Assessing Clinical Reasoning Ability in Fourth-year Medical Students via an Integrative Group History-taking Workshop With an Individual Reasoning Teaching Programme

Background: The most important factor in evaluating a physician’s competence is strong clinical reasoning ability, leading to correct principal diagnoses. The process of clinical reasoning includes history taking, physical examinations, validating medical records, and determining a nal diagnosis. In this study, we designed a teaching programme to evaluate the clinical reasoning competence of fourth-year medical students. Methods: We created ve patient scenarios for our standardised patients, including haemoptysis, abdominal pain, fever, anaemia, and chest pain. A group history-taking workshop with individual reasoning principles was implemented to teach and evaluate students’ abilities to take histories, document key information, and arrive at the most likely diagnosis. Residents were trained to act as teachers, and a post-study questionnaire was employed to evaluate the students’ satisfaction with the training programme. Results: A total of 76 students, ve teachers, and ve standardised patients participated in this clinical reasoning training programme. The average history-taking score was 64%, the average key information number was 7, the average diagnosis number was 1.1, and the average correct diagnosis rate was 38%. Standardised patients presenting with abdominal pain (8.3%) and anaemia (18.2%) had the lowest diagnosis rates. The scenario of anaemia presented the most dicult challenge for students in history taking (3.5/5) and clinical reasoning (3.5/5). The abdominal pain scenario yielded even worse results (history taking: 2.9/5 and clinical reasoning 2.7/5). We found a correlation in the clinical reasoning process between the correct and incorrect most likely diagnosis groups (group history-taking score, p=0.045; key information number, p=0.009 and diagnosis number, p=0.004). The post-study questionnaire results indicated signicant satisfaction with the teaching programme (4.7/5) and the quality of teacher feedback (4.9/5). Conclusions: We concluded that the clinical reasoning skills of fourth-year medical students beneted from this training programme, and the lower correction of the most likely diagnosis rate found with abdominal pain, anaemia, and fever might be due to a system-based teaching programme in fourth-year medical students; cross-system remedial reasoning training is


Introduction
Differential diagnosis is important for clinicians and involves a deeper higher order thinking process about the evaluation of history taking, physical examination, review of laboratory data, and diagnostic images that exceed memorisation, facts, and concepts. 1 The ability to formulate a case-speci c principal diagnosis from the list of possibilities is an important clinical skill because it serves an important role in diagnosis-related group (DRG) codes to assign a patient and healthcare billing. Koenemann et al. reported that clinical case discussions with peer-taught and physician-supervised collaborative learning formats could promote clinical reasoning in medical students. 2 However, we used problem-based learning (PBL) in schools to train the clinical reasoning process for fourth-year medical students using a module system base that could easily restrict students' thinking in the same organ system.
Assessing a medical student's ability concerning differential diagnosis is important; however, there is no consensus on the most effective approaches to evaluate these reasoning skills. Many efforts have been made to develop a valid and reliable measure of clinical reasoning ability, including key feature questions and script concordance tests. [3][4] Simulation-based testing methods have also been developed to meet the need for assessment procedures that are both authentic and well structured. Sutherland et al. allowed students to watch a video trigger and discuss their diagnostic reasoning with an examiner demonstrating that it could be assessed. 5 Fürstenberg et al. developed a clinical reasoning indicators history-taking scale to quantitatively assess clinical reasoning indicators during history taking in undergraduate medical students, 6 which was deemed suitable for the assessment of fourth-year medical students' clinical reasoning ability.
The objective structured clinical examination (OSCE) evaluation has proven to be a reliable and valid method for assessing the six competencies de ned by the Accreditation Council for Graduate Medical Education (ACGME) in surgery. The competencies assessed by a well-constructed OSCE include patient care and medical knowledge as well as skills like data synthesis and the ability to list differential diagnoses. 7 This evaluation method was able to identify signi cant de ciencies in musculoskeletal examination skills and the diagnostic reasoning of fourth-year medical students based on principles of the hypothesis-driven physical examination. 8 Using a group OSCE format makes it possible to assess the individual ability of a large number of students without the usual time and expense needed. 9 As the fourth-year medical students had no clinical reasoning curriculum except PBL training, in this study, we aimed to train their clinical reasoning through a group history-taking workshop with standardised patients using scenarios that mimic clinical conditions and then creating individual students' most likely diagnosis with supporting data to assess their clinical diagnosis ability.

Material And Methods
Problem identi cation and target needs of fourth-year medical students' clinical reasoning ability before clinical practice The curriculum at Mackay Medical College for fourth-year medical students is an integrated eight modules of divided organ systems based on the concise clinically relevant anatomical structure, functions, and behaviours of abnormal and diseased persons, as well as clinical knowledge and skills, including clinical reasoning training. In this systemic module, PBL is implanted and integrated into semesters, and how to assess the students' clinical reasoning ability is our problem and target needs.

