Journal of General Internal Medicine

, Volume 32, Issue 11, pp 1242–1246 | Cite as

Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors

  • Joseph Rencic
  • Robert L. TrowbridgeJr
  • Mark Fagan
  • Karen Szauter
  • Steven Durning
Original Research



Recent reports, including the Institute of Medicine’s Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools.


To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning.


Cross-sectional multicenter study.


US institutional members of the Clerkship Directors in Internal Medicine (CDIM).

Main Measures

Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school’s clinical reasoning curriculum.

Key Results

The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers.


Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.



The authors wish to thank the CDIM Survey and Scholarship Committee for their contributions to this manuscript.

Author Contributions

All authors contributed to study concept and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and descriptive statistical analysis. The CDIM Survey Committee aided in data acquisition.

Dr. Rencic had full access to all of the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis.



Compliance with Ethical Standards

Ethical Approval

The study was approved by the institutional review board at the Washington D.C. VA Medical Center in April 2015.

Conflict of Interest

The authors declare that they have no conflict of interest.

Supplementary material

11606_2017_4159_MOESM1_ESM.docx (421 kb)
ESM 1 (DOCX 420 kb)


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Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Joseph Rencic
    • 1
  • Robert L. TrowbridgeJr
    • 2
  • Mark Fagan
    • 3
  • Karen Szauter
    • 4
  • Steven Durning
    • 5
  1. 1.Tufts Medical CenterBostonUSA
  2. 2.Maine Medical CenterPortlandUSA
  3. 3.Rhode Island HospitalProvidenceUSA
  4. 4.University of Texas Medical BranchGalvestonUSA
  5. 5.Uniformed Services University of the Health SciencesBethesdaUSA

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