Keywords

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If clinical reasoning is considered critical for any physician and an ability a student should acquire during undergraduate medical education, then educators should attempt to assess whether students satisfactorily meet this objective.

In earlier chapters we have establish that clinical reasoning has two components: analytic reasoning and nonanalytic reasoning (i.e., pattern recognition ). Hence these two may be the focus of assessment: (1) Do students understand physiology and the pathophysiologic mechanisms and enabling conditions that lead to disease and consequently recognize signs and symptoms observable in patients? and (2) Do students build a mental repository of illness scripts that allow them to recognize patterns in the patients they encounter?

Clearly these objectives require substantial medical knowledge and substantial experience in patient care. And if clinical reasoning by definition, as some say, must include the context in which the physicians works (Woods and Mylopoulos 2015), how reasonable is it to test preclinical student on their clinical reasoning ability? According to Bowen and Ilgen, diagnostic reasoning is not a discrete, enduring, or reliably measurable skill. Accurate measurement in fact requires an observer to interpret processes that are heavily context dependent, usually not explicitly articulated, and often occur below conscious awareness of the observed clinician (Bowen and Ilgen 2014). Nevertheless, authors have attempted to infer progress in clinical reasoning ability across years using a written progress test (Williams et al. 2011).

Case-based clinical reasoning education, or any other approach recommended for preclinical education, attempts to prepare students for clinical encounters. While assessing clinical reasoning in context may not be reasonable for these students, a more limited approach, using written test approaches, is possible. Analytic reasoning is practiced in basic science or integrated courses, and pattern recognition ability may already be acquired on a very basic level. The CBCR course, as described in Part II of this book, has the deliberate intention to help students build a limited illness script mental repository for a number of common medical conditions including the differential diagnosis of adjacent conditions. This can be the focus of a test.

Without mentioning the word validity, these introductory sentences pertain to validity. The validity of educational and psychological tests has been reconceptualized in the past decades by scholars such as Messick and Kane (Cook et al. 2015). The validity of a test should be argued from the perspective of the content, response process , internal structure, relationship to other variables, and consequences of the test (AERA/APA/NCME 2014; Downing 2003). For clinical reasoning in preclinical students, the consequences should be the readiness to encounter patients in the clinical setting. The content should focus on important knowledge to allow analytic reasoning as can be expected in such encounters and for the recognition of patterns they have encountered in preclinical education. Response processes, or the way questions in such tests are asked, should resemble the clinical thinking pathways that happen in such encounters and the relationship to other variables may be a hindsight evaluation whether students with a high score indeed seem to do well in clinical reasoning in practice. While we have stressed the limitations in clinical reasoning that must be faced in the preclinical period, it is important to simulate situations they will face once they assume patient-related clinical tasks. As assessment is a powerful stimulus for learning, tests should be designed in such a way that students spend their energy optimally in anticipation of clinical encounters.

Current Methods of Assessing Clinical Reasoning

Educators looking for methods to assess clinical reasoning will find most recommended approaches to be used in clinical education, such as at the bedside, and only few focusing on the testing of reasoning in the preclinical phase, e.g., in a written test format. In terms of Miller’s four-level pyramid of assessment in medical education (knows – knows how – shows how – does), the highest three are all to some extent suitable for the assessment of clinical reasoning (Miller 1990). A “knows how” test would present a patient case and asks the candidate to arrive at a diagnosis and/or a therapy. During a “shows how” test, an examiner would ask the student to clinically reason in a standardized patient encounter such as during an objective structured clinical examination (OSCE) , and an assessment at the “does” level would ask a student to reason related to a real patient case in the hospital. Table 5.1 summarizes some frequently used, or specifically designed, methods to assess clinical reasoning with reference to Miller’s Pyramid. In addition to this list, a specific test format has been developed for CBCR courses, which is discussed in Chap. 7.

Table 5.1 Approaches to the assessment of clinical reasoning from the literature
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For preclinical students, Miller’s levels of shows how and does are less applicable. To assess students’ clinical reasoning ability in students before they encounter patients, a written or electronic test format is more suitable for several reasons. Cohort of students can be tested at once, standards can be set, and reliable scores can be generated. One can argue that clinical reasoning should ideally measure actual performance. That would yield the best construct alignment between the goals and objectives , what is taught, and what is tested.

For CBCR courses with large numbers of students a written, or preferably an electronic, test format is recommended to establish a reliable examination. In a recent literature review on question types for clinical reasoning tests suitable for electronic tests, Van Bruggen and colleagues identified eight types (van Bruggen et al. 2012): script concordance test questions, extended matching questions, comprehensive integrative puzzle questions, modified essay/short-answer questions, long-menu questions , multiple-choice questions, and true/false questions. The latter two were identified as least suitable, and we added two formats, all briefly discussed in Table 5.2. Features from different formats have been combined in the CBCR test format explained more extensively in Chap. 7.

Table 5.2 Questions suitable for written or electronic assessment of clinical reasoning ability
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Almost all of the test forms in Table 5.2 use a key-feature approach. Key-feature questions focus on critical steps in the solution of a clinical problem and may pertain to aspects that learners generally find difficult or that are critical in patient management (Page et al. 1995). The development of the key-feature approach in the 1990s was a move away from the traditional assessment of clinical reasoning using a comprehensive examination of a patient management problem (Page and Bordage 1995). A recent review reconfirmed the generally favorable psychometric properties of question types derived from the key-feature approach (Hrynchak et al. 2014).

In this chapter, we have provided a brief overview of current methods assessment of clinical reasoning, with a focus on methods suitable for preclinical students in a written fashion. We acknowledge this overview is limited. An excellent recent overview of more clinically oriented approaches was provided by Rencic and colleagues (2016). In addition, many studies have been conducted to measure clinical reasoning ability, and several of these have used experimental outcome measures that might be suitable for standard assessment at some time. Computer-based tests (Kunina-Habenicht et al. 2015), virtual reality assessment (Forsberg et al. 2016), eye-tracking (Kok and Jarodzka 2017), neuroimaging (Durning et al. 2015), and other sophisticated methods require however further evaluation before they translate to established and feasible methods, meeting Van der Vleuten’s utility criteria of reliability , validity, cost-effectiveness, educational impact and acceptability, and other useful measures of quality (van der Vleuten and Schuwirth 2005).