Reasoning like a doctor or like a nurse? A systematic integrative review.

When physicians and nurses are looking at the same patient, they may not see the same picture. If assuming that the clinical reasoning of both professions is alike and ignoring possible differences, aspects essential for care can be overlooked. Understanding the multifaceted concept of clinical reasoning of both professions may provide insight into the nature and purpose of their practices and benefit patient care, education and research. We aimed to identify, compare and contrast the documented features of clinical reasoning of physicians and nurses through the lens of layered analysis and to conduct a simultaneous concept analysis. The protocol of this systematic integrative review was published doi: 10.1136/bmjopen-2021-049862. A comprehensive search was performed in four databases (PubMed, CINAHL, Psychinfo, and Web of Science) from 30th March 2020 to 27th May 2020. A total of 69 Empirical and theoretical journal articles about clinical reasoning of practitioners were included: 27 nursing, 37 medical, and five combining both perspectives. Two reviewers screened the identified papers for eligibility and assessed the quality of the methodologically diverse articles. We used an onion model, based on three layers: Philosophy, Principles, and Techniques to extract and organize the data. Commonalities and differences were identified on professional paradigms, theories, intentions, content, antecedents, attributes, outcomes, and contextual factors. The detected philosophical differences were located on a care-cure and subjective-objective continuum. We observed four principle contrasts: a broad or narrow focus, consideration of the patient as such or of the patient and his relatives, hypotheses to explain or to understand, and argumentation based on causality or association. In the technical layer a difference in the professional concepts of diagnosis and the degree of patient involvement in the reasoning process were perceived. Clinical reasoning can be analysed by breaking it down into layers, and the onion model resulted in detailed features. Subsequently insight was obtained in the differences between nursing and medical reasoning. The origin of these differences is in the philosophical layer (professional paradigms, intentions). This review can be used as a first step toward gaining a better understanding and collaboration in patient care, education and research across the nursing and medical professions.

Illness scripts in nursing: Directed content analysis.

AIMS: To explore the possible extension of the illness script theory used in medicine to the nursing context. DESIGN: A qualitative interview study. METHODS: The study was conducted between September 2019 and March 2020. Expert nurses were asked to think aloud about 20 patient problems in nursing. A directed content analysis approach including quantitative data processing was used to analyse the transcribed data. RESULTS: Through the analysis of 3912 statements, scripts were identified and a nursing script model is proposed; the medical illness script, including enabling conditions, fault and consequences, is extended with management, boundary, impact, occurrence and explicative statements. Nurses often used explicative statements when pathophysiological causes are absent or unknown. To explore the applicability of Illness script theory we analysed scripts' richness and maturity with descriptive statistics. Expert nurses, like medical experts, had rich knowledge of consequences, explicative statements and management of familiar patient problems. CONCLUSION: The knowledge of expert nurses about patient problems can be described in scripts; the components of medical illness scripts are also relevant in nursing. We propose to extend the original illness script concept with management, explicative statements, boundary, impact and occurrence, to enlarge the applicability of illness scripts in the nursing domain. IMPACT: Illness scripts guide clinical reasoning in patient care. Insights into illness scripts of nursing experts is a necessary first step to develop goals or guidelines for student nurses' development of clinical reasoning. It might lay the groundwork for future educational strategies.

Assessing Knowledge of Pharmacokinetics in an Integrated Medical Curriculum.

Pharmacokinetics is the branch of pharmacology that describes how the body processes drugs. As most physicians will prescribe drugs during their career, knowledge of pharmacokinetics is indispensable for medical students. Students, however, experience pharmacokinetics as difficult, probably due to its abstract and mathematical nature. In many medical curricula, pharmacokinetic topics are taught and examined as a part of integrated medical courses. As pharmacokinetics is a relatively small subject, unit examinations contain only few questions on the topic. The combination of a difficult subject and a few questions has raised concerns that students could perform poorly in pharmacokinetics and still pass the examinations and, hence, end up with insufficient knowledge of pharmacokinetics. In this study, we investigate this issue by contrasting students' performance on pharmacokinetics questions with their performance on the rest of the examinations (all non-pharmacokinetics questions lumped together). The results expressed as pass-fail scores showed that students failed more often on the pharmacokinetics part of the test than on the other questions, in two consecutive academic years. Despite the suboptimal knowledge in pharmacokinetics, students can still acquire their bachelor's degree. These results show that poor knowledge in pharmacokinetics could be a side effect of curricular integration. Attention should therefore be paid to provide insight into one's own performance in individual disciplines. This would avoid knowledge deficiency and incompetence in the future.