Educational objectives and assessment method
Accurate diagnostic reasoning is the fundamental basis for ensuring patient care and safety; thus, the development of diagnostic reasoning is a key component of UGY medical education. We created a group objective structured clinical examination (GOSCE) teaching programme for clinical reasoning at Mackay Medical College which is an elective pre-clerkship education course for fourth-year medical students, with the aim of training assessing students' clinical reasoning ability. To evaluate clinical reasoning ability, Haring et al. developed an observation tool that consists of an 11-item observation rating form and a post encounter rating tool which are both feasible, valid, and reliable to assess students' clinical reasoning skills in clinical practice. 10 They also reported that by observing and assessing clinical reasoning during medical students' history taking, general and speci c phenomena could be used as indicators, including taking control, recognising, and responding to relevant information, specifying symptoms, asking speci c questions that point to pathophysiological thinking, placing questions in a logical order, checking agreement with patients, summarising, and body language. 11 We modi ed the methods that were used for the GOSCE workshop to include history taking and clinical reasoning each time we let four to ve students visit a standardised patient with a clinical case to collect enough data, and then individually write down key information and make a correct differential diagnosis. For assessment of clinical reasoning, and to train their principal diagnosis ability, students were asked to list 15 items of key information for differential diagnoses and list the three most likely diagnoses, including the rst.

Study setting of the GOSCE workshop
Five R1 residents of internal medicine were recruited as teaching faculty in Mackay Memorial Hospital and requested to recognise the educational content and assess the trainees' GOSCE performance and provide immediate feedback. We created ve clinical scenarios: haemoptysis, abdominal pain, fever, anaemia, and chest pain. The participants were divided into small groups consisting of four to ve trainees per team. During the process of GOSCE training, the trainees were expected to perform history taking while gathering clinical information from the standardised patients as well as acknowledge the symptoms and signs of the disease in each scenario. Documenting key words from history taking which requires as many as 15 clues, is also crucial to re ect students' comprehension of a patient's problems. From the patient's information, the trainees were asked to differentiate the diagnosis with associated status and nally reach their most likely diagnosis along with two tentative diagnoses. After GOSCE training, the residents who observed the trainees' performance would be required to share their comments and experiences as well as resolve the trainee's questions. The post-GOSCE questionnaire, which was designed to focus on the satisfaction of the teaching programme, provides an opportunity for the students to review and self-evaluate improvement in clinical reasoning and history taking through the GOSCE programme. The process and learning objectives of the GOSCE training programme for fourthgrade medical students are presented in Table1. Participants and educational content Fourth-grade medical students from Mackay Medical College were enrolled to participate electively in a system-based teaching programme. We also trained ve residents from Mackay Memorial Hospital as teachers to evaluate the trainees' performances based on GOSCE checklists and then provide post-GOSCE feedback. Additionally, ve standardised patients (SPs) who simulated the symptoms and signs of the teaching scenarios were also able to offer post-study remarks.
The GOSCE was designed to provide an opportunity for fourth-grade medical students to perform history taking while gathering clinical information from the SPs as well as acknowledge the symptoms and signs of the disease in each scenario. Five patient scenarios were created as follows: lung cancer presenting with haemoptysis, acute pancreatitis presenting with abdominal pain, acute pyelonephritis presenting with fever, uterine myoma bleeding presenting with anaemia, and acute coronary syndrome presenting with chest pain. The case settings of haemoptysis and chest pain were regarded as system-based thinking logics, whereas those with abdominal pain, fever, and anaemia were multisystem-related. Each scenario highlighted different key words in the patient's history, which could be clues for approaching the nal and tentative diagnosis. The educational strategies for clinical reasoning in each scenario are presented in Table 2. 2. Practice to differ uterus myoma bleeding (the most likely diagnosis), GI tract bleeding and Vitamin B12 de ciency; and then to recommend initial examination such as CBC, MCV, serum iron and ferritin, arrange UGI endoscopy and colonoscopy and consult GYN evaluation.

5.
Chest pain 1. Understanding the presentations including pain location, quality, provocation / palliative factors, region / radiation, timing and associated risk factors.
2. Practice to differ acute coronary syndrome (the most likely diagnosis), pleuritis and pneumothorax; and then to recommend initial examination such as12-lead EKG,cardiac enzyme, CXR and white cell count.

Assessment and feedback
In this study, we focused on four major components: (1) the trainee's GOSCE score, (2) number of key information points, (3) diagnosis numbers and a correct most likely diagnosis rate, and (4) feedback questionnaire. The residents were capable of rating the GOSCE scores of trainees using the checklist, based on observation of the overall performance of each trainee. By collecting the record paper at the end of this teaching programme, we were able to accumulate the number of key information notes documented by each trainee. Meanwhile, from the record paper, we could check the number of diagnoses and whether they were correct or not. Moreover, a post-study questionnaire consisting of the degree of satisfaction with the GOSCE programme, self-evaluation of ability and di culty in clinical reasoning, and history taking was issued. The rubrics and questionnaire were based on a 5-point Likert scale for level of satisfaction.

