[Clinical reasoning and simulation: facilitating hypothesis prioritization using simulated patients. Data from quantitative research]

BACKGROUND

Prioritizing diagnostic hypotheses can be difficult for novice medical students given their limited clinical exposure. Simulated clinical reasoning (CR) clinics allow students to practice focused histories with a simulated patient (SP). The delivery of clinical data by SPs can influence hypothesis generation.

OBJECTIVE

This pilot study seeks to test whether the transmission of key elements through SP acting influences CR prioritization among medical students.

METHOD

The diagnostic hypotheses of two cohorts of students of the same academic level were compared following a virtual interview with an SP. The SPs in the experimental group were given a targeted script and briefing on key elements while the SPs in the control group were given a traditional script and briefing. The difference between the distributions of frequencies of the hypotheses of the two groups was determined using the chi-square calculation.

RESULTS

The students in the experimental group prioritized expert-validated hypotheses more than those in the control group. The control group showed greater variability in their diagnostic choices.

CONCLUSION

Targeting the delivery of key elements by SPs could be a way to help novice medical students prioritize their diagnostic hypotheses. Simulated CR clinics therefore become a space for learning about CR in the absence of clinical exposure. The risk of inducing premature closure of clinical reasoning needs further research.

The key-features approach to assess clinical decisions: validity evidence to date

The key-features (KFs) approach to assessment was initially proposed during the First Cambridge Conference on Medical Education in 1984 as a more efficient and effective means of assessing clinical decision-making skills. Over three decades later, we conducted a comprehensive, systematic review of the validity evidence gathered since then. The evidence was compiled according to the Standards for Educational and Psychological Testing's five sources of validity evidence, namely, Content, Response process, Internal structure, Relations to other variables, and Consequences, to which we added two other types related to Cost-feasibility and Acceptability. Of the 457 publications that referred to the KFs approach between 1984 and October 2017, 164 are cited here; the remaining 293 were either redundant or the authors simply mentioned the KFs concept in relation to their work. While one set of articles reported meeting the validity standards, another set examined KFs test development choices and score interpretation. The accumulated validity evidence for the KFs approach since its inception supports the decision-making construct measured and its use to assess clinical decision-making skills at all levels of training and practice and with various types of exam formats. Recognizing that gathering validity evidence is an ongoing process, areas with limited evidence, such as item factor analyses or consequences of testing, are identified as well as new topics needing further clarification, such as the use of the KFs approach for formative assessment and its place within a program of assessment.