Clinical Reasoning: Where Do We Stand on Identifying and Remediating Difficulties?


Ten to fifteen percent of medical trainees have academic difficulties, the majority of which are cognitive in nature, including clinical reasoning. Many obstacles impede the rapid identification of clinical reasoning difficulties in medical learners. This article reviews the literature on detection and remediation of clinical reasoning difficulties, and offers specific, practical steps for accurately diagnosing and quickly resolving identified problems with clinical reasoning. Faculties need to become more involved in the development and establishment of tools for encouraging direct observation of the development of clinical reasoning in medical learners, and for strengthening the teachers’ pedagogical competencies.

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Audétat, M. , Lubarsky, S. , Blais, J. & Charlin, B. (2013). Clinical Reasoning: Where Do We Stand on Identifying and Remediating Difficulties?. Creative Education, 4, 42-48. doi: 10.4236/ce.2013.46A008.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Ark, T., Brooks, L., & Eva, K. (2007). The benefits of flexibility: The pedagogical value of instructions to adopt multifaceted diagnostic reasoning strategies. Medical Education, 41, 281-287. doi:10.1111/j.1365-2929.2007.02688.x
[2] Audétat, M., Laurin, S., Sanche, G., Béique, C., Caire-Fon, N., Blais, J., & Charlin, B. (2012). Clinical reasoning difficulties: A taxonomy for clinical teachers. Medical Teacher, 35, e984-e989.
[3] Audétat, M. C., Dory, V., Nendaz, M., Vanpee, D., Pestiaux, D., Junod Perron, N., & Charlin, B. (2012). What is so difficult about managing clinical reasoning difficulties? Medical Education, 46, 216-227. doi:10.1111/j.1365-2923.2011.04151.x
[4] Audétat, M. C., Faguy, A., Jacques, A., Blais, J., & Charlin, B. (2011). Exploratory study of perceptions and practices of clinical teachers engaged in a process of diagnosis and remediation of clinical reasoning difficulties. Pédagogie Médicale, 12, 7-16. doi:10.1051/pmed/2011014
[5] Audétat, M. C., & Laurin, S. (2010a). Clinician and supervisor, same challenge! Le Médecin du Québec, 45, 53-57.
[6] Audétat, M. C., & Laurin, S. (2010b). Supervision of clinical reasoning: Methods and a tool to support and promote clinical reasoning. Canadian Family Physician, 56, 127-129.
[7] Audétat, M. C., Laurin, S., & Sanche, G. (2011). Tackling clinical reasoning from a pedagogical perspective I. A conceptual framework to identify clinical reasoning problems. Pédagogie Médicale, 12.
[8] Barrows, H., & Pickell, G. (1991). Developing clinical problem-solving skills: A guide to more effective diagnosis and treatment. New York: Norton Medical Books.
[9] Belleflamme, M., Boulouffe, C., Gérard, V., De Cannière, L., & Vanpee, D. (2009). How can we foster our student’s clinical reasoning when there is little time. Louvain Médical, 128, 165-169.
[10] Bordage, G. (1994). Elaborated knowledge: A key to successful diagnostic thinking. Academic Medicine, 69, 883-885. doi:10.1097/00001888-199411000-00004
[11] Bordage, G. (1999). Why did I miss the diagnosis? Some cognitive explanations and educational implications. Academic Medicine, 74, S138-S143. doi:10.1097/00001888-199910000-00065
[12] Bordage, G. (2007). Prototypes and semantic qualifiers: From past to present. Medical Education, 41, 1117-1121. doi:10.1111/j.1365-2923.2007.02919.x
[13] Bordage, G., & Zacks, R. (1984). The structure of medical knowledge in the memories of medical students and general practitioners: Categories and prototypes. Medical Education, 18, 406-416. doi:10.1111/j.1365-2923.1984.tb01295.x
[14] Borleffs, J., Custers, E., Van Gijn, J., & Ten Cate, O. (2003). “Clinical reasoning theater”: A new approach to clinical reasoning education. Medical Education, 78, 322-325. doi:10.1097/00001888-200303000-00017
[15] Bowen, J. (2006). Educational strategies to promote clinical diagnostic reasoning. New England Journal of Medicine, 355, 2217-2225. doi:10.1056/NEJMra054782
[16] Catton, P., et al. (2002). An academic difficulty in postgraduate medical education: Results of remedial progress at University of Toronto. The Annals of RCSC.
