Implementation of Chief Complaint-Based Clinical Reasoning Training in Periodontal Internships.

BACKGROUND: The gap between theoretical knowledge and clinical skills highlights the need for clinical reasoning training curriculum in periodontal education, especially in periodontal internships. This study aims to develop a Chief Complaint-Based Clinical Reasoning Training (CCB-CRT) program and evaluate its impact on periodontal interns' clinical reasoning abilities and overall performance. METHODS: The CCB-CRT program was developed based on eight common chief complaints (CCs) identified through surveys of periodontal specialists and an analysis of patient visit data from a university-affiliated hospital's periodontal clinic. The study involved a comparison between a control group of fifth-year dental students (2021) and a CCB-CRT group (2022). Both groups completed an 8-week training course. The CCB-CRT group received additional training focused on the 8 common CCs, using student-led discussions, flipped classroom, mind mapping, and presentations. Evaluation criteria included overall performance, disease diagnosis and treatment plan, misdiagnosis rates, and students' satisfaction. RESULTS: After 1 year of CCB-CRT implementation, participants in the CCB-CRT group showed substantial improvements in overall performance, diagnostic accuracy, and satisfaction compared to traditional teaching methods. The program enhanced students' understanding of theoretical knowledge, improved their interpretation of clinical manifestations and examination results, and enhanced their clinical reasoning skills and diagnostic accuracy. CONCLUSIONS: The successful application of the CCB-CRT program in periodontology education demonstrates its efficacy in improving clinical reasoning skills and diagnostic efficiency among students. The structured approach facilitates the transition from theoretical knowledge to practical application, contributing to better patient care in periodontal practice.

A systematic review of medical practitioners' retention and application of basic sciences to clinical practice.

BACKGROUND: Medical education offers the foundational base for future healthcare professionals, with basic sciences playing a pivotal role in providing essential knowledge and skills for clinical practice. However, the long-term retention and application of this knowledge in clinical practice remain a significant challenge. This systematic review synthesised global evidence from diverse studies on the short / long-term retention and clinical application of basic sciences among medical doctors. METHODS: A comprehensive search was conducted across six databases, including Web of Science, Scopus, Medline, CINAHL, Emcare, and Informit. The review included studies that encompassed a variety of study designs, participant groups, and educational interventions. The Quality Assessment with Diverse Studies (QuADS) tool was utilised to assess the quality of the reviewed studies. RESULTS: A total of 10 studies were included in the review. The findings revealed that rehearsals significantly optimise the retention of basic science knowledge among medical practitioners. Retention varied by discipline, with medical practitioners retaining more knowledge in anatomy (mean scores ranging from 45.0 to 82.9%), while microbiology had the lowest retention score (39.1%). Factors influencing retention included age, gender, and curriculum type. Educational interventions such as targeted courses, integration of basic sciences with clinical skills, generative retrieval and continuous quality improvement in the curriculum were found to enhance both knowledge retention and clinical reasoning. The concept of 'encapsulated knowledge' demonstrates that integrated basic science knowledge helps in synthesising clinical presentations, reducing the need for detailed recall as clinical experience increases. The reviewed studies primarily involved interns and surgeons, leaving a significant gap in research for specialties like internal medicine and primary care/ general practice. CONCLUSION: Detailed retention of basic science knowledge may diminish over time; however, the conceptual framework remains essential for ongoing learning and clinical reasoning. This review's findings highlight the need for specialised educational interventions to improve long-term retention. Continuous professional development and targeted educational techniques are vital for maintaining clinical competence and applying basic science knowledge effectively throughout a medical career. Further research is needed to address gaps in specialty-specific knowledge application and the impact of different instructional methods.

Enabling diagnostic excellence in the real world: Managing complexity, uncertainty and clinical responsibility.