Reasoning like a doctor or like a nurse? An integrative review protocol.

INTRODUCTION: Clinical reasoning, a major competency for all health professionals, has been defined and studied 'within' each profession. We do not know if content, process and outcomes are comparable 'between' physician and nursing clinical reasoning. This paper aims to set up a protocol for an integrative review to analyse and synthesise the scientific nursing and medical clinical reasoning literature. It builds on the history of nursing and medical clinical reasoning research and aims to create a higher level of conceptual clarity of clinical reasoning, to increase mutual understanding in collaboration in patient care, education and research. METHODS AND ANALYSIS: This integrative review follows stepwise the methods described by Whittmore and Knafl: problem identification, literature search, data evaluation, data analysis and presentation.The initial systematic and comprehensive search strategy is developed in collaboration with the clinical librarian and is performed in electronic databases, PubMed, CINAHL, PsycInfo and Web of Science from 30 March 2020 to 27 May 2020. Empirical and theoretical studies are included. This search will be accompanied by ancestry searching and purposeful sampling. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart will summarise the selection process. The quality of eligible studies will be evaluated with a checklist, suitable for diverse study methods.The data analysis is inspired by concept analysis of Walker and Avant and layered analysis of an intervention of Cianciolo and Regehr. We will extract the data of the included studies conforming these layers and features, to capture the multifaceted nature of clinical reasoning in both professions. The data will be presented in a validity matrix to facilitate comparing and contrasting. ETHICS AND DISSEMINATION: Ethics approval is not required. The outcomes will be disseminated through conference presentations and publications.

Approaches of anatomy teaching for seriously resource-deprived countries: A literature review.

Background: Teaching anatomy is an important but expensive part of the medical curriculum, potentially more than many countries can afford. In the search for efficient methods, cost-effectiveness is of utmost importance for such countries. The aim of this contribution is to provide a review of the literature on anatomy teaching methods, evaluating these for feasibility in resource-deprived countries. Methods: A literature review was carried out to identify distinct approaches to anatomy teaching published in the period 2000-2014, using the databases of PubMed, Wiley Online Library, Elsevier, HINARI, Springer, and ERIC. The approaches found were compared against their conceptual, operational, technical, and economic feasibility and Mayer's principles of effective instruction. Results: Our search yielded 432 papers that met the inclusion criteria. We identified 14 methods of teaching anatomy. Based on their conceptual feasibility, dissection and technology enhanced learning approaches appeared to have more benefits than others. Dissection has, besides benefits, many specific drawbacks. Lectures and peer teaching showed better technical and economic feasibility. Educational platforms, radiological imaging, and lectures showed the highest operational feasibility. Dissection and surgery were found to be less feasible with regard to operational, technical, and economic characteristics. Discussion: Based on our findings, the most important recommendations for anatomy teaching in seriously resource-deprived countries include a combination of complementary strategies in 3 different moments, lecturing at the beginning, using virtual learning environment (for self-study), and at the end, using demonstration through prosected specimens and radiological imaging. This provides reasonable insights in anatomy through both dead and living human bodies and their virtual representations.

Theories of truth and teaching clinical reasoning and problem solving.

In this paper, we will first discuss two current meta-theories dealing with different, aspects of "truth". The first metatheory conceives of truth in terms of coherence (rationality, consistency): a body of knowledge is true when it contains no inconsistencies and has at least some credibility. The second metatheory conceives of truth as correspondence, i.e., empirical accuracy. The two metatheories supplement each other, but are also incommensurable, i.e., they cannot be expressed in each other's terms, for they employ completely different criteria to establish truth (Englebretsen in Bare facts and naked truths: a new correspondence theory of truth, Routledge, London, 2005). We will discuss both the role of both metatheories in medicine, in particular in medical education in a clinical context. In line with Hammond's view (Med Decis Mak 16(3):281-287, 1996a; Human judgment and social policy: irreducible uncertainty, inevitable error, unavoidable injustice, Oxford University Press, New York, 1996b), we will extend the two metatheories to two forms of competence: coherence competence and correspondence competence, and demonstrate that distinguishing these two forms of competence increases our insights as to the best way to teach undergraduate students clinical problem solving.

