Clinical Reasoning and Written Communication Educational Strategies Assessment Challenges

Definition of Clinical Reasoning the ability to select and use information effectively in solving problems…a teachable cognitive skill independent of specific clinical knowledge. Elstein et al, 1978

Educational Strategies: Clinical Reasoning Historically – assumed student learned in clinical years Integrated into comprehensive clinical skills course (Example: WV-SOM) Specific Differential Diagnosis course (Example: UNE-COM) Case-based learning

Strategy: Case-based Learning Students are given detailed subjective information: Chief complaint/history of present illness Past medical history Personal health influencing behaviors Family medical history Sexual history Social history and lifestyle Review of systems

Strategy: Case-based Learning Students are given detailed objective information: Vital signs General appearance Results of physical exam

Strategy: Case-based Learning Students are given tasks to guide analysis of the case. Construct differential diagnosis for chief complaint. List symptoms and identify significant abnormalities of this patient. Identify conditions in differential diagnosis that may apply to this patient. List and explain diagnostic recommendations. Students are then given requested diagnostic results. Construct a management plan (including OMM) for this patient. Discuss biopsychosocial aspects of case.

Written Communication SOAP Notes Larry Weed: Problem Oriented Medical Record (POMR) in 1968 SOAP (Subjective, Objective, Assessment, Plan) note written for each problem Purpose: reflection of clinical reasoning

Educational Strategies: Written Communication Historically – assumed students learned in clinical years Students write SOAP notes on real clinical patient encounters (Example: WV-SOM) Students write SOAP notes on standardized patient encounters (Example: UNE-COM) Feedback provided by faculty

Strategy: OU-COM Focus on active learning First term: Introductory lecture Faculty member provides history Individual students write a SOAP note Faculty member provides feedback Small groups write SOAP note on volunteer group member history Faculty provide feedback

Strategy: OU-COM Focus on active learning Remainder of first and second years: Complete or partial SOAP notes for every standardized patient encounter SOAP notes reviewed by faculty or critiqued by peers

Assessment: Clinical Reasoning Skills Written exams SOAP note evaluations OSCEs Comprehensive Integrative Puzzle (CIP)

Challenges: Clinical Reasoning Skills and Written Communication Electronic Medical Records (EMR) Joint Commission limitations on student charting