Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research.

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Programmatic Assessment of Clinical Reasoning: New Opportunities to Meet an Ongoing Challenge.

Issue: Clinical reasoning is essential to physicians' competence, yet assessment of clinical reasoning remains a significant challenge. Clinical reasoning is a complex, evolving, non-linear, context-driven, and content-specific construct which arguably cannot be assessed at one point in time or with a single method. This has posed challenges for educators for many decades, despite significant development of individual assessment methods. Evidence: Programmatic assessment is a systematic assessment approach that is gaining momentum across health professions education. Programmatic assessment, and in particular assessment for learning, is well-suited to address the challenges with clinical reasoning assessment. Several key principles of programmatic assessment are particularly well-aligned with developing a system to assess clinical reasoning: longitudinality, triangulation, use of a mix of assessment methods, proportionality, implementation of intermediate evaluations/reviews with faculty coaches, use of assessment for feedback, and increase in learners' agency. Repeated exposure and measurement are critical to develop a clinical reasoning assessment narrative, thus the assessment approach should optimally be longitudinal, providing multiple opportunities for growth and development. Triangulation provides a lens to assess the multidimensionality and contextuality of clinical reasoning and that of its different, yet related components, using a mix of different assessment methods. Proportionality ensures the richness of information on which to draw conclusions is commensurate with the stakes of the decision. Coaching facilitates the development of a feedback culture and allows to assess growth over time, while enhancing learners' agency. Implications: A programmatic assessment model of clinical reasoning that is developmentally oriented, optimizes learning though feedback and coaching, uses multiple assessment methods, and provides opportunity for meaningful triangulation of data can help address some of the challenges of clinical reasoning assessment.

Assessment of management reasoning: Design considerations drawn from analysis of simulated outpatient encounters.

PURPOSE: Management reasoning is a distinct subset of clinical reasoning. We sought to explore features to be considered when designing assessments of management reasoning. METHODS: This is a hybrid empirical research study, narrative review, and expert perspective. In 2021, we reviewed and discussed 10 videos of simulated (staged) physician-patient encounters, actively seeking actions that offered insights into assessment of management reasoning. We analyzed our own observations in conjunction with literature on clinical reasoning assessment, using a constant comparative qualitative approach. RESULTS: Distinguishing features of management reasoning that will influence its assessment include management scripts, shared decision-making, process knowledge, illness-specific knowledge, and tailoring of the encounter and management plan. Performance domains that merit special consideration include communication, integration of patient preferences, adherence to the management script, and prognostication. Additional facets of encounter variation include the clinical problem, clinical and nonclinical patient characteristics (including preferences, values, and resources), team/system characteristics, and encounter features. We cataloged several relevant assessment approaches including written/computer-based, simulation-based, and workplace-based modalities, and a variety of novel response formats. CONCLUSIONS: Assessment of management reasoning could be improved with attention to the performance domains, facets of variation, and variety of approaches herein identified.

What Stops Fairness from Emerging in Assessment? The Forces on a Complex Adaptive System.

Introduction: Workplace-based assessment occurs in authentic, dynamic clinical environments where reproducible, measurement-based assessments can often not be implemented. In these environments, research approaches that respect these multiple dynamic interactions, such as complexity perspectives, are encouraged. Previous research has shown that fairness in assessment is a nonlinear phenomenon that emerges from interactions between its components and behaves like a complex adaptative system. The aim of this study was to understand the external forces on the complex adaptive system which may disrupt fairness from emerging. Methods: We conducted online focus groups with a purposeful sample of nineteen academic leaders in the Netherlands. We used an iterative approach to collection, analysis and coding of the data and interpreted the results using a lens of complexity, focusing on how individual elements of fairness work in concert to create systems with complex behaviour. Results: We identified three themes of forces which can disrupt fairness: forces impairing interactivity, forces impairing adaption and forces impairing embeddedness. Within each of these themes, we identified subthemes: assessor and student forces, tool forces and system forces. Discussion: Consistent with complexity theory, this study suggests there are multiple forces which can hamper the emergence of fairness. Whilst complexity thinking does not reduce the scale of the challenge, viewing forces through this lens provides insight into why and how these forces are disrupting fairness. This allows for more purposeful, meaningful changes to support the use of fair judgement in assessment in dynamic authentic clinical workplaces.

