A Qualitative Study Exploring the Relationship of Curricular Models to the Development of Clinical Reasoning Skills Among Medical Students

Dr. Khin-Htun, S.^1* & Dr. Kushairi, A.²

¹Medical Education Fellow and Honorary Assistant Professor, University of Nottingham, United Kingdom
²Faculty of Medicine and Health Sciences, University of Nottingham, United Kingdom

*Correspondence to: Dr. Swe Khin-Htun, Medical Education Fellow and Honorary Assistant Professor, University of Nottingham, United Kingdom.

Copyright © 2018 Dr. Swe Khin-Htun. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abbreviations (if used)
CR: Clinical reasoning
CP1: Clinical phase 1, the first clinical phase for University of Nottingham medical students, in third year of the undergraduate course and in the second year of the graduate course.
CP3: Clinical phase 3, the third and final clinical phase for University of Nottingham medical students, in fifth year of the undergraduate course and in the fourth year of the graduate course.
GEM: Graduate Entry Medicine, or the graduate entry course for medical students at the University of Nottingham
UoN: The University of Nottingham
PBL: Problem-based learning

Introduction
CR is an essential skill to successfully navigate the everyday world of medicine. CR has been defined as the ability to incorporate different types of knowledge, assess critical evidence and gain insight on the process for arriving at a diagnosis [1]. What exactly underpins and affects the development of CR skills in students has been a subject of debate. For one, the structure of medical school curriculum may influence the learning and cognitive processes of students. It has been suggested that the way students learn may be an important influence on the development of CR [2-6].

PBL has been described to contribute more to the development of CR compared to other models [7-15]. Moreover, PBL seemed to increase motivation, interest and self-directed learning skills in medical students [16].

However, numerous studies describe conflicting evidence on the positive effects of PBL on CR [5,17-24]. Both CR and problem-solving skills were only weakly associated with the PBL curriculum [25,26].

Interestingly, despite studies proving the superiority one curriculum over others, there would still be other factors influencing the development of CR [27]. The nature of these factors has been widely debated. For instance, proving the superiority of the PBL model is complicated by the wide variety of PBL styles within the model itself [17]. These authors emphasize that the research agenda should analyse specific aspects of PBL on defined variables rather than only focusing on the curriculum as a whole. Such studies would then contribute to a better understanding of the complex interactions and dynamics taking place within the PBL model that influences CR skills of students.

Furthermore, many of these studies were focused on comparing the traditional curriculum with PBL [14,28-31]. Only a few studies considered the other widely used type of curriculum, the integrated model, in addition to the problem-based and traditional curricula. The two main curriculum models discussed in this study are the PBL model and the integrated model. Moreover, many of these studies comparing the effect of different curricular by comparing the students’ performance on different CR tests. In contrast to existing literature, this novel study would purely explore the students’ opinion, beliefs and experiences without testing or observing their CR skills and performance.

Materials and Methods
During the pre-clinical stage at the UoN, undergraduate students learn via an integrated curriculum while graduate entry students undergo problem-based learning (PBL). While the two groups start the pre-clinical course on the two separate curriculum models, they then combine to enter the same course at the clinical stage from CP1 to the point of graduation. The researcher met the CP1 and CP3 students face-to-face, explained the aim of the study and distributed volunteer information sheets and an informed consent form. Those who consented to participating in the study were invited to be interviewed.

After identifying the point of data saturation, the total number of participants eventually included 28 students. From the integrated group, there were eleven CP3 and ten CP1 students. From the PBL group, there were seven CP3 students. Inductive thematic data analysis was conducted up to the manifest, semantic or explicit level. In reporting of results, each participating student was identified by code and a number. The code represented what phase they were in and whether they were in the PBL or integrated group. The number referred to the order in which the student was interviewed. For example, “CP3 I 1” represents the first interviewee from the integrated curriculum from CP3 and so on.

