Teaching from the clinical reasoning literature: combined reasoning strategies help novice diagnosticians overcome misleading information


Kevin W Eva PhD, Department of Clinical Epidemiology and Biostatistics, Program for Educational Research and Development, MDCL 3522, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada. Tel: 00 1 905 525 9140 (ext 27241); Fax: 00 1 905 572 7099; E-mail: evakw@mcmaster.ca


Objective  Previous research has revealed a pedagogical benefit of instructing novice diagnosticians to utilise a combined approach to clinical reasoning (familiarity-driven pattern recognition combined with a careful consideration of the presenting features) when diagnosing electrocardiograms (ECGs). This paper reports 2 studies demonstrating that the combined instructions are especially valuable in helping students overcome biasing influences.

Methods  Undergraduate psychology students were trained to diagnose 10 cardiac conditions via ECG presentation. Half of all participants were instructed to reason in a combined manner and half were given no explicit instruction regarding the diagnostic task. In Study 1 (= 60), half of each group was biased towards an incorrect diagnosis through presentation of counter-indicative features. In Study 2 (= 48), a third of the test ECGs were presented with a correct diagnostic suggestion, a third with an incorrect suggestion, and a third without a suggestion.

Results  Overall, the instruction to utilise a combined reasoning approach resulted in greater diagnostic accuracy relative to leaving students to their own intuitions regarding how best to approach new cases. The effect was particularly pronounced when cases were made challenging by biasing participants towards an incorrect diagnosis, either through mention of a specific feature or by making an inaccurate diagnostic suggestion.

Discussion  These studies advance a growing body of evidence suggesting that various diagnostic strategies identified in the literature on clinical reasoning are not mutually exclusive and that trainees can benefit from explicit guidance regarding the value of both analytic and non-analytic reasoning tendencies.