Diagnostic error is a significant category within preventable patient harm, and it takes many years of effort to develop proficiency in diagnostic reasoning. One of the key challenges medical schools must address is preparing students for the complexity, uncertainty and clinical responsibility in going from student to doctor. Recognising the importance of both cognitive and systems-related factors in diagnostic accuracy, we designed the QUID Prompt (Questions to Use for Improving Diagnosis) for students to refer to at the bedside. This set of questions prompts careful consideration, analysis, and signposting of decision-making processes, to assist students in transitioning from medical school to the real-world of work and achieving diagnostic excellence in clinical settings.

The impact of unfolding case studies combined with think-aloud strategies on the clinical reasoning and self-directed learning abilities of postgraduate students: A mixed methods study.

AIM: To conduct unfolding case studies and test their effectiveness in improving clinical reasoning, teamwork and self-directed learning among postgraduate students. BACKGROUND: Postgraduate students, as advanced nursing professionals in clinical settings, are the driving force behind the rapid development of the nursing profession. Effective clinical reasoning is a fundamental nursing skill that postgraduate students must cultivate, having a direct impact on patient health outcomes. The development and usation of unfolding case studies, which reflect the evolving conditions of patients, combined with think-aloud teaching methods, can enhance postgraduate students' clinical reasoning abilities and foster communication and self-reflection, thereby achieving this goal. DESIGN: Mixed methods design. METHODS: The Nurses' Clinical Reasoning Scale and the Nursing Students' Self-Directed Learning Ability Scale were used to evaluate the clinical reasoning and self-directed learning abilities of nursing students. A qualitative exploratory design with a think-aloud interview technique was employed to explore the clinical reasoning process of nursing students in unfolding cases. Twenty-one nursing students completed the questionnaire survey. Data analysis was conducted using Wilcoxon signed-rank tests, Spearman correlations, regressions and inductive content analysis. RESULTS: After implementing the case study, there was a statistically significant improvement in students' clinical reasoning, self-directed learning and teamwork abilities. Think-aloud analysis revealed that the cognitive strategies most employed by students in clinical reasoning were 'Making choices', 'Forming relationships', 'Searched for information' and 'Drawing conclusions'. CONCLUSION: Unfolding case studies combined with think-aloud strategies provide a conducive learning environment for postgraduate students, effectively enhancing their clinical reasoning and self-directed learning abilities.

Debriefing to nurture clinical reasoning in nursing students: A design-based research study.

BACKGROUND: Students' clinical reasoning can be stimulated by guiding them to use their experiences with patients to develop own illness scripts. Debriefing during hospital shifts invites students to put patient experiences into words, link them to previously acquired knowledge and make connections. OBJECTIVES: To develop, implement and evaluate a debriefing procedure for nursing internships based on illness script theory and generate corresponding design principles. DESIGN: Qualitative design-based research. SETTING: Clinical education in dedicated educational hospital units. PARTICIPANTS: Nurse educators, nursing students. METHODS: From a collaboration between nurse educators and a researcher, a short, peer-debriefing procedure was designed, tested and enacted through four cycles of planning, action, evaluation and reflection. Students drew mind maps about patients. Nurse educators and students joined focus group discussions to evaluate outcomes and processes. Mind map and iterative thematic analysis were applied to these data. RESULTS: An adjusted design and more extensive design principles resulted. Differences in mind maps were evident over time. Three themes in the process evaluation were established: trigger to reason; energy giving and taking; and form follows function. CONCLUSIONS: This design-based investigation displays how nurse educators could design and implement a debriefing procedure to facilitate students' clinical reasoning skills and how students could learn from this. This method integrates research, innovation and collaboration. The design and enactment under real-life hospital conditions generated design principles for educators and researchers which may be useful for those seeking to improve teaching and learning clinical reasoning in practice. More clarification is needed about the path from design through enactment to real change in practice.

Neck or Shoulder? Establishing Consensus for Spine Screening in Patients with Shoulder Pain: an International Modified Delphi Study.