Does Masking MCAT Scores During Admissions Increase Equity?

PURPOSE: To improve admissions process equity, the Uniformed Services University masked Medical College Admission Test (MCAT) scores at or above the 51st percentile to admissions committee members. This policy was aimed at improving admissions rates for applicants in 2 priority groups: those from races and ethnicities underrepresented in medicine (URM) and those from lower socioeconomic status, represented by first-generation college (FGC) graduates. METHOD: All applicants invited to interview were included: 1,624 applicants from admissions years 2014-2016 before MCAT score masking and 1,668 applicants from admissions years 2018-2020 during MCAT score masking. Logistic regression determined admissions likelihood before and during masking. Independent sample t tests compared average admissions committee scores for all applicants and for those in priority groups. Linear regression determined the weight of MCAT scores on admissions committee scores. RESULTS: Despite there being more priority group applicants during MCAT score masking, the admissions likelihood for an individual priority group applicant decreased during this period. URM applicants had an odds ratio of 0.513 for acceptance during MCAT score masking compared to before masking, and FGC applicants had an odds ratio of 0.695. Masking significantly reduced mean admissions committee scores, which decreased approximately twice as much for priority group applicants as for nonpriority group applicants (0.96 points vs 0.51 points). These score decreases were highest for priority group applicants with MCAT scores above the 67th percentile. Masking reduced the weight of MCAT scores; 10.9% of admissions committee score variance was explained by MCAT scores before masking and only 1.2% during masking. CONCLUSIONS: Despite known disparities in MCAT scores with respect to race, ethnicity, and socioeconomic status, admissions decisions in this study were more equitable when MCAT scores were included. While masking MCAT scores reduced the influence of the exam in admissions decisions, it also reduced admissions rates for URM and FGC applicants.

Fairness in Assessment: Identifying a Complex Adaptive System.

Introduction: Assessment design in health professions education is continuously evolving. There is an increasing desire to better embrace human judgement in assessment. Thus, it is essential to understand what makes this judgement fair. This study builds upon existing literature by studying how assessment leaders conceptualise the characteristics of fair judgement. Methods: Sixteen assessment leaders from 15 medical schools in Australia and New Zealand participated in online focus groups. Data collection and analysis occurred concurrently and iteratively. We used the constant comparison method to identify themes and build on an existing conceptual model of fair judgement in assessment. Results: Fairness is a multi-dimensional construct with components at environment, system and individual levels. Components influencing fairness include articulated and agreed learning outcomes relating to the needs of society, a culture which allows for learner support, stakeholder agency and learning (environmental level), collection, interpretation and combination of evidence, procedural strategies (system level) and appropriate individual assessments and assessor expertise and agility (individual level). Discussion: We observed that within the data at fractal, that is an infinite pattern repeating at different scales, could be seen suggesting fair judgement should be considered a complex adaptive system. Within complex adaptive systems, it is primarily the interaction between the entities which influences the outcome it produces, not simply the components themselves. Viewing fairness in assessment through a lens of complexity rather than as a linear, causal model has significant implications for how we design assessment programs and seek to utilise human judgement in assessment.

Reflecting on LTCOS Scholarship and Implications for Educational Practice.

The Long Term Career Outcome Study is a central program of research in the Center for Health Professions Education at the Uniformed Services University. The overarching goal of Long Term Career Outcome Study is to perform evidence-based evaluations before, during, and after medical school, and as such, it represents a form of educational epidemiology. In this essay, we highlighted the findings of the investigations published in this special issue. These investigations span from "before" medical school matriculation to "during" medical school and "after" learners go on to graduate training and practice. Furthermore, we discuss how this scholarship might shed light on improving the educational practices at the Uniformed Services University and potentially elsewhere. We hope that this work demonstrates how research can enhance medical education processes and connect research, policy, and practice.

A Comparison of HPSP and USU Graduates' Preparation for Residency.