Results
In terms of difference in CR between integrated and PBL students, there was a range of responses leaning towards higher CR identified in PBL students. Students’ answers to the question “Do you notice any difference in the CR between PBL students and Integrated students?”

a. All final year integrated student believed that PBL students are better in CR at early clinical phase. An example quote from CP3 I 11 stated about PBL students:

“I think in that respect their knowledge is probably slightly better. Like coming up with differentials and things like that, they were a lot quicker. I remember on CP1 thinking some of the words they were using, I’d never heard them before, but as I read, then they were coming to me.”

b. Similarly, almost all CP3 PBL students agreed that their CR is better. One of them, CP3 P 6 was quoted as stating, about the integrated students:

“The knowledge of basic pathology and how it presents is not there really in a lot of cases. So they’re very scientific and have very little clinical, which I found quite surprising”

c. Among the CP1 students, half of the integrated students said that PBL students have better knowledge and application, for example from CP1 6:

d. However, one important caveat exists about the superiority of CR in PBL students over integrated students: the difference in CR only existed at the beginning of CP1. All CP3 students across both groups uniformly accepted that there was no discrepancy at all in CR skills at different points as the course progressed such as at the end of CP1, the entry of CP3 or during CP3. A student, CP3 I 10 was quoted as saying:

“By the end we were much a par with each other. I think it didn’t actually take that long to be honest. So I think it was only a couple of months--- you couldn’t tell anymore. I think we were all at a similar level then.”

The Effect of Curricular Model/Educational Strategies They Use in Pbl Curriculum
CP1 8 was quoted as saying:

“They’re used to not being spoon-fed and actually having to go and do it themselves whereas we’ve – learning what’s in the lecture slides.”

Many students deduced that GEM (PBL) students have better CR because of the curriculum model. The undergraduate (integrated) students concluded that their curriculum had more emphasis on basic sciences while the GEM course was more clinically-based. CP3 I 9 stated:

“I find it really helpful to have the solid systematic approach – they were already thinking in that directions, whereas we were still thinking in the opposite direction where if you told us, ‘How does a heart attack present?’ then we could tell you, ‘Oh yes. Chest pain’ – but if you said, ‘You’ve got a patient with chest pain’, we wouldn’t have necessarily have thought of a heart attack.”

The PBL environment was envisioned as grounding for CR and made the PBL students far ahead of the integrated group. On the integrated group, a PBL student CP3 P 2 said: “I think they learnt in the traditional way of lectures and workshops and things whereas we always had a clinical perspective – and how you move forwards as a doctor to deal with it, which helped us learn a lot of information very quickly.”

Among the CP1 students, the PBL students were better in CR possibly because they were more comfortable with a case approach learning. CP3 integrated students also reaffirmed that PBL students have had earlier exposure to clinical cases and could pick out clinical signs more quickly.

The Other Factors That Affect CR
While there was a clear difference in CR between the undergraduate integrated students and the graduate PBL students at the start of clinical placement 1, this may not all be attributed to the difference in curriculum model. Several themes emerged from the students that may also contribute to the difference in CR.

Firstly, PBL students were said to have more confidence than the integrated students, said a student, CP1 3:

“I think they’ve got the confidence to just keep attempting, whereas we’re more shy maybe.” The students believed that the superior CR skills of the GEM students were due to their confidence that came with age. One undergraduate student, CP3 I 10 said: “It might just be a confidence thing and the fact that a lot of the GEM students are a lot older than the undergrads.”

A second theme that emerged as possibly contributing to the difference in CR was timing. The integrated students had spent one semester on their research projects before starting clinical phase. PBL students believed that the timing of the start of clinical phase contributed to a drop in their CR skills. For instance, one PBL student stated:

“I think part of it was because we’d (PBL) come straight from exams. So we were already sort of primed and sort of in running mode, whereas they’d (integrated) had like a few weeks off – and their projects. So they’d just come back from a break.” (CP3 P 3)

Motivation was also mentioned to be a factor in the superiority of the GEMs’ CR skills. One integrated student, CP3 I 9 spoke of the enthusiasm of the GEM students:

“They wanted it a lot more, you know, you’re a GEM (PBL) student. You’ve gone through a lot more to get into medical school in the first place and I think they worked a lot harder than we did to make themselves ready for CP1.”

