Clerkship Students' Use of Clinical Reasoning Concepts After a Pre-clinical Reasoning Course

BackgroundMany medical schools have incorporated clinical reasoning (CR) courses into their pre-clinical curricula to address the quality and safety issue of diagnostic error. It is unknown how students use concepts and practices from pre-clinical CR courses once in clerkships.ObjectiveWe sought to understand how students utilize CR concepts from a pre-clinical course during clerkships and to identify facilitators and barriers to the use of reasoning concepts.DesignWe used structured interviews to gain insight into medical students' experiences with CR concepts in clerkships.ParticipantsWe interviewed 16 students who had completed a pre-clinical CR course and subsequently completed a neurology, internal medicine, or pediatrics clerkship.ApproachWe used constructivist grounded theory to perform a qualitative analysis and to develop a theoretical model to describe findings.Key ResultsInsights fell into three main areas: (1) CR concept carryover, representing concepts taught in the CR course, such as problem representation, illness scripts, schema, and prioritized differential diagnosis, which were utilized in clerkships; (2) CR concept reinforcers, which included the clerkship setting and supervising physicians who emphasized and provided feedback on CR; and (3) CR concept diminishers, which included time constraints and supervisors who were unfamiliar with or did not reinforce CR concepts.ConclusionsConcepts taught in a pre-clinical CR course influenced how students prepared for and navigated clinical encounters. Contextual factors both enhanced and inhibited the utilization of CR concepts. Our findings align with social learning theories including social cognitive theory and ecological psychology. This contextual view-taking into account interactions between personal, social, and environmental factors-can help educators integrate CR education from the classroom to the clinical setting.