Does an Additional Online Anatomy Course Improve Performance of Medical Students on Gross Anatomy Examinations?

AIM: An online learning course in anatomy was added to the regular academic anatomy course in the 2nd year of medicine at UNAN-Leon in Nicaragua, using the MOODLE platform. This study aims to determine the learning effect of this course. METHOD: Second-year medical students were randomly allocated to an experimental (N = 25) and control group (N = 50). Only the experimental group had access to the online learning module. We compared the performance of the experimental and the control group on both regular anatomy assessment and an objective structured practical exam (OSPE). Additionally, five focus groups were interviewed to learn about their experiences of the expanded course. RESULTS: Of students in the experimental group 94.1% and 81.6% of students in the control group took the OSPE. The experimental group significantly outperformed the control group (41.1 ± 19.3 points vs. 32.1 ± 23.1 points) on the OSPE. No differences between the two groups were found on the regular anatomy examination. Focus group interviews revealed students' opinions about the online course were generally positive. CONCLUSION: In general, the addition of an online course to the regular course was beneficial. The results of the qualitative evaluation of this intervention provides us with input about how to teach and evaluate the anatomy course and how to further improve the online course to enhance anatomy learning.

The History of Medical Education in Europe and the United States, With Respect to Time and Proficiency.

In this article, the authors present a historic overview of the development of medical education in the United States and Europe (in particular the Netherlands), as it relates to the issues of time (duration of the course) and proficiency (performance requirements and examinations). This overview is necessarily limited and based largely on post hoc interpretation, as historic data on time frames are not well documented and the issue of competence has only recently been addressed.During times when there were few, if any, formal regulations, physicians were primarily "learned gentlemen" in command of few effective practical skills, and the duration of education and the competencies acquired by the end of a course simply did not appear to be issues of any interest to universities or state authorities. Though uniform criteria gradually developed for undergraduate medical education, postgraduate specialty training remained, before accreditation organizations set regulations, at the discretion of individual institutions and medical societies. This resulted in large variability in training time and acquired competencies between residency programs, which were often judged on the basis of opaque or questionable criteria. Considering the high costs of health care today and the increasing demand for patient safety and educational efficiency, continuing historic models of nonstandardized practices will no longer be feasible. Efforts to constrain, restructure, and individualize training time and licensing tracks to optimize training for safe care, both in the United States and Europe, are needed.

Illness script development in pre-clinical education through case-based clinical reasoning training.

OBJECTIVES: To assess illness script richness and maturity in preclinical students after they attended a specifically structured instructional format, i.e., a case based clinical reasoning (CBCR) course. METHODS: In a within-subject experimental design, medical students who had finished the CBCR course participated in an illness script experiment. In the first session, richness and maturity of students' illness scripts for diseases discussed during the CBCR course were compared to illness script richness and maturity for similar diseases not included in the course. In the second session, diagnostic performance was tested, to test for differences between CBCR cases and non-CBCR cases. Scores on the CBCR course exam were related to both experimental outcomes. RESULTS: Thirty-two medical students participated. Illness script richness for CBCR diseases was almost 20% higher than for non-CBCR diseases, on average 14.47 (SD=3.25) versus 12.14 (SD=2.80), respectively (p<0.001). In addition, students provided more information on Enabling Conditions and less on Fault-related aspects of the disease. Diagnostic performance was better for the diseases discussed in the CBCR course, mean score 1.63 (SD=0.32) versus 1.15 (SD=0.29) for non-CBCR diseases (p<0.001). A significant correlation of exam results with recognition of CBCR cases was found (r=0.571, p<0.001), but not with illness script richness (r=-0.006, p=NS). CONCLUSIONS: The CBCR-course fosters early development of clinical reasoning skills by increasing the illness script richness and diagnostic performance of pre-clinical students. However, these results are disease-specific and therefore we cannot conclude that students develop a more general clinical reasoning ability.