The backgrounds of the GEM students were also touched on to affect CR skills. One PBL student recalled the fact that integrated students had less exposure to patients prior to clinical phase. A lot of the PBL students claimed to have come from clinical backgrounds so they were more used to think from a clinical perspective. As stated by a PBL student, CP3 P 6:

“I’ve been a paramedic for many years before being a medical student. So I’ve – an amount of clinical acumen before (and) some CR and this has sort of added to it.”

Finally, related to age, the increased life experience of the PBL students were said to contribute to their increased CR skills. A PBL student, CP3 P 6 stated about the integrated students:

“Their experience of talking to patients is not as good as the GEMS (PBL) I would say. A lot shyer, which is obviously an age thing as well and experience.”

Another student, CP3 9 said:

“I think it’s more about where you’ve ended up for training, your placement at CP3 stage rather than whether you started out as a GEM (PBL) or an undergrad (integrated).”

Discussion
In this study, more than 90% participants declared that PBL students were better at CR and CP3 PBL students stressed that experience on the GEM course consolidated their experience in reality. For example, in the integrated curriculum, the students attended lectures on many diseases whereas the PBL course was more symptom-focused with a symptom-to-diagnosis approach. There are many causes of abdominal pain but the patient must have one definite diagnosis in order to receive the right management which must all be worked out by the clinician.

Another factor brought up by students that influenced CR acquisition was the ‘research year’ underwent by integrated students before starting their clinical phase. Even in other PBL courses, such a feature can affect the development of CR. Goss et al conducted a study in 2011 to examine the effectiveness of the PBL curriculum on the development of diagnostic reasoning skills in medical students. They found that students on a traditional curriculum had higher flexibility in thinking and memory structure, and consequently had a higher level of diagnostic reasoning than students on the PBL curriculum [32]. The reason for these results may be explained by the PBL curriculum model where there was a research year before the clinical years. In our study, the integrated students had a research module before CP1 while the PBL students did not.

Other possible factors mentioned that influenced the difference between the PBL and integrated group was not only the curriculum model and the educational strategies used in PBL but also the timing of research year, confidence, life experience, motivation, as well as clinical background. CR takes account of patient and environmental factors, as well as motivation, emotional state, knowledge, experience, communication, confidence and personality. All these factors shape and modify a clinician’s thinking in conscious and unconscious ways, resulting in variable clinical performance.

One key finding of this study was that all CP3 groups uniformly accepted that there was no discrepancy at all in CR after CP1 has progressed and exposure to clinical practice may have an impact on CR development. Da Silva (2013) studied such aspects in a traditional medical school (Coimbra, Portugal), and more contemporary integrated curriculum as well as a problem-based curriculum (UoN) [33]. The authors found that although there were significant differences in CR ability of PBL students compared to traditional students, the difference diminishes when students progressed to their final year suggesting that towards graduation there were no differences in CR based on the type of pre-clinical curriculum. The similar results are noted by Groves, O’rourke, & Alexander, 2003 [34]. The finding that the discrepancy in CR skills diminish in the later stages of the course contributes to the evidence that progression in the clinical course and exposure to clinical practice may enhance CR development.

Although multiple studies have examined the effect of curriculum model on CR, its role in enhancing the development of CR is still not well understood [7,19,32,35,36]. Most findings were contradictory and there was no consensus on a single best curriculum model to enhance CR skills.

Conclusions
Our study found that PBL students were described by themselves and their peers to have better CR skills than students in the integrated course. However, this difference only existed at the start of CP1 and disappears as the course progressed. There was evidence for the difference in educational strategies and exposure to clinical practice influencing the discrepancy in CR skills. The lack of difference in CR skills between the two groups in the later stages of the course suggests the positive effects of progression in the clinical course and exposure to clinical practice on the development of CR. Similarly, there were emergent themes of factors outside the curriculum model that affected the greater CR skills of PBL students such as difference in confidence levels, timing of clinical phase, motivation, background and life experience. More research is needed into the role of pre-clinical curriculum models in developing the CR skills of future clinicians.