OBJECTIVE: There is no established consensus for screening the spine in patients with shoulder pain. The aim of this study was to explore the role of the spine in shoulder pain and generate a set of recommendations for assessing the potential involvement of the spine in patients with shoulder pain. METHODS: A modified Delphi study was conducted through use of an international shoulder physical therapist's expert panel. Three domains (clinical reasoning, history, physical examination) were evaluated using a Likert scale, with consensus defined as Aiken Validity Index ≥0.7. RESULTS: Twenty-two physical therapists participated. Consensus was reached on a total of 30 items: clinical reasoning (n = 9), history (n = 13), and physical examination (n = 8). The statement that spinal and shoulder disorders can coexist, sometimes influencing each other and at other times remaining independent issues, along with the concept of radiating pain as an explanatory phenomenon for the spine contribution to shoulder pain, achieved the highest degree of consensus. CONCLUSION: International physical therapists shoulder experts reached consensus on key aspects when screening the spine in people with shoulder pain, including consideration of the distal location of symptoms relative to the shoulder, the presence or previous history of neck pain, the changes in symptoms related to neck movements, and the presence of neuropathic-like symptoms. They also acknowledged the importance of assessing active cervical or cervicothoracic movements and the usefulness of the Spurling test and symptom modification techniques applied to the spine.

Physiotherapy educators' perceptions of physiotherapists' competencies and continuing education in the practice of musculoskeletal physiotherapy direct access.

INTRODUCTION: The aim of direct access (DA) physiotherapy practice in Finland is the treatment of musculoskeletal (MSK) conditions by physiotherapists who have completed continuing DA education. It is difficult to pinpoint the competencies of DA physiotherapists as their roles and scope of practice varies. PURPOSE: The present study aimed to explore the competencies and education of DA physiotherapists through the perceptions of DA educators. METHODS: Data were collected through individual semi-structured interviews of eleven Finnish physiotherapy educators who described their perceptions of DA physiotherapists' competencies and their continuing DA education. The interviews were recorded and transcribed verbatim and then examined using a reflexive thematic analysis. RESULTS: Two main themes were formulated on the basis of the data, conveying the educators' perceptions. The first theme, Interaction as grounds for meaningful clinical reasoning, had two subthemes: Meaningful encounter and Rationally and safely locating the core of the client's problem. The second theme, Continuing professional development in an expert role, had four subthemes: Continuous learning, Self-reflection, Deep understanding and Taking responsibility for one's own expertise. CONCLUSION: The present study revealed how DA educators perceive the competencies of DA physiotherapists. The findings highlight the perceived significance of the physiotherapists' interaction with the client as a ground for meaningful clinical reasoning, and their responsibility for their own continuing professional self-development.

Making clinical teaching visible-A time and motion study of hospital rounds in undergraduate medical teaching.

Background: Teaching medical students in the clinical setting is frequently perceived as a demanding commitment by attending physicians. There is a paucity of data measuring the duration and efficacy of teaching during clinical rounds. Aim: The aim of this study was to assess both the quantity and quality of clinical teaching time dedicated to medical students on hospital ward rounds. Methods: A cross-sectional direct structured observational study was conducted during the morning rounds of attending physicians involved in teaching undergraduate medical students at three different clinical facilities in three different specialties. A validated observational tool was used by four observers to record teaching time and quality indicators. Results: In terms of teaching duration, it was observed that 25% of the total morning round time was allocated to teaching. However, this measure varied widely between different physicians and specialties. As for teaching quality, actions categorized as active teaching by the teachers were observed in 19% of the interactions observed per round, while active learning by the students was observed in 17% of the interactions per round. Teacher high-cognition interactions were similarly observed in 23% of actions per round, while student high-cognition interactions occurred in 16% of actions per round. Internal Medicine tended to score higher than both Pediatrics and Surgery in terms of percentage teaching time as well as percentage of active teaching observed per round. Using liberal criteria, rounds characterized overall as predominantly active or high-cognition by both teachers and students were observed in only 21% of the total number of rounds observed. Conclusion: These results indicate that the percentage of teaching time during ward rounds is highly variable, and that round teaching generally consists of passive and low-cognition interactions. Future work is needed to train clinical faculty to achieve a desired level of teaching quality, and to determine if there are any changes in teaching time commitments and student outcomes.

Evaluating the effectiveness of illness script teaching on clinical reasoning skills in post-baccalaureate nursing students.