Statistical analysis
Data from the post-course feedback questionnaire and GOSCE scores are shown as the mean ± standard deviation (SD). The correlations observed between the correct diagnosis group and the incorrect diagnosis group were analysed using Student's t-test. Statistical analyses were performed using SPSS 23.0 statistical package (SPSS, Chicago, IL, USA). All statistical analyses were based on two-sided hypothesis tests with a signi cance level of p < 0.05.

Results
A total of 76 fourth-year medical students participated in this study, and ve Mackay Memorial Hospital R1 residents were recruited as teachers in this clinical reasoning training programme. Regarding the trainees' score in GOSCE with individual reasoning workshop, the best score in the group history-taking scenario was chest pain (76.9%) and the worst was haemoptysis (50.1%), with an average GOSCE history-taking score of 63.5%. The number of key words the medical students were permitted to write down was between ve and eight, and the average number was seven; fever had the best number of key words in the scenarios (8), with the worst for abdominal pain (5). The average diagnosis number in each scenario was one to two; and the correct "the most likely diagnosis" rate ranged from 8.3-87.5%, with chest pain as the best scenario and abdominal pain as the worst (Table 3). Concerning the post-GOSCE and individual reasoning workshop feedback questionnaire, the overall satisfaction degree of the students with GOSCE was about 4.6/5 to 4.8/5. The teacher's feedback and teaching ability were rated from approximately 4.7/5 to 4.9/5. The anaemia score of the participants' self-evaluation in these ve scenarios was the most di cult in history taking (3.4/5) and clinical reasoning (3.5/5). Self-evaluation ability in history taking was worse for the abdominal pain (2.9/5) and anaemia scenarios (2.8/5); the self-evaluation ability in clinical reasoning was also worst in the abdominal pain (2.7/5) and anaemia scenarios (2.8/5) (Table 4). Table 4 Post GOSCE and individual reasoning workshop feedback questionnaire The rubrics and questionnaire were based on the Likert scale for the Level of Satisfaction: & very satis ed (5); satis ed (4); unsure (3); dissatis ed (2); very dissatis ed (1) $ Level of Agreement: strongly agree (5); agree (4); neither agree nor disagree (3); disagree (2); strongly disagree (1) # Level of quality: excellent (5); very good (4); good (3); fair (2); poor (1) Regarding 'the most likely diagnosis' after GOSCE and individual reasoning, we divided the participants into 'correct the most likely diagnosis group (n=29)' and 'incorrect the most likely diagnosis group (n=47)' and found signi cant differences between these two groups, including the GOSCE history-taking score (p=0.045), number of key words written down (p=0.009), and diagnosis numbers (p=0.004) ( Table 5). Table 5 The correlation between correct "the most likely diagnosis group" and incorrect "the most likely diagnosis group" in clinical reasoning (n=76)  17 In our study, we found that the ability to correct "the most likely diagnosis" is very important, due to its correlation with history taking, identifying key information, and reasoning ability ( Table 5). The purpose of group OSCE is to increase more data of key information from the training group which can improve individual clinical reasoning, however, reasoning also depends on the background of individual knowledge and critical thinking ability.
Does the OSCE score of clinical reasoning re ect the ability of medical students' performance? Falcone stated that third-year medical students are generally accurate in their ability to diagnose acute abdominal pain by OSCE, but the surgical faculty's Likert-based assessments of students' ability to analyse data do not correspond with OSCE performance; the length of exposure to patients before OSCE might be a confounding variable. 18 Weinstein et al. successfully implemented a faculty development workshop for diagnosing and remediating clinical reasoning di culties to help clinical teachers improve their skills. 19 In our study, we created a teaching faculty including R1 residents, and the R1 teacher gave students 30 minutes immediate group feedback post workshop which earned high satisfaction.
This study has several limitations. First, it was performed in a single institution with only 76 fourth-grade students. Therefore, these results may not be generalisable to other institutions, which may have different clinical clerkship programmes and student evaluation systems. Second, the authors tested only ve case scenarios, which may not be su cient to generalise these conclusions across a wider population. Third, the GOSCE score used for the present analysis was based only on the group of patient encounters, not personal encounters.
In conclusion, our school uses a divided organ systemic module teaching programme which possibly restricts students' cross-system reasoning ability. We found that the students' reasoning was worse in the scenarios for abdominal pain, fever, and anaemia, so we included R1 residents as clinical reasoning teaching faculty and used group OSCE with individual reasoning training which demonstrated high satisfaction. We further created e-learning scenario videos to improve other students' cross-system reasoning ability. Availability of data and materials:

List Of Abbreviations
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests: "The authors declare that they have no competing interests" Funding: There is no funding in this study.
Authors' contributions: Dr. Lin substantial contributions to conception and design of the study, Dr. Lail and Dr. Cheng acquisition of data, or analysis and interpretation of data; Dr. Lin and Dr. Lain and Dr, Cheng drafting the article, Dr. Lin and Dr. Wu revising it critically for important intellectual content and nal approval of the version to be published.