INTRODUCTION: Military medical students enter residency through two main pathways: (1) The Uniformed Services University (USU) and (2) the Armed Services Health Professions Scholarship Program (HPSP). The purpose of this study was to compare how these two pathways prepare military medical students for residency. METHODS: We conducted semi-structured interviews with 18 experienced military residency program directors (PDs) in order to explore their perceptions of the preparedness of USU and HPSP graduates. We used a transcendental phenomenological qualitative research design to bracket our biases and guide our data analysis. Our research team coded each of the interview transcripts. We then organized these codes into themes, which served as the results of our study. RESULTS: Five themes emerged from our data regarding the residents' preparedness: (1) Ability to navigate the military culture, (2) understanding of the military's medical mission, (3) clinical preparation, (4) ability to navigate the Military Health System (MHS), and (5) teamwork. The PDs described how USU graduates better understand the military's medical mission and are more easily able to navigate the military culture and the MHS because of their lived experiences during military medical school. They also discussed the various levels of clinical preparation of HPSP graduates, in contrast to the USU graduates' more consistent skills and abilities. Finally, the PDs believed both groups to be strong team players. CONCLUSIONS: USU students were consistently prepared for a strong start to residency because of their military medical school training. HPSP students often experienced a steep learning curve because of the newness of the military culture and MHS.

Prior Enlisted Medical Students at the Uniformed Services University: Outcomes During Four Years of Medical School.

INTRODUCTION: The Uniformed Services University (USU) implemented the Enlisted to Medical Degree Preparatory Program (EMDP2) with the goal of enhancing the diversity of the military physician corps. Programs like EMDP2 can assist students in making the social and intellectual transition from undergraduate studies to medical school and beyond. These types of programs are also opportunities to reduce health disparities and prepare students to work in multicultural settings. The purpose of this study was to evaluate whether there was any significant difference in performance between USU medical students who had attended the EMDP2 and those who had not. MATERIALS AND METHODS: We compared the results of National Board of Medical Examiners (NBME) Clinical Science Subjects, United States Medical Licensing Examination (USMLE) Step 1, and USMLE Step 2 Clinical Knowledge exams of EMDP2 learners from the School of Medicine classes of 2020 to 2023 to those of four similarly sized cohorts of their peers who varied by age and prior military service. RESULTS: We found that the performance of EMDP2 graduates was comparable to their peers who followed more traditional and other alternative paths to medical school. For example, regression models showed that EMDP2 status was not a statistically significant predictor of average clerkship NBME exam score, nor of USMLE Step 1 failure. CONCLUSION: EMDP2 graduates performed on a par with their medical school peers, and EMDP2 status does not appear to influence NBME or USMLE performance. EMDP2 provides a focused curriculum and addresses the mandate to make medical education opportunities available to a more diverse population.

Addressing HPSP Learner Needs: A Pilot Study of a "Fundamentals of Military Medicine" Course.