BACKGROUND: Typically, nurse education curricula are separated into the teaching of theoretical knowledge and practical skills. This separation may hinder nursing students' development of clinical reasoning skills, making it difficult for them to prioritize tasks and make decisions about interventions. Illness scripts have been shown to help medical students improve their clinical reasoning skills; however, they are rarely used in nurse education. OBJECTIVES: To evaluate the influence of illness script teaching method on post-baccalaureate nursing students' clinical reasoning skills. DESIGN: The study adopted a single-arm quantitative pre-experimental research design and incorporated qualitative focus group discussions. SETTINGS/PARTICIPANTS: This study was conducted at a university in northern Taiwan. Participants included 35 post-baccalaureate nursing students who were enrolled in an elective course focused on clinical skills. METHODS: To enhance nursing students' clinical reasoning skills, illness scripts for five clinical scenarios were developed and implemented as part of their curriculum. The Nurses Clinical Reasoning Scale was utilized to assess self-rated clinical reasoning abilities, while dual-teacher scoring was used to evaluate clinical reasoning objectively. The VARK learning preference questionnaire was used to examine how learning preferences affect learning outcomes. After the course, semi-structured focus groups were held to collect student feedback on the effectiveness of the teaching methods and the learning outcomes. RESULTS: This study's quantitative and qualitative results show that illness script-based teaching improves nursing students' clinical reasoning. Quantitative results showed significant objective reasoning score improvements. However, minimal changes in self-rated scores suggest a learning style-influenced gap between perceived and actual abilities. Qualitative findings showed that students valued linking clinical issues to practical applications but struggled with knowledge gaps and engagement. CONCLUSIONS: The illness script teaching method improved students' understanding of clinical scenarios and enhanced their clinical reasoning abilities. Incorporating illness scripts into nurse education was beneficial for nursing students.

Exploring context and culture in clinical reasoning medical education: A qualitative exploratory study.

BACKGROUND: Clinical reasoning processes are complex and interwoven with culture and context. While these relationships have been explored to understand the outcomes of clinical reasoning, there has been little exploration of how to integrate these relationships when teaching and learning clinical reasoning. METHODS: Using semi-structured interviews, this research explored the role of context and culture in clinical reasoning medical education. Participants were clinical teachers recruited from across Northern Ontario. The data were analysed independently by two reviewers using both thematic analysis and critical discourse analysis, and peer reviewed by a third researcher. RESULTS: The role of context and culture is inherent to the personal, professional and pedagogical aspects of clinical reasoning, especially when teaching about the complexities of Northern Ontario. The major themes that came through were: 1) teaching and learning clinical reasoning needs reflexivity, 2) developing clinical reasoning skills needs time and 3) clinical reasoning pedagogy should acknowledge and encompass practice variation and patient diversity. CONCLUSION: Teaching clinical reasoning in Northern Ontario involves being aware of the complexities that are inherent in interacting with patients and communities. Through personal, professional and pedagogical models, the students and teachers can address the complexities of cultural and contextual clinical reasoning.

Using Group History-Taking and Individual Reasoning to Identify Shortcomings in Clinical Reasoning for Medical Students.

OBJECTIVE: It is crucial that teaching faculties determine and remain informed of medical school learners' clinical reasoning competence. We created an innovative assessment method for fourth-year medical students to identify deficiencies in various components of their clinical reasoning ability. METHODS: This was a cross-sectional observational study of fourth-year medical students' reasoning assessments from 2019 to 2022. Teams of four-five trainees questioned standardized patients in clinical scenarios, including fever, abdominal pain, and weight loss. They then individually documented key information to reflect comprehension of patient problems. Trainees were tasked with differentiating diagnoses and associated statuses and reaching the most likely diagnosis along with two tentative diagnoses. The correlations observed between 2020 and 2022 for abdominal pain were analyzed using student t-tests. RESULTS: A total of 177 students participated in this study. Across the scenarios, there was no significant difference in key information representation scores (56%-58%). Reasoning ability scores were 49% for fever, 57% for abdominal pain, and 61% for weight loss. A comparison between 2020 and 2022 revealed a significant improvement in the objective structured clinical examination scores and differential diagnoses (P < .01). Shortcomings included brief chief complaint duration, lack of detailed presentation, and insufficient description of negative information. Differential diagnosis and diagnostic justification were inadequate for acute and chronic conditions, and disease location clarity within the organ system was lacking. On average, students presented two correct diagnoses. CONCLUSIONS: Fourth-year medical students exhibited inadequate reasoning abilities, particularly in fever and abdominal pain scenarios, with deficiencies in hypothesis generation and differential diagnosis. Group history-taking with individual reasoning assessment identified students' shortcomings and provided faculty feedback to improve their teaching strategies.