Preparation by mandatory E-modules improves learning of practical skills: a quasi-experimental comparison of skill examination results.

BACKGROUND: Until recently, students at UMC Utrecht Faculty of Medicine prepared for practical skills training sessions by studying recommended literature and making written assignments, which was considered unsatisfactory. Therefore, mandatory e-modules were gradually introduced as substitute for the text based preparation. This study aimed to investigate whether this innovation improved students' performance on the practical skills (OSCE) examination. METHOD: In both the 2012 and 2013 OSCEs, e-modules were available for some skill stations whereas others still had text based preparation. We compared students' performance, both within and between cohorts, for skill stations which had e-module preparation versus skill stations with text based preparation. RESULTS: We found that performance on skill stations for which students had prepared by e-modules was significantly higher than on stations with text based preparation, both within and between cohorts. This improvement cannot be explained by overall differences between the two cohorts. CONCLUSION: Our results show that results of skills training can be improved, by the introduction of e-modules without increasing teacher time. Further research is needed to answer the question whether the improved performance is due to the content of the e-modules of to their obligatory character.

Thirty years of illness scripts: Theoretical origins and practical applications.

AIM: This study describes the introduction and spread of the concept of "illness script" in the medical education literature. METHOD: First, I will concisely discuss the development of the "script" concept in the general psychological literature and the results of the studies performed to provide it with the necessary empirical basis. Next, I will sketch how "scripts" entered the medical domain via efforts to develop diagnostic systems in the field of artificial intelligence. Subsequently, I will describe how the illness script concept was elaborated and specified by medical educators and educational researchers. RESULTS AND DISCUSSION: The illness script concept has solid underpinnings and can be used to elucidate aspects of medical expertise development. It can also be used to formulate recommendations for clinical teaching and has yielded a specific test, the Script Concordance Test.

A comparison of medical and pharmacy students' knowledge and skills of pharmacology and pharmacotherapy.

AIM: Pharmacotherapy might be improved if future pharmacists and physicians receive a joint educational programme in pharmacology and pharmacotherapeutics. This study investigated whether there are differences in the pharmacology and pharmacotherapy knowledge and skills of pharmacy and medical students after their undergraduate training. Differences could serve as a starting point from which to develop joint interdisciplinary educational programmes for better prescribing. METHODS: In a cross-sectional design, the knowledge and skills of advanced pharmacy and medical students were assessed, using a standardized test with three domains (basic pharmacology knowledge, clinical or applied pharmacology knowledge and pharmacotherapy skills) and eight subdomains (pharmacodynamics, pharmacokinetics, interactions and side-effects, Anatomical Therapeutic Chemical Classification groups, prescribing, prescribing for special groups, drug information, regulations and laws, prescription writing). RESULTS: Four hundred and fifty-one medical and 151 pharmacy students were included between August 2010 and July 2012. The response rate was 81%. Pharmacy students had better knowledge of basic pharmacology than medical students (77.0% vs. 68.2% correct answers; P < 0.001, δ = 0.88), whereas medical students had better skills than pharmacy students in writing prescriptions (68.6% vs. 50.7%; P < 0.001, δ = 0.57). The two groups of students had similar knowledge of applied pharmacology (73.8% vs. 72.2%, P = 0.124, δ = 0.15). CONCLUSIONS: Pharmacy students have better knowledge of basic pharmacology, but not of the application of pharmacology knowledge, than medical students, whereas medical students are better at writing prescriptions. Professional differences in knowledge and skills therefore might well stem from their undergraduate education. Knowledge of these differences could be harnessed to develop a joint interdisciplinary education for both students and professionals.

Medical education and cognitive continuum theory: an alternative perspective on medical problem solving and clinical reasoning.