INTRODUCTION: Military medicine is uniquely different from civilian medicine, and military physicians in the USA are primarily recruited through the Health Professions Scholarship Program (HPSP) and the Uniformed Services University of the Health Sciences (USUHS). Medical students at the USUHS receive more than 650 hours of military-specific curriculum and spend 21 days engaged in field exercises. HPSP students complete two 4-week officer training sessions during their 4 years of medical school. There is a clear discrepancy in preparation for military medicine between HPSP and USUHS students. The USUHS School of Medicine undertook an initiative to develop a fully online self-paced course on the fundamentals of military medicine topics to help HPSP students bridge the gap in their preparation. This article will describe how the online self-paced course was designed and present feedback from the pilot offering of this course. MATERIALS AND METHODS: As proof of concept of the effectiveness of an online self-paced course for teaching the fundamentals of military medicine to HPSP students, two chapters from the "Fundamentals of Military Medicine" published by the Borden Institute were transferred to an online format. Each chapter was offered as a module. In addition to the chapters, an introduction and closing module were added to the pilot course. The pilot course was offered over 6 weeks. Data for this study were obtained from module feedback surveys, pre- and post-course quizzes, participant focus groups, and course evaluation surveys. Pre- and post-test scores were analyzed to evaluate content knowledge. The open-ended survey questions on the feedback forms and focus group transcripts were collated and analyzed as textual data. RESULTS: Fifty-six volunteers enrolled in the study, and 42 completed the pre- and post-course quizzes. This participant pool included HPSP students (79%, n = 44) and military residents in civilian graduate medical education programs (21%, n = 12). The module feedback surveys showed that most participants spent 1 to 3 hours on each of the modules, which they rated as extremely or quite reasonable (Module 1: 64%, Module 2: 86%, Module 3: 83%). There was not much difference between the overall quality of the three modules. The participants found content on application to the military-specific context very valuable. Of the different course elements, video content was rated as the most effective. Participant feedback clearly highlighted that HPSP students want a course that informs them about the fundamentals of military medicine and demonstrates how the information would apply to their lives. Overall, the course was effective. HPSP students showed knowledge gains and self-reported satisfaction with the course's objectives. They were able to locate information easily and understand the course expectations. CONCLUSIONS: This pilot study has shown that there is a need for a course that provides the fundamentals of military medicine to HPSP students. A fully online self-paced course provides flexibility for the students and improves access.

Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159.

Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.

Gender and Racial Representation Trends Among Internal Medicine Department Chairs from 2010-2020.

BACKGROUND: Quality medical education, reduction in health disparities, and healthcare research that includes all members of society are enhanced by diversity in departments of internal medicine (IM). Research on increasing diversity within the academic medicine student body or faculty notes the important role of leadership. Yet, there is a scarcity in research into diversity in leadership. OBJECTIVE: The purpose of this study is to go beyond aggregate numbers and answer the question: What is the level of parity representation, by gender and race, at department chair positions in academic IM departments? DESIGN: A cross-sectional analysis of race/ethnicity and gender in IM medical school departments from 2010 to 2020 was conducted using data from the American Association of Medical College's (AAMC) Faculty Roster. The proportion of IM department chairs to IM faculty by race/ethnicity for each year (2010-2020) was used to calculate the Leadership Parity Index (LPI) in this study. LPI by gender and by gender and race/ethnicity were also calculated for each year. RESULTS: In aggregate numbers, Black or African American and Hispanic, Latino, or of Spanish Origin faculty remain under-represented in academic IM each making up, on average, approximately 4% of the total IM faculty. The LPI calculations revealed that faculty who identified as White were consistently over-represented as department chairs while Asian faculty were consistently under-represented in leadership and ranked lowest in leadership parity among the ethnic groups studied. The leadership parity index also showed that women faculty across all races were under-represented. CONCLUSION: Women and Asian faculty encounter a ceiling effect that may be at play in IM departments. While significant progress still needs to be made in the representation of under-represented minorities, the findings of this study show that aggregate data does not provide a true picture of equity and parity in Internal Medicine faculties.

Advancing the assessment of clinical reasoning across the health professions: Definitional and methodologic recommendations.

The importance of clinical reasoning in patient care is well-recognized across all health professions. Validity evidence supporting high quality clinical reasoning assessment is essential to ensure health professional schools are graduating learners competent in this domain. However, through the course of a large scoping review, we encountered inconsistent terminology for clinical reasoning and inconsistent reporting of methodology, reflecting a somewhat fractured body of literature on clinical reasoning assessment. These inconsistencies impeded our ability to synthesize across studies and appropriately compare assessment tools. More specifically, we encountered: 1) a wide array of clinical reasoning-like terms that were rarely defined or informed by a conceptual framework, 2) limited details of assessment methodology, and 3) inconsistent reporting of the steps taken to establish validity evidence for clinical reasoning assessments. Consolidating our experience in conducting this review, we provide recommendations on key definitional and methodologic elements to better support the development, description, study, and reporting of clinical reasoning assessments.

The pursuit of fairness in assessment: Looking beyond the objective.