Investigating clinical decision-making in bleeding complications among nursing students: A longitudinal mixed-methods study.

AIM: To describe undergraduate nursing students' clinical decision-making in post-procedural bleeding scenarios and explore the changes from the first to the final year of their program. BACKGROUND: Bleeding is a common complication following invasive procedures and its effective management requires nurses to develop strong clinical decision-making competencies. Although nursing education programs typically address bleeding complications, there is a gap in understanding how nursing students make clinical decisions regarding these scenarios. Additionally, little is known about how their approach to bleeding management evolves over the course of their education. DESIGN: Longitudinal mixed-methods study based on the Recognition-Primed Decision Model. METHODS: A total of 59 undergraduate students recorded their responses to two clinical decision-making vignettes depicting patients with signs of bleeding post-hip surgery (first year) and cardiac catheterization (final year). Their responses were analyzed using content analysis. The resulting categories capture the cues students noticed, the goals they aimed to achieve, the actions they proposed and their expectations for how the bleeding situations might unfold. Code frequencies showing the most variation between the first and final years were analyzed to explore changes in students' clinical decision-making. RESULTS: Nearly all students focused on two primary categories: 'Bleeding' and 'Instability and Shock.' Fewer students addressed six secondary categories: 'Stress and Concern,' 'Pain,' 'Lifestyle and Social History,' 'Wound Infection,' 'Arrhythmia,' and 'Generalities in Surgery.' Students often concentrated on actions to manage bleeding without further assessing its causes. Changes from the first to the final year included a more focused assessment of instability and shifts in preferred actions. CONCLUSIONS: This study reveals that nursing students often prioritize immediate actions to stop bleeding while sometimes overlooking the assessment of underlying causes or broader care goals. It suggests that concept-based learning and reflection on long-term outcomes could improve clinical decision-making in post-procedural care.

Beliefs and experiences of educators when involved in the design of a Learning-by-concordance tool: A qualitative interpretative study.

BACKGROUND: Based on the involvement of qualified educators in its design, the Learning-by-Concordance tool aims to promote the learning of reasoning in contexts of uncertainty. However, data are still scarce on the experience of educators in terms of sharing and exposing their reasoning processes using this tool. PURPOSE: This study sought to explore the beliefs and experiences of educators when involved in the design of a Learning-by-Concordance tool. METHOD: This research used a descriptive qualitative design. Four dialogue groups were conducted with educators with different roles and responsibilities while designing a Learning-by-Concordance tool. A descriptive interpretative analysis of educators' verbatim quotes was done. FINDINGS: A total of 14 participants took part in the study. The results show the discomfort of educators despite their recognized expertise. Three themes emerged: 1- the need to be reassured by the opinions of colleagues; 2-feeling like impostors; and 3- concerns for the quality of instructional supports. CONCLUSIONS: The role taken by educators for teaching reasoning in contexts of uncertainty is to draw on practical experience where different types of knowledge intersect and are mobilized, to overcome feelings of insecurity, and to engage in close and authentic conversation with learners.

Collaborative framework to assess achievement of American Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculties patient-centered competencies using evolving case studies.