[17] Chamberland, M. (1998). Learning sessions of clinical reasoning. Les Annales de Médecine Interne, 149, 479-484.
[18] Chamberland, M., & Hivon, R. (2005). Skills of clinical teachers and role models in clinical training. Pédagogie Médicale, 6, 98-111. doi:10.1051/pmed:2005015
[19] Chang, A., Chou, C., & Hauer, K. (2008). Clinical skills remedial training for medical education. Medical Education, 42, 1118-1119. doi:10.1111/j.1365-2923.2008.03191.x
[20] Chapman, G., & Sonnenberg, F. (2000). Decision making in health care: Theory, psychology, and applications. New York: Cambridge University Press.
[21] Charlin, B., Bordage, G., & Van Der Vleuten, C. (2003). Clinical reasoning evaluation. Pédagogie Médicale, 4, 42-52.
[22] Charlin, B., Boshuizen, H., Custers, E., & Feltovich, P. (2007). Scripts and clinical reasoning. Medical Education, 41, 1178-1184. doi:10.1111/j.1365-2923.2007.02924.x
[23] Charlin, B., Gagnon, R., Sibert, L., & Van der Vleuten, C. (2002). Script concordance test, a clinical reasoning evaluation tool. Pédag ogie Médicale, 3, 135-144.
[24] Coté, L., & Bordage, G. (2012). Content and conceptual frameworks of preceptor feedback related to residents’ educational needs. Academic Medicine, 87, 1274-1281. doi:10.1097/ACM.0b013e3182623073
[25] Croskerry, P. (2009). A universal model of diagnostic reasoning. Academic Medicine, 84, 1022-1028. doi:10.1097/ACM.0b013e3181ace703
[26] Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78, 775-780. doi:10.1097/00001888-200308000-00003
[27] Dudek, N., Marks, M., & Regehr, G. (2005). Failure to fail: The perspectives of clinical supervisors. Academic Medicine, 80, S84-S87. doi:10.1097/00001888-200510001-00023
[28] Elstein, A., & Schwartz, A. (2002). Clinical problem solving and diagnostic decision-making: Selective review of the cognitive literature. British Medical Journal, 324, 729-732. doi:10.1136/bmj.324.7339.729
[29] Elstein, A., Shulman, L., & Sprafka, S. (1978). Medical problem solving: An analysis of clinical reasoning. Cambridge: Harvard University Press.
[30] Ericsson, K. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine, 79, S70-S81. doi:10.1097/00001888-200410001-00022
[31] Eva, K. (2004). What every teacher needs to know about clinical reasoning. Medical Education, 39, 98-106. doi:10.1111/j.1365-2929.2004.01972.x
[32] Eva, K., Cunnington, J., Reiter, H., Keane, D., & Norman, G. (2004). How can I know what I don’t know? Poor self assessment in a well-defined domain. Advances in Health Sciences Education, 9, 211-224. doi:10.1023/B:AHSE.0000038209.65714.d4
[33] Eva, K., & Norman, G. (2005). Heuristics and biases—A biased perspective on clinical reasoning. Medical Education, 39, 870-872. doi:10.1111/j.1365-2929.2005.02258.x
[34] Evans, D., Alstead, E., & Brown, J. (2010). Applying your clinical skills to students and trainees in academic difficulty. The Clinical Teacher, 7, 230-235. doi:10.1111/j.1743-498X.2010.00411.x
[35] Evans, R., Stanley, R., Mestrovic, R., & Rose, L. (1991). Effects of communication skills training on students’ diagnostic efficiency. Medical Education, 25, 517-526. doi:10.1111/j.1365-2923.1991.tb00105.x
[36] Faustinella, F., Orlando, P., Colletti, L., Juneja, H., & Perkowski, L. (2004). Remediation strategies and students’ clinical performance. Medical Teacher, 26, 664-665.