Health professions education has undergone significant changes over the last few decades, including the rise of competency-based medical education, a shift to authentic workplace-based assessments, and increased emphasis on programmes of assessment. Despite these changes, there is still a commonly held assumption that objectivity always leads to and is the only way to achieve fairness in assessment. However, there are well-documented limitations to using objectivity as the 'gold standard' to which assessments are judged. Fairness, on the other hand, is a fundamental quality of assessment and a principle that almost no one contests. Taking a step back and changing perspectives to focus on fairness in assessment may help re-set a traditional objective approach and identify an equal role for subjective human judgement in assessment alongside objective methods. This paper explores fairness as a fundamental quality of assessments. This approach legitimises human judgement and shared subjectivity in assessment decisions alongside objective methods. Widening the answer to the question: 'What is fair assessment' to include not only objectivity but also expert human judgement and shared subjectivity can add significant value in ensuring learners are better equipped to be the health professionals required of the 21st century.

Design and Assessment of a Mobile Health Care Solution for the Military Pediatrician: The DHA Pediatrics App.

INTRODUCTION: Mobile health technology design and use by patients and clinicians have rapidly evolved in the past 20 years. Nevertheless, the technology has remained in silos of practices, patients, and individual institutions. Uptake across integrated health systems has lagged. MATERIALS AND METHODS: In 2015, the authors designed a mobile health application (App) aimed at augmenting the capabilities of clinicians who care for children within the Military Health System (MHS). This App incorporated a curated, system-based collection of Clinical Practice Guidelines, access to emergency resuscitation cards, call buttons for local market subspecialty and inpatient teams, links to residency academic calendars, and other web-based resources. Over the next 5 years, three Plan-Do-Study-Act cycles facilitated multiple enhancements for the App which eventually transitioned from the Android/iOS stores to a web browser. The "People At the Centre of Mobile Application Development" tool which has validity evidence captured user experience. The team assessed the App's global effectiveness using Google Analytics. A speed test measured time saved and accuracy of task completion for clinicians using the App compared to non-users. Finally, MHS medical librarians critiqued the App using a questionnaire with validity evidence. The Walter Reed National Military Medical Center Institutional Review Board reviewed the study and deemed it exempt. RESULTS: Clinician respondents (n = 68 complete responses across six MTFs, 51% graduate medical trainees representing a 7.4% response rate of active duty pediatrician forces) perceived the App to have appropriate qualities of efficiency, effectiveness, learnability, memorability, errors, satisfaction, and cognitive properties following App use in clinical practice. Google Analytics demonstrated more than 1,000 unique users on the App from May 1, 2020 to January 20, 2021. There were 746 instances (26% of all sessions) when a user navigated between more than one military treatment facility. App users were faster and more accurate at task completion during a digital scavenger hunt. Medical librarians measured the App to have acceptable usefulness, accuracy, authority, objectivity, timeliness, functionality, design, security, and value. CONCLUSIONS: The App appears to be an effective tool to extend a clinician's capabilities and inter-professional communication between world-wide users and six MHS markets. This App was designed-and used-for a large health care network across a wide geographic footprint. Next steps are establishing an enduring chain of App champions for continued updates and sharing the App's code with other military medical disciplines and interested civilian centers.

Clinical Reasoning Needs to Be Explicitly Addressed in Health Professions Curricula: Recommendations from a European Consortium.

Clinical reasoning entails the application of knowledge and skills to collect and integrate information, typically with the goal of arriving at a diagnosis and management plan based on the patient's unique circumstances and preferences. Evidence-informed, structured, and explicit teaching and assessment of clinical reasoning in educational programs of medical and other health professions remain unmet needs. We herein summarize recommendations for clinical reasoning learning objectives (LOs), as derived from a consensus approach among European and US researchers and health professions educators. A four-step consensus approach was followed: (1) identification of a convenience sample of the most relevant and applied national LO catalogues for health professions educational programs (N = 9) from European and US countries, (2) extraction of LOs related to clinical reasoning and translation into English, (3) mapping of LOs into predefined categories developed within the Erasmus+ Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators (DID-ACT) consortium, and (4) synthesis of analysis findings into recommendations for how LOs related to clinical reasoning could be presented and incorporated in LO catalogues, upon consensus. Three distinct recommendations were formulated: (1) make clinical reasoning explicit, (2) emphasize interprofessional and collaboration aspects of clinical reasoning, and (3) include aspects of teaching and assessment of clinical reasoning. In addition, the consortium understood that implementation of bilingual catalogues with English as a common language might contribute to lower heterogeneity regarding amount, structure, and level of granularity of clinical reasoning LOs across countries. These recommendations will hopefully motivate and guide initiatives towards the implementation of LOs related to clinical reasoning in existing and future LO catalogues.