BACKGROUND: The American Association of Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculties (NONPF) emphasize the role of clinical reasoning in nurse practitioner (NP) competencies. Evidence-based clinical reasoning is vital to patient safety. Collaborative technology tools can aid in assessing progress towards achieving clinical reasoning competency. PURPOSE/AIMS: The purpose of this article is to describe an electronic, collaborative learning framework to teach and assess second year NP students in systematically selecting and eliminating diagnoses and forming treatment plans. DESIGN/METHODS: Post gap analysis, the collaborative learning framework was created. This visual, collaborative resource was scaffolded across two sequential advanced NP second year clinical synthesis courses and embedded with evolving case studies. Students identified pertinent positives and negatives from the history, physical, and diagnostic findings. Each student developed a unique differential diagnosis and plan of care and critiqued their peers. RESULT/FINDINGS: The tool exceeded expectations. Faculty were able to visualize data, provide clarification on interpretation of data and pharmacology, and grade in small groups. CONCLUSION: The collaborative learning framework provided real-time visualization of students' work in clinical reasoning. It was easy to use and integrate into second year NP courses to meet learning objectives and assess clinical reasoning competency.

A graphical model to make explicit pharmacist clinical reasoning during medication review.

Pharmacists' roles have evolved substantially from traditional drug compounding and dispensing to encompass patient-centred clinical services. Pharmacist clinical reasoning, though fundamental to these new roles, generally remains implicit and understudied, particularly compared with that of other healthcare professionals, such as physicians. However, teaching and supervising the clinical services provided by pharmacists require a thorough understanding of the reasoning process involved. Several models describing pharmacist clinical reasoning have been developed, but they lack unified mapping. Here, we used an instrumental case study approach to develop a model of pharmacist clinical reasoning during medication review. Our model is adapted from a previously published modelling-using-typified-objects model of physician clinical reasoning in all its cognitive complexity. Our pharmacist model, validated after iterative development and expert consultation, aligns components of pharmacist clinical reasoning with those of physician clinical reasoning. The clinical case contains drug-related problems of variable clinical relevance, as well as numerous key elements (e.g., laboratory results, vital signs) necessary for conducting a medication review. The case serves both as the foundation for model development and as an illustrative step-by-step example within this article. Our model delineates the subprocesses of pharmacist clinical reasoning during medication review, offering a flexible, multipath structure that underscores the dynamic, nonlinear nature of the reasoning. The model might be able to clarify implicit cognitive processes, thus furthering the overarching objective of promoting reflective skill development among learners rather than relying solely on tacit knowledge gained through practice experience.

"(Not) knowing what you know": Exploring educators' perceptions of critical thinking in occupational therapy.

BACKGROUND: Critical thinking is key for responsible occupational therapy practice. However, the degree to which educators understand critical thinking and the conceptualizations of such concept in teaching remains unclear. AIM: This study aimed to describe occupational therapy educators' perceptions and experiences of teaching critical thinking. MATERIAL AND METHODS: Social constructivism underpins the study. Eight participants were included in three online synchronous focus groups. One participant was interviewed in person due to time constraints. Data were analysed using content analysis. RESULTS: This study reveals a considerable diversity of perceptions and experiences of ambiguity regarding educators' perceptions of what they know about and how to teach critical thinking. Most educators interpret critical thinking in ways that differs from their colleagues. Furthermore, educators encounter divergent expectations pertaining to their role as educators and the readiness of their students. CONCLUSIONS: This study reveal a paradox within the occupational therapy profession, where critical thinking is highly valued yet educators experience ambiguity, differing expectations of their role, time constraints, and lack of formal education to support students' development of critical thinking. SIGNIFICANCE: This study provides the foundation for further inquiry into the invisible effects and benefits of different understandings of critical thinking on occupational therapy practice.

Exploring ambulance clinicians' clinical reasoning when training mass casualty incidents using virtual reality: a qualitative study.