[37] Frellsen, S. L. M. D., Baker, E. A. M. D. M., Papp, K. K. P., & Durning, S. J. M. D. (2008). Medical school policies regarding struggling medical students during the internal medicine clerkships: Results of a national survey. Academic Medicine, 83, 876-881. doi:10.1097/ACM.0b013e318181da98
[38] Gallant, M., MacDonald, J.-A., & Smith Higuchi, K. (2006). A remediation process for nursing students at risk for clinical failure. Nurse Educator, 31, 223-227. doi:10.1097/00006223-200609000-00010
[39] Groves, M. (2005). Problem-based learning and learning approach: Is there a relationship? Advances in Health Sciences Education, 10, 315-326. doi:10.1007/s10459-005-8556-3
[40] Groves, M., O'Rourke, P., & Alexander, H. (2003). Clinical reasoning: The relative contribution of identification, interpretation and hypothesis errors to misdiagnosis. Medical Teacher, 25, 621-625. doi:10.1080/01421590310001605688
[41] Hauer, K., Ciccone, A., Henzel, T., Katsufrakis, P., Miller, S., Norcross, W., & Irby, D. (2009). Remediation of the deficiencies of physicians across the continuum from medical school to practice: A thematic review of the literature. Academic Medicine, 84, 1822-1832. doi:10.1097/ACM.0b013e3181bf3170
[42] Hauer, K., Holmboe, E., & Kogan, J. (2010). Twelve tips for implementing tools for direct observation of medical trainees’ clinical skills during patient encounters. Medical Teacher, 2011, 27-33.
[43] Hauer, K., Teherani, A., Irby, D., Kerr, K., & O’Sullivan, P. (2008). Approaches to medical student remediation after a comprehensive clinical skills examination. Medical Education, 42, 104-112. doi:10.1111/j.1365-2923.2007.02937.x
[44] Hauer, K., Teherani, A., Kerr, K., O'Sullivan, P., & Irby, D. (2007). Student performance problems in medical school clinical skills assessments. Academic Medicine, 82, S69-S72.
[45] Hicks, P. J., Cox, S. M., Espey, E. L., Goepfert, A. R., Bienstock, J. L., Erickson, S. S., & Puscheck, E. E. (2005). To the point: Medical education reviews—Dealing with student difficulties in the clinical set ting. American Journal of Obstetrics and Gynecology, 193, 1915 1922. doi:10.1016/j.ajog.2005.08.012
[46] Higgs, J., & Jones, M. (2008). Chapter 1: Clinical decision making and multiple problem spaces. In J. Higgs, & M. Jones (Eds.), Clinical Reasoning in the Health Professions (pp. 3-17). Oxford: Butterworth Heineman Ltd.
[47] Higgs, J., & Mcallister, L. (2006). Being a clinical educator. Advances in Health Sciences Education, 12, 187. doi:10.1007/s10459-005-5491-2
[48] Howley, L., & Wilson, W. (2004). Direct observation of students during clerkship rotations: A multi-year descriptive study. Academic Medicine, 79, 276-280. doi:10.1097/00001888-200403000-00017
[49] Hunink, M., Glasziou, P., Siegel, J., Weeks. J., Pliskin, J., Elstein, A. S., & Elstein. A. S. (2001). Decision making in health and medicine: Integrating evidence and values. New York: Cambridge University Press.
