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This chapter introduces the concept of clinical reasoning. It attempts to define what clinical reasoning is and what its features are. Solving clinical problems involves the ability to reason about causality of pathological processes, requiring knowledge of anatomy and the working and pathology of organ systems, and it requires the ability to compare patient problems as patterns with instances of illness scripts of patients the clinician has seen in the past and stored in memory.

The purpose of the book, supporting the teaching of clinical reasoning before students enter the clinical arena, faces the paradoxical problem of the lack of clinical experience that is so essential for building proficiency in clinical reasoning. So where to start if students are to be best prepared for first clinical encounters?

The method of case-based clinical reasoning is summarized and explained in its potential to provide early rudimentary illness scripts through elaboration and systematic discussion of the courses of action between the initial presentation of the patient and the final steps of clinical management. Meanwhile, the method requires student to apply knowledge of anatomy, physiology, and pathology.

The CBCR method has been applied successfully in several medical schools over a period of decades, and support for its validity is provided.

This chapter provides a general background and summarizes the CBCR method.

This chapter discusses how across the ages clinical reasoning has evolved, and has been affected by religious and societal influences, and how historical healers and physicians have contributed to what is now called clinical reasoning.

The reader follows from the early days of Hippocrates and Galen with their humoral theory (disease caused by disturbance in yellow bile, black bile, blood, or phlegm) to the first descriptions of bedside teaching described in Padua in 1543. A significant impetus to bedside teaching was given in Holland’s Golden Age by Van Straaten, Van Heurne, and above all Herman Boerhaave, who integrated contemporary theoretical knowledge and clinical experience and was known for his clinical teaching throughout Europe, even indirectly influencing educators in the United States through the Edinburgh school, which was heavily influenced by Boerhaave. In the mid-eighteenth century, Thomas Bond added a new dimension by predicting findings in autopsies based on clinical signs and symptoms; by using feedback from failed predictions for learning and improvement, he moved clinical medicine one additional step ahead. Another famous educator, Sir William Osler, introduced the discipline of differential diagnosis in the late nineteenth century. In the early twentieth century, Abraham Flexner saw the clinic as a laboratory for investigation and learning, just as he had stressed the importance of basic science as a grounding for rational medicine. Half a century later, computer-aided instruction, patient management problems, artificial intelligence, and problem-based learning were introduced. Meanwhile Elstein’s research findings in 1978 showed that experience determines expertise more than any general reasoning skill – “there is not much that formal theories of problem solving, judgment and decision making can do to facilitate this slow process.” Case specificity in clinical reasoning was found to reveal that knowledge about diseases heavily determines the quality and success of reasoning.

The chapter concludes with a few general recommendations for the teaching of clinical reasoning.

Rather than a historical overview as in Chap. 2, this chapter provides the reader with insight into the various approaches that have been used to understand clinical reasoning. We review concepts and major scholars who have been involved in such investigations. Cognitive psychologists Newel and Simon theorized about problem-solving skills and artificial intelligence and initiated the use of computers as metaphors of thinking. Elstein and colleagues found that there is no such thing as a general problem-solving skill, independent of medical knowledge, and thus clinical reasoning is case specific. Reasoning then became analyzed in approaches, including from data to diagnosis; with nature, from hypothesis to diagnosis; and to understand early hypothesis generation that is so characteristic in clinical reasoning, elaborated by Patel and colleagues. Bordage introduced to characterize how physicians may remember illness presentations and to denote the shortened conceptual language and labels physicians use to store medical information systematically in memory. represent how encounters with diseases are remembered by physicians and were introduced by Feltovich and Barrows. Schmidt and Boshuizen elaborated the concept further and propose as a hypothetical process that happens when physicians regularly and routinely apply shortcuts in thinking typically ellaborated as pathophysiology. Reasoning ability appears not only to be case specific-- it is also situation or . Clinicians with broad reasoning ability have extensive experience. with many cases and in varying contexts is recommended by Ericsson to acquire reasoning expertise. To improve reasoning, some authors have focused on and error prevention. Norman, however, concludes that bias reduction strategies are unlikely to be successful but correcting knowledge deficiencies is likely to lead to reasoning success. Kahnemann promoted and thinking for instant (nonanalytic reasoning) and . What actually happens in the brain during clinical reasoning is the domain of neuroscience, which may provide insights from research in the near future.

This chapter focuses on six necessary skills and habits of clinicians that may receive attention in medical school before students engage in the clinical ward:

The method of case-based clinical reasoning for preclinical students meets most if not all of these requirements.

This chapter provides a brief overview of methods for the assessment of clinical reasoning ability with brief summaries and references to more elaborate descriptions.

While the assessment of preclinical students has inherent limitations in terms of what may be achieved in education before patient encounters, several useful methods have been described.

This chapter describes in detail how a CBCR course can be organized. All roles of students, peer teachers, and consultants are discussed, as well as the materials, required facilities, and coordinator tasks. A variation, using senior medical students acting as consultant, is described. A brief section on effectiveness concludes the chapter.

This chapter discusses a test format that has been used to evaluate whether students meet the objectives of a CBCR course. The test closely resembles the discussion format during CBCR sessions and combines features of a number of established tests designed for the asssessment of clinical reasoning that have appeared in the literature. Psychometric evaluation data of 12 test administrations in the past are provided.

The chapter concludes with guidelines for the writing of CBCR test items.

This chapter guides clinicians through the process of writing cases. The chapter includes a template, and prospective authors of cases are advised to start with creating this template in a Word file, ready for multiple cases.

Writing, reviewing, and rewriting a case may take several days, but great cases can be used many times and even exchanged with other institutions, as if were they an academic publication.

This chapter introduces the reader with general concepts of curriculum, curriculum development, and faculty development. Then these concepts are applied to CBCR. Seven components of curriculum development for CBCR are derived from Kern’s six-step approach, and four components of faculty development for CBCR courses are recommended.

The chapter concludes with a case study of implementing CBCR at Tbilisi State Medical University in the period 2011–2014 and lessons learned from this project.

This chapter is written as a draft template for a study guide, based on experiences at the University Medical Center Utrecht. Local details without generalizable usefulness have been left out. The description can serve as a format to write a CBCR study guide and to adapt to local needs. The following should be kept in mind: