cognitive psychology theory 22,23,24 showed that the reasoning process consists of System 1 and System 2 processes.25,26 System 1 is an intuitive thinking process, which is unconscious and quick but at the same time it is prone to various cognitive biases27, while System 2 is an analytical thinking process, which is deliberate and slow28 to reduce System 1 biases physicians use instead with System 2 process that assesses whether a diagnosis made using the intuitive process is correct or not by analysing more information.29,30 The combination of System 1 and 2 will certainly ensure the safest outcome of the clinical reasoning process applied by the clinician. Recent research indicated clinical reasoning is fundamental to medical education and practice31 and was one of the most important indicators of competent clinicians. However, clinical reasoning is often regarded as difficult to conceptualise and teach, posing challenges to clinical teachers.32,33 Recent evidence showed motivated clinicians showcasing the pivotal role of clinical reasoning for more efficient teaching and practice in systematic and evidence-based manner, making clinical reasoning being regarded as an art rather than a science.34 This reflection paper has certainly focussed on promoting the above-mentioned medical educational points of clinical reasoning through the students’ reflections during the elective and six months after. CR learned by the students during this elective and after is using system 2 by dissecting the clinical management steps through case report writing. Selecting an appropriate case to report for publication is how system 2 was used in practice. The academic benefits of writing a case report for journal submission will inform curricular development in terms of theoretical study, OSCE exam and clinical placement.
CR learned by the students through bedside demonstration and case report writing during this elective has a similar approach as the Script Concordance Test (SCT) being increasingly used in ongoing postgraduate medical education in CR. Script theory explains how physicians progressively acquire knowledge adapted to their clinical tasks.35,36 The SCT is a tool for assessment of clinical reasoning that is increasingly being used in continuing professional development in medical education.37 SCT is the unique form of clinical assessment based on clinical scenarios designed to measure clinical data interpretation. An expert reference panel, including 10-20 members with different disciplines, are recommended for optimal reliability on the learning outcomes.38 Reflecting on our exchange elective, and students’ reflections in terms of bedside demonstration, case reports and integrated clinical reasoning learning have only two supervisors on the expert reference panel. One would propose that we will gain more learning points for CR if their reflections can be reviewed and discussed by more supervisors from different disciplines. Thus, we can plan our next exchange elective by adopting SCT style with involvement of more supervisors for discussion and feedback from research perspectives. Our case report writing for the students has provided a platform for case-based review of the selected cases to maximise the learning outcome. The highlighted benefit of this collaborative exchange elective is of adequate resources of cases specially for the students to learn on a preorganised teaching ward round. We need to plan multi-specialty feedback sessions at the next exchange elective. During the ensuing clinical placement, they have not only used the “SNAPPS” and “PICO” frameworks but also referred the cases to multiple supervisors for advice to increase the learning input.
Another important aspect of clinical reasoning during the elective is that recent review39 has observed clinical reasoning’s variation with the clinical context influenced by patient factors, doctor factors, and environmental factors. Research about clinical reasoning has tended to focus on the individual, assessing their ability to perform clinical reasoning tasks. This review identifies areas for continued research, including which contexts have a negative or positive impact, and the effect of multiple contexts (cognitive loading) on clinical reasoning. In terms of patient factors, recent study showed 25 physicians videotaped encounters by altering one or more contextual factors including low English proficiency, emotional volatility, incorrect diagnosis suggestion, or atypical presentation. The research team found that participating physicians were more likely to misinterpret key clinical reasoning data if two contextual factors were present. The research team postulated that multiple contextual factors led to increased cognitive load, leading to a negative perception of the clinical situation, consequent mistaken interpretation, and adverse clinical reasoning outcome.40 During our exchange elective, low English proficiency may be one of the major patient factors impacting on the clinical reasoning learning despite our supervisors being shadow as language translators. Another study looked at patient’s disruptive behaviour and diagnostic difficulty of presentation. Diagnostic accuracy was significantly lower for both the difficult patients (p=0.017) and the diagnostically difficult cases (p<0.001), however applying clinical reasoning with critical reflection did improve diagnostic rates (p=0.002).41 The research team repeated the study by investigating why difficult patients reduced diagnostic accuracy by providing cases to 74 physicians including half with ‘difficult patients’ and half with ‘neutral patients’. The study concluded that diagnostic scores were significantly lower for difficult patients (p < 0.01) and participating physicians recalled fewer clinical findings and more behaviour observations from the difficult patients (p < 0.001).42 During our elective, we have come across ‘difficult patients’ with behavioural issues impairing the accuracy of the clinical reasoning process and the initial clinical diagnosis. The eventual positive outcome was reached by the clinical management discussion with the patient and next of kin in a clinical priority way. The students did greatly appreciate their clinical reasoning learning through a difficult patient. Another interesting study looked at patient appearance and the effect on clinical reasoning. Participating physicians were given case-based scenarios with classed patient pictures as ‘poor and dirty’ in appearance or as ‘rich and clean’. There was no significant difference in diagnostic accuracy, however participating physicians reported processing the case more extensively if the patient appeared ‘rich and clean’ (p = 0.04).43
The study has three major limitations. One was that we need to collect feedback or reflections from supervisors at the First Affiliated Hospital, Sun Yat-sen University about the students’ learning during the elective. Further research should focus on feedback from both supervisors and students. A second limitation of this study is that longer term reflections and learning outcome is somewhat disrupted by the COVID-19 lockdown and online curriculum delivery. Students have very limited face-to-face access to patients and cases during the longer-term follow-up. Through further face-to-face follow-up interview with both students and supervisors, clinical reasoning will be even more integrated into their future daily clinical practice with facilitation of career choices and evidence-based care for patients. The third limitation about the study will be lack of adequate consideration of teaching clinical reasoning at real life context, especially patient factors because supervisors in charge have preselected all the cases for a teaching ward round at different disciplines.