Bibliography

1. Naveed, T. & Bhatti, N. M. (2017). reliability of a direct observational tool to assess clinical reasoning (DOT-CR). Pakistan Oral and Dental Journal, 37(2), 302-305.
2. Anderson, K., Peterson, R., Tonkin, A. & Cleary, E. (2008). The assessment of student reasoning in the context of a clinically oriented PBL program. Medical Teacher, 30(8), 787-794.
3. Medin, D. L., Altom, M. W. & Murphy, T. D. (1984). Given versus induced category representations: Use of prototype and exemplar information in classification. Journal of Experimental Psychology: Learning, Memory, and Cognition, 10(3), 333-352.
4. Naumann, F., Yang, J. L., Thai, T., Ford, C. & Polly, P. (2016). Virtual patient consultations and the use of an ePortfolio assessment to support student learning of integrated professional skills. Focus on Health Professional Education: A Multi-Disciplinary Journal, 17(3), 69-80.
5. Patel, V. L., Groen, G. J. & Norman, G. R. (1993). Reasoning and instruction in medical curricula. Cognition and Instruction, 10(4), 335-378.
6. Schmidt, H. G., Dauphinee, W. D. & Patel, V. L. (1987). Comparing the effects of problem-based and conventional curricula in an international sample. Academic Medicine, 62(4), 305-315.
7. Patel, V. L., Groen, G. J. & Norman, G. R. (1991). Effects of conventional and problem-based medical curricula on problem solving. Medical Education, 66(7), 380-389.
8. Hmelo, C. E. (1998). Cognitive consequences of problem-based learning for the early development of medical expertise. Teaching and Learning in Medicine, 10(2), 92-100.
9. Prosser, M. & Sze, D. (2014). Problem-based learning: student learning experiences and outcomes. Clinical linguistics and phonetics, 28(1-2), 131-142.
10. Choi, E., Lindquist, R. & Song, Y. (2014). Effects of problem-based learning vs. traditional lecture on Korean nursing students’ critical thinking, problem-solving, and self- directed learning. Nurse education today, 34(1), 52-56.
11. Martyn, J., Terwijn, R., Kek, M. Y. & Huijser, H. (2014). Exploring the relationships between teaching, approaches to learning and critical thinking in a problem-based learning foundation nursing course. Nurse education today, 34(5), 829-835.
12. Bassir, S. H., Sadr-Eshkevari, P., Amirikhorheh, S. & Karimbux, N. Y. (2014). Problem-based learning in dental education: a systematic review of the literature. Journal of dental education, 78(1), 98-109.
13. Savery, J. R. (2015). Overview of problem-based learning: Definitions and distinctions. Essential readings in problem-based learning: Exploring and extending the legacy of Howard S.