Innovation Reports: Successes and Limitations for Promoting Innovation in Medical Education.

In 2013, Academic Medicine introduced a new article type, Innovation Reports, with the intent to promote innovation by providing a forum for publishing promising new ideas at an early stage of development. In this article, the authors examine Innovation Reports as a means for promoting innovation within the medical education community.The authors undertook a 2-part analysis. In July 2018, they examined submission data, Altmetric scores, and citations for the first 5 years of the feature. To explore authors' perceptions of the impact of publishing an Innovation Report, in October 2018, they conducted a web-based survey of corresponding authors.Between October 2013 and May 2018, 920 manuscripts were submitted under the Innovation Report category, of which 335 were sent for review and 151 were published (16% overall acceptance rate). The mean citation rate for the published Innovation Reports was 4.3 (range 0-47). The mean Altmetric Attention Score was 14.3 (range 0-441). An Altmetric score of 14 places an article in the top 20% of articles published in Academic Medicine.The 151 published Innovation Reports had 148 unique corresponding authors, of whom 85 (57%) responded to the survey. Almost all respondents (n = 82; 96%) reported that publishing an Innovation Report promoted their individual career growth. For many corresponding authors, the publication of early ideas in an Innovation Report appeared to be an end point rather than a springboard for further development and innovation, as only 14 (16%) reported publication of a subsequent related study.Reflecting on the successes and limitations of Innovation Reports over the first 5 years, the authors suggest that soliciting input from more stakeholders and being explicit about the goals of this article type would help inform how Innovation Reports should evolve in the future so they can better launch creative thought and spur innovation.

A situated cognition model for clinical reasoning performance assessment: a narrative review.

Background Clinical reasoning performance assessment is challenging because it is a complex, multi-dimensional construct. In addition, clinical reasoning performance can be impacted by contextual factors, leading to significant variation in performance. This phenomenon called context specificity has been described by social cognitive theories. Situated cognition theory, one of the social cognitive theories, posits that cognition emerges from the complex interplay of human beings with each other and the environment. It has been used as a valuable conceptual framework to explore context specificity in clinical reasoning and its assessment. We developed a conceptual model of clinical reasoning performance assessment based on situated cognition theory. In this paper, we use situated cognition theory and the conceptual model to explore how this lens alters the interpretation of articles or provides additional insights into the interactions between the assessee, patient, rater, environment, assessment method, and task. Methods We culled 17 articles from a systematic literature search of clinical reasoning performance assessment that explicitly or implicitly demonstrated a situated cognition perspective to provide an "enriched" sample with which to explore how contextual factors impact clinical reasoning performance assessment. Results We found evidence for dyadic, triadic, and quadratic interactions between different contextual factors, some of which led to dramatic changes in the assessment of clinical reasoning performance, even when knowledge requirements were not significantly different. Conclusions The analysis of the selected articles highlighted the value of a situated cognition perspective in understanding variations in clinical reasoning performance assessment. Prospective studies that evaluate the impact of modifying various contextual factors, while holding others constant, can provide deeper insights into the mechanisms by which context impacts clinical reasoning performance assessment.

Assessment of clinical reasoning: three evolutions of thought.

Although assessing clinical reasoning is almost universally considered central to medical education it is not a straightforward issue. In the past decades, our insights into clinical reasoning as a phenomenon, and consequently the best ways to assess it, have undergone significant changes. In this article, we describe how the interplay between fundamental research, practical applications, and evaluative research has pushed the evolution of our thinking and our practices in assessing clinical reasoning.