[50] Hunt, D. D., Carline, J., Tonesk, X., Yergan, J., Siever, M., & Loebel, J. (1989). Types of problems students encountered by clinical teachers and clerkships. Medical Education, 23, 14-18. doi:10.1111/j.1365-2923.1989.tb00806.x
[51] Irby, D. (1994). What clinical teachers need to know. Academic Medicine, 69, 333-342. doi:10.1097/00001888-199405000-00003
[52] Irby, D. M. (1992). How attending physicians make instructional decisions when conducting teaching rounds. Academic Medicine, 67, 630-638. doi:10.1097/00001888-199210000-00002
[53] Janssens, S., Verschaffel, L., De Corte, E., Elen, J., Lowyck, J., Struyf, E., & Vandenberghe, R. (2000). Didactics on the move.
[54] Johnson, G. (2004). Constructivist remediation: Correction in context. International Journal of Special Education, 19, 72-88.
[55] Kahneman, D., Slovic, P., & Tversky, A. (1982). Judgment under un certainty: Heuristics and biases. New York: Cambridge University Press. doi:10.1017/CBO9780511809477
[56] Kassirer, J. (1983). Teaching clinical medicine by iterative hypothesis testing: Let’s preach what we practice. The New England Journal of Medicine, 309, 921-923.
[57] Kassirer, J. (2010). Teaching clinical reasoning: Case-based and coached. Academic Medicine, 85, 1118-1124. doi:10.1097/ACM.0b013e3181d5dd0d
[58] Kempainen, R., Migeon, M., & Wolf, F. (2003). Understanding our mistakes: A primer on errors in clinical reasoning. Medical Teacher, 25, 177-181. doi:10.1080/0142159031000092580
[59] Kilminster, S., Cottrell, D., Grant, J., & Jolly, B. (2007). AMEE guide No. 27: Effective educational and clinical supervision. Medical Teacher, 29, 2-19. doi:10.1080/01421590701210907
[60] Langlois, J. P., & Thach, S. (2000). Preventing the difficult learning situation. Family Medicine, 32, 232-234.
[61] Ludmerer, K. (2000). Time and medical education. Annals of Internal Medicine, 132, 25-27. doi:10.7326/0003-4819-132-1-200001040-00005
[62] Mamede, S., Schmidt, H., & Rikers, R. (2007). Diagnostic errors and reflective practice in medicine. Journal of Evaluation in Clinical Practice, 13, 138-145. doi:10.1111/j.1365-2753.2006.00638.x
[63] Mitchell, D., Russo, J., & Pennington, N. (1989). Back to the future: Temporal perspective in the explanation of events. Journal of Behavioral Decision Making, 2, 25-38. doi:10.1002/bdm.3960020103
[64] Mitchell, M., Srinivasan, M., West, D. C., Franks, P., Keenan, C., & Henderson, M. (2005). Factors affecting resident performance: Development of a theoretical model and a focused literature review. Academic Medicine, 80, 376-389. doi:10.1097/00001888-200504000-00016
[65] Nendaz, M., Charlin, B., Leblanc, V., & Bordage, G. (2005). Le raison nement clinique: Données issues de la recherche et implications pour l'enseignement. Pédagogie Médicale, 6, 235-254. doi:10.1051/pmed:2005028
[66] Norman, G. (2005). Research in clinical reasoning: Past history and current trends. Medical Education, 39, 418-427. doi:10.1111/j.1365-2929.2005.02127.x
[67] Perin, D. (2001). Making remediation more learner-centered: Promising approaches from case studies. Community College Journal, 72, 53 56.
[68] Reamy, B., & Harman, J. (2006). Residents in trouble: An in-depth assessment of the 25-year experience of a single family medicine residency. Family Medicine, 38, 252-257.
[69] Regehr, G., & Eva, K. (2006). Self-assessment, self-direction, and the self-regulating professional. Clinical orthopaedics and related research, 449, 34-38.
[70] Regehr, G., & Norman, G. (1996). Issues in cognitive psychology: Implication for professional education. Academic Medicine, 71, 988 1001. doi:10.1097/00001888-199609000-00015
[71] Sanche, G., Béland, N., & Audétat, M. C. (2011). La création et l’im plantation réussie d’un outil de remédiation en résidence de médecine familiale. Le Médecin de famille canadien, 57, e468-e472.