14. Dolmans, D., Michaelsen, L., Van Merrienboer, J. & van der Vleuten, C. (2015). Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds! Medical teacher, 37(4), 354-359.
15. Hoffman, K., Hosokawa, M, Blake, R. Jr., Headrick, L. & Johnson, G. (2006). Problem-based learning outcomes: ten years of experience at the University of Missouri-Columbia School of Medicine. Academic Medicine, 81(7), 617-625.
16. Norman, G. R. & Schmidt, H. G. (1992). The psychological basis of problem-based learning: A review of the evidence. Academic Medicine, 67(9), 557-565.
17. Albanese, A. (2000). Reviews of the effectiveness of problem-based learning.
18. Norman, G. R. & Schmidt, H. G. (2000). Effectiveness of problem-based learning curricula: theory, practice and paper darts. Medical Education, 34(9), 721-728.
19. Schmidt, H., Machiels-Bongaerts, M., Hermans, H., Ten Cate, O., Venekamp, R. & Boshuizen, H. (1996). The development of diagnostic competence: A comparison between a problem-based, an integrated, and a conventional medical curriculum. Academic Medicine, 71(6), 658-664.
20. Gross, M., Moore, Z. E., Gardner, F. L., Wolanin, A. T., Pess, R. & Marks, D. R. (2016). An empirical examination comparing the Mindfulness-Acceptance-Commitment approach and Psychological Skills Training for the mental health and sport performance of female student athletes. International Journal of Sport and Exercise Psychology, 16(4), 431-451.
21. Prince, K. J., Van De Wiel, M., Scherpbier, A. J., Can Der Vleuten, C. P. & Boshuizen, H. P. (2000). A Qualitative Analysis of the Transition from Theory to Practice in Undergraduate Training in a PBLMedical School. Advanced in Health Science Education, Theory and Practice, 5(2), 105-116.
22. Nafea, E. (2015). CR in dental students: A comparative cross-curricular study Doctoral Dissertation. University of Nottingham.
23. Kaufman, D. R., Yoskowitz, N. A. & Al, E. (2008). Clinical reasoning and biomedical knowledege: implications for teaching. In: HIGGS, J., JONES, M. A., LOFTUS, S. & AL, E. Clinical Reasoning in the Health Professions. (3^rd Ed). Philadelphia: Elsevier.
24. Boshuizen, H. P. A. (2003). Expertise development: How to bridge the gap between school and work. In Boshuizen, H. P. A. Expertise development: The transition between school and work. Open Universities Nederland, 7-31.
25. Koh, G., C., Khoo, H. E., Wong, M. L. & Koh, D. (2008). The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ, 178(1), 34-41.
26. Mamede, S., Schmidt, H. G. & Geoffrey, R. (2006). Innovations in Problem-based Learning: What can we Learn from Recent Studies? Advances in Health Sciences Education, 11(4), 403-422.
27. Norman, G. & Eva, K. (2003). Doggie diagnosis, diagnostic success and diagnostic reasoning strategies: An alternative view. Medical Education, 37(8), 676-677.
28. Findyartini, A., Hawthorne, L., McColl, G. & Chiavaroli, N. (2016). How clinical reasoning is taught and learned: Cultural perspectives from the University of Melbourne and Universitas Indonesia. BMC medical education, 16(1), 185-198.
29. Neufeld, V., Norman, G., Feightner, J. & Barrows, H. (1981). Clinical problem-solving by medical students: A cross-sectional and longitudinal analysis. Medical Education, 15(5), 315-322.
30. Servant, V. F. & Schmidt, H. G., (2016). Revisiting foundations of problem‐based learning: some explanatory notes. Medical education, 50(7), 698-701.
31. Stanczyk, K., Hruskocy, C., Houston, C. & Ligeikis, K. (2015). Efficacy of Problem-Based Learning in an Integrated Skills Course at Improving the Clinical Reasoning Skills of Dietetics Students. Journal of the Academy of Nutrition and Dietetics, 115(9), A64-A79.
32. Goss, B., Reid, K., Dodds, A. & McColl, G. (2011). Comparison of medical students’ diagnostic reasoning skills in a traditional and a problem based learning curriculum. International Journal of Medical Education, 2, 87-93.
33. Da Silva, A. (2013). Clinical Reasoning Development in Medical Students: An Educational and Transcultural Comparative Study. PhD Dissertation. The University of Nottingham.
34. Groves, M., O’rourke, P. & Alexander, H. (2003). The association between student characteristics and the development of clinical reasoning in a graduate-entry, PBL medical programme. Medical Teacher, 25(6), 626-631.
35. Patel, V. L., Evans, D. A. & Groen, G. J. (1989). Reconciling basic science and clinical reasoning. Teaching and Learning in Medicine, 1(3), 116-121.
36. Sefton, A., Gordon, J. & Field, M. (2008). Teaching clinical reasoning to medical students. In: Higgs, J., Jones, M. A., Loftus, S. & Christensen, N. Clinical Reasoning in the Health Professions. Philadelphia, Elsevier, (pp. 249-276).