BACKGROUND: How ambulance clinicians (ACs) handle a mass casualty incident (MCI) is essential for the suffered, but the training and learning for the ACs are sparse and they don't have the possibility to learn without realistic simulation training. In addition, it is unclear what type of dilemmas ACs process in their clinical reasoning during an MCI. With virtual reality (VR) simulation, the ACs clinical reasoning can be explored in a systematic way. Therefore, the objective was to explore ambulance clinicians' clinical reasoning when simulating a mass casualty incident using virtual reality. METHODS: This study was conducted as an explorative interview study design using chart- stimulated recall technique for data collection. A qualitative content analysis was done, using the clinical reasoning cycle as a deductive matrix. A high-fidelity VR simulation with MCI scenarios was used and participants eligible for inclusion were 11 senior ACs. RESULTS/CONCLUSION: All phases of the clinical reasoning cycle were found to be reflected upon by the participants during the interviews, however with a varying richness of analytic reflectivity. Non-analytic reasoning predominated when work tasks followed specific clinical guidelines, but analytical reasoning appeared when the guidelines were unclear or non-existent. Using VR simulation led to training and reflection on action in a safe and systematic way and increased self-awareness amongst the ACs regarding their preparedness for MCIs. This study increases knowledge both regarding ACs clinical reasoning in MCIs, and insights regarding the use of VR for simulation training.

Physicians have feelings: illuminating the relationship between emotional valence, clinical reasoning and context specificity.

INTRODUCTION: Research demonstrates that emotions play an important role in clinical reasoning (CR); however, the relationship between emotional valence, CR, and the context in which reasoning takes place, remains to be empirically explored. While situated cognition has been used to investigate CR and context specificity (e.g. the presence of contextual factors, things other than the information directly related to establishing a diagnosis), it has not explicitly examined the role of emotional valence during CR encounters. Our research question was how do emotional valence and arousal emerge in CR, particularly in the presence or absence of contextual factors? METHODS: Physicians (n = 45) reviewed two video cases, one with contextual factors and one without. Immediately afterwards, participants completed a 'think-aloud' while reviewing cases. Thematic analysis was used to code transcribed think-alouds for CR activities, emotional valence (positive, neutral or negative) and arousal by three researchers. Frequencies and relationships between codes were compared, both in the presence or absence of contextual factors. RESULTS: The majority of emotional valence codes were neutral (85.2%), with negative valence more frequent (11.2%) than positive valence (3.5%). Five CR themes were consistently demonstrated: knowledge organization (with two sub-themes of linking and differential diagnosis formation), proceeding with caution, curiosity, assumption, and reflection. In the presence of contextual factors, there was an increase in negative valence with a decrease in positive valence, as well as a shift in CR from knowledge organization to curiosity and proceeding with caution. DISCUSSION: The complex interaction between clinical reasoning themes, emotional valence, and changes with contextual factors have important implications for clinical practice, education, and future research on CR.

Interprofessional Coproduction of Diagnosis with Medical and Pharmacy Students: An Interactive Case-Based Workshop.

Introduction: The Institute of Medicine and national competencies emphasize the importance of interprofessional education to reduce diagnostic error. Clinical pharmacists are increasingly integrated into clinical teams and participate in the diagnostic process. However, few educational resources explicitly teach medical and pharmacy students to collaborate on the production of diagnoses. Methods: We implemented a 2-hour, online, case-based workshop with 154 second-year medical students and third-year pharmacy students. After brief didactics on the diagnostic process and scope of practice of pharmacists, small groups of eight to 12 medical and pharmacy students with faculty facilitators worked through a case unfolding in two aliquots. Students were provided different but complementary information authentic to their profession. They had to communicate with each other to develop an appropriate differential diagnosis. Students then reflected on how communicating with the other profession impacted their diagnostic reasoning. Comments were coded and counted. Results: The majority (99%) of students identified their data gathering and differential diagnoses were impacted by working through the case together. More pharmacy students commented on how medical students broadened their differential diagnosis (71%) and added information (72%), contextualizing information, such as past history, medication indications, and physical exam data. More medical students commented on how pharmacy students helped justify (54%) and clarify (22%) the differential diagnosis, often connecting the underlying mechanism of medications with clinical findings. Discussion: This interactive case-based workshop was effective in teaching medical and pharmacy students to collaborate in the coproduction of diagnosis. It is feasible with minimal resources.