Recently, human reasoning, problem solving, and decision making have been viewed as products of two separate systems: "System 1," the unconscious, intuitive, or nonanalytic system, and "System 2," the conscious, analytic, or reflective system. This view has penetrated the medical education literature, yet the idea of two independent dichotomous cognitive systems is not entirely without problems.This article outlines the difficulties of this "two-system view" and presents an alternative, developed by K.R. Hammond and colleagues, called cognitive continuum theory (CCT). CCT is featured by three key assumptions. First, human reasoning, problem solving, and decision making can be arranged on a cognitive continuum, with pure intuition at one end, pure analysis at the other, and a large middle ground called "quasirationality." Second, the nature and requirements of the cognitive task, as perceived by the person performing the task, determine to a large extent whether a task will be approached more intuitively or more analytically. Third, for optimal task performance, this approach needs to match the cognitive properties and requirements of the task. Finally, the author makes a case that CCT is better able than a two-system view to describe medical problem solving and clinical reasoning and that it provides clear clues for how to organize training in clinical reasoning.

Very long-term retention of basic science knowledge in doctors after graduation.

CONTEXT: Despite frequent complaints that biomedical knowledge is quickly forgotten after it has been learned, few investigations of actual long-term retention of basic science knowledge have been conducted in the medical domain. OBJECTIVES: Our aim was to illuminate the long-term retention of basic science knowledge, particularly of unrehearsed knowledge. METHODS: Using a cross-sectional study design, medical students and doctors in the Netherlands were tested for retention of basic science knowledge. Relationships between retention interval and proportion of correct answers on a knowledge test were investigated. RESULTS: The popular notion that most of basic science knowledge is forgotten shortly after graduation is not supported by our findings. With respect to the full test scores, which reflect a composite of unrehearsed and rehearsed knowledge, performance decreased from approximately 40% correct answers for students still in medical school, to 25-30% correct answers for doctors after many years of practice. When rehearsal during the retention interval is controlled for, it appears that little knowledge is lost for 1.5-2 years after it was last used; from then on, retention is best described by a negatively accelerated (logarithmic) forgetting curve. After ≥ 25 years, retention levels were in the range of 15-20%. CONCLUSIONS: Conclusions about the forgetting of unrehearsed knowledge in this study are in line with findings reported in other domains: it proceeds in accordance with the Ebbinghaus curve for meaningful material, except that in our findings the 'downward' part appears to start later than in most other studies. The limitations of the study are discussed and possible ramifications for medical education are proposed.

Commentary: Flexner and Dutch medical education: a misinterpretation?

Abraham Flexner's 1910 report, Medical Education in the United States and Canada, was hardly noticed in the Netherlands, and though his 1925 book, Medical Education: A Comparative Study, was extensively discussed in the Dutch Medical Journal, it did not and could not affect medical education in the Netherlands. Until the 1970s, the medical curriculum in the Netherlands consisted of four phases: the propaedeutic year (premedical sciences), two preclinical years, two theoretical clinical years, and one-and-a-half to two years of clerkships. When in the 1970s interest in curriculum innovation arose in the Netherlands, it was based on developments in North America that challenged "Flexnerian" norms in medical education. As hardly anyone in the Netherlands cared to study Flexner's work closely, his name became synonymous with the conventional curriculum just as it had in North America. However, the Dutch conventional curriculum was quite different from the American conventional curriculum, so attributing its origins to Flexner's work was a serious misrepresentation. In this commentary, the author clarifies common misconceptions about the history of Dutch medical education and argues that the curriculum as Flexner saw it differed considerably from the Dutch medical curriculum a century ago.

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert.

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices' decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases.

Long-term retention of basic science knowledge: a review study.

In this paper, a review of long-term retention of basic science knowledge is presented. First, it is argued that retention of this knowledge has been a long-standing problem in medical education. Next, three types of studies are described that are employed in the literature to investigate long-term retention of knowledge in general. Subsequently, first the results of retention studies in general education are presented, followed by those of studies of basic science knowledge in medical education. The results of the review, in the general educational domain as well as in medical education, suggest that approximately two-third to three-fourth of knowledge will be retained after one year, with a further decrease to slightly below fifty percent in the next year. Finally, some recommendations are made for instructional strategies in curricula to improve long term retention of the subject matter dealt with.