University of Lynchburg DMSc Doctoral Project Assignment Repository

University of Lynchburg DMSc Doctoral Project Assignment Repository


Medical Education


Dr. Laura Witte, PhD, PA-C



CONTEXT: Medical students have traditionally been taught clinical reasoning (CR) skills during the clinical clerkship years of their education. There has been a push to include CR courses in pre-clinical education to improve students’ diagnostic reasoning before starting their clerkship. It is not clear which instructional interventions are the most effective at improving CR skills at this stage of education. The purpose of this article is to review the available empirical research on the pedagogy of pre-clinical medical CR instruction.

METHODS: A systematic review of the literature on CR instruction was conducted. Searches on PubMed, Google Scholar, and ERIC were performed for articles published from June 2012 to September 2022. Additional publications were identified from the references cited in the original papers. Instructional approaches were categorized, and empirical findings were noted. Forty-four articles were initially identified. Twenty-five studies met the inclusion criteria for this review.

RESULTS: The approaches to CR instruction varied. Eighteen studies compared case-based learning formats. Two studies compared traditional lectures to team-based learning. The five remaining studies applied either simulation, Bayesian reasoning, problem-solving exercises, walking, or error-based instruction. Twenty-three studies reported improvement in student CR scores after the intervention.

CONCLUSIONS: Several educational interventions are effective for teaching CR skills to medical students, but the effectiveness of each intervention is dependent on the medical knowledge of the students at the time of the intervention. Students with low clinical knowledge derive the most benefit from approaches that require them to draw connections between the pathophysiology of disease and the clinical signs and symptoms. Instructional approaches using self-explanation and illness script formation are the most beneficial at this stage. As students gain a larger fund of medical knowledge, case-based instruction with deliberate reflective practice confers improved CR skills. The format of case delivery has no discernable effect on learning outcomes. Whole-case vs serial-cue had similar results, and students performed equally well after paper cases, video cases, and live case discussion groups. Similarly, the level of authenticity, or similarity to actual practice, has no measurable effect on learning outcomes. Error-based instruction increases the cognitive load on students with low self-efficacy to the point of being detrimental to learning. Process-oriented approaches to instruction were shown to be largely ineffective at all phases of training.


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