[72] Saxena, V., O’Sullivan, P., Teherani, A., Irby, D., & Hauer, K. (2009). Remediation techniques for student performance problems after a comprehensive clinical skills assessment. Academic Medicine, 84, 669-676.
[73] Schmidt, H., Norman, G., & Boshuizen, H. (1990). A cognitive perspective on medical expertise: Theory and implications. Academic Medicine, 65, 611-621. doi:10.1097/00001888-199010000-00001
[74] Schmidt, H., & Rikers, R. (2007). How expertise develops in medicine: Knowledge encapsulation and illness script formation. Medical Education, 41, 1133-1139.
[75] Schuster, P. M. (2000). Concept mapping: Reducing clinical care plan paperwork and increasing learning. Nurse Educator, 25, 76-81.
[76] Schuwirth, L. (2002). Can clinical reasoning be taught or can it only be learned? Medical Education, 36, 695-696. doi:10.1046/j.1365-2923.2002.01274.x
[77] Smith, C. S. (2008). A developmental approach to evaluating competence in clinical reasoning. Journal of Veterinary Medical Education, 35, 375-381. doi:10.3138/jvme.35.3.375
[78] Smith, C. S., Stevens, N., & Servis, M. (2007). A general framework for approaching residents in difficulty. Family Medicine, 39, 331 336.
[79] Steinert, Y. (2011). Commentary: Faculty development: The road less traveled. Academic Medicine, 86, 409-411. doi:10.1097/ACM.0b013e31820c6fd3
[80] Steinert, Y., & Lewitt, C. (1993). Working with the “problem” resident: Guidelines for definition and intervention. Family Medicine, 25, 627 632.
[81] Struyf, E., Beullens, B., Van Damme, B., Janssen, P., & Jaspaert, H. (2005). A new methodology for teaching clinical reasoning skills: Problem solving clinical seminars. Medical Teacher, 27, 364-368. doi:10.1080/01421590500046411
[82] Szumacher, E., Catton, P., Jones, G., Bradley, R., Kwan, J., Cherryman, F., & Nyhof-Young, J. (2007). Helping learners in difficulty—The incidence and effectiveness of remedial programmes of the medical radiation sciences programme at University of Toronto and the Michener Institute for applied sciences, Toronto, Ontario, Canada. Annals of the Academy of Medicine, Singapore, 36, 725-734.
[83] Tardif, J. (1992). Pour un enseignement stratégique: L’apport de la psychologie cognitive. Montréal: Les éditions Logiques.
[84] Teherani, A., O’Sullivan, P., Aagaard, E., Morrison, E., & Irby, D. (2007). Student perceptions of the one minute preceptor and traditional preceptor models. Medical Teacher, 29, 323-327. doi:10.1080/01421590701287988
[85] Vaughn, L., Baker, R., & De Witt, T. (1998). The problem learner. Teaching and Learning in Medicine, 10, 217-222. doi:10.1207/S15328015TLM1004_4
[86] Windish, D. (2000). Teaching medical students clinical reasoning skills. Academic Medicine, 75, 90. doi:10.1097/00001888-200001000-00022
[87] Windish, D., Price, E., Clever, S., Magaziner, J., & Thomas, P. (2005). Teaching medical students the important connection between communication and clinical reasoning. Journal of General Internal Medicine, 20, 1108-1113.
[88] Wolpaw, T., Papp, K., & Bordage, G. (2009). Using SNAPPS to facilitate the expression of clinical reasoning und uncertainties: A randomized comparison group trial. Academic Medicine, 84, 517-524. doi:10.1097/ACM.0b013e31819a8cbf
[89] Yates, J., & James, D. (2006). Predicting the “strugglers”: A case control study of students at Nottingham University Medical School. British Medical Journal, 332, 1009-1013. doi:10.1136/bmj.38730.678310.63

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