Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter November 2, 2018

Teaching Diagnostic Reasoning: A Review of Evidence-Based Interventions

Leah Burt ORCID logo and Susan Corbridge

Abstract

Problem/Background: The ability to accurately diagnose patients based on symptom profiles is a vital yet challenging skill that Nurse Practitioners (NPs) undertake frequently. Purpose: This integrative literature review highlights a variety of evidence based, practical educational strategies that foster the development of diagnostic reasoning. Methods: An integrative literature review was conducted in order to identify original research focusing on diagnostic reasoning educational interventions. Results: Eighteen primary sources met inclusion and exclusion criteria. Results are synthesized in terms of sample and setting, methodological features, interventions, and outcomes. Interventions broadly fit into five educational themes: testing strategies, cognitive biases, simulation programs, course formats, and instructional approaches. Discussion: Interventions are simple and can be implemented in multiple educational settings. Future research should occur in populations of NP students. Validated, easy-to-use measurement tools as well as more precise diagnostic reasoning concept development should occur.

References

American Association of Nurse Practitioners (AANP). (2014). 2012 National AANP Sample Survey. https://www.aanp.org/images/documents/research/2012%20NP%20Sample%20Survey%20Part%201.pdfSearch in Google Scholar

American Association of Nurse Practitioners (AANP). (2017). What’s an NP? https://www.aanp.org/all-about-nps/what-is-an-np/#qualificationsSearch in Google Scholar

Benner, P., Hughes, R. G., & Sutphen, M. (2008). Clinical reasoning, decisionmaking, and action: thinking critically and clinically. In R. G. Hughes (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2643/Search in Google Scholar

Blissett, S., Cavalcanti, R. B., & Sibbald, M. (2012). Should we teach using schemas? Evidence from a randomised trial. Medical Education, 46(8), 815–822. doi:10.1111/j.1365-2923.2012.04311.xSearch in Google Scholar PubMed

Bosner, S., Pickert, J., & Stibane, T. (2015). Teaching differential diagnosis in primary care using an inverted classroom approach: student satisfaction and gain in skills and knowledge. BMC Medical Education, 15(63), 1–7. doi:10.1186/s12909-015-0346-xSearch in Google Scholar PubMed PubMed Central

Brush, J. E., Jr., Sherbino, J., & Norman, G R. (2017). How expert clinicians intuitively recognize a medical diagnosis. American Journal of Medicine, 130(6), 629–634. doi:10.1016/j.amjmed.2017.01.045Search in Google Scholar PubMed

Chamberland, M., Mamede, S., St-Onge, C., Setrakian, J., Bergeron, L., & Schmidt, H. (2015). Self-explanation in learning clinical reasoning: The added value of examples and prompts. Medical Education, 49(2), 193–202. doi:10.1111/medu.12623Search in Google Scholar PubMed

Chamberland, M., Mamede, S., St-Onge, C., Setrakian, J., & Schmidt, H. G. (2015). Does medical students’ diagnostic performance improve by observing examples of self-explanation provided by peers or experts? Adv Health Sci Educ Theory Pract, 20(4), 981–993. doi:10.1007/s10459-014-9576-7Search in Google Scholar PubMed

Chamberland, M., St-Onge, C., Setrakian, J., Lanthier, L., Bergeron, L., Bourget, A., Rikers, R. (2011). The influence of medical students’ self-explanations on diagnostic performance. Medical Education, 45(7), 688–695. doi:10.1111/j.1365-2923.2011.03933.xSearch in Google Scholar PubMed

Coderre, S., Mandin, H., Harasym, P. H., & Fick, G. H. (2003). Diagnostic reasoning strategies and diagnostic success. Medical Education, 37(8), 695–703. doi:10.1046/j.1365-2923.2003.01577.xSearch in Google Scholar PubMed

Colella, C. L., & Beery, T. A. (2014). Teaching differential diagnosis to nurse practitioner students in a distance program. Journal of Nursing Education, 53(8), 433–438. doi:10.3928/01484834-20140724-02Search in Google Scholar PubMed

Cornell University Center for Teaching Innovation. (2017). Problem-based learning. Retrieved from https://www.cte.cornell.edu/teaching-ideas/engaging-students/problem-based-learning.html.Search in Google Scholar

Diemers, A. D., van de Wiel, M. W., Scherpbier, A. J., Baarveld, F., & Dolmans, D. H. (2015). Diagnostic reasoning and underlying knowledge of students with preclinical patient contacts in PBL. Med Educ, 49(12), 1229–1238. doi:10.1111/medu.12886Search in Google Scholar PubMed

DiNardo, D., Tilstra, S. A., Follansbee, W., Barnato, A. E., Zimmer, S. M., Farris, C., & McNeil, M. (2016). Combatting cognitive bias: A clinical reasoning curriculum for internal medicine residency education. Journal of General Internal Medicine, 31(2), S161–S162.Search in Google Scholar

Eva, K. W., Hatala, R. M., Leblanc, V. R., & Brooks, L. R. (2007). Teaching from the clinical reasoning literature: combined reasoning strategies help novice diagnosticians overcome misleading information. Medical Education, 41(12), 1152–1158. doi:10.1111/j.1365-2923.2007.02923.xSearch in Google Scholar PubMed

Gandhi, T. K., Kachalia, A., Thomas, E. J., Puopolo, A. L., Yoon, C., Brennan, T. A., & Studdert, D. M. (2006). Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Annals of Internal Medicine, 145(7), 488–496. doi:10.7326/0003-4819-145-7-200610030-00006Search in Google Scholar PubMed

Garrard, J. (2017). Health sciences literature reviews made easy: the matrix method. Burlington, MA: Jones and Bartlett Learning.Search in Google Scholar

Gonzalez, C. (2004). Learning to make decisions in dynamic environments: effects of time constraints and cognitive abilities. Human Factors, 46(3), 449–460. doi:10.1518/hfes.46.3.449.50395Search in Google Scholar PubMed

Gunning, W. T., & Fors, U. G. (2012). Virtual patients for assessment of medical student ability to integrate clinical and laboratory data to develop differential diagnoses: comparison of results of exams with/without time constraints. Medical Teacher, 34(4), e222–228. doi:10.3109/0142159x.2012.642830Search in Google Scholar PubMed

Heitzmann, N., Fischer, F., Kuhne-Eversmann, L., & Fischer, M. R. (2015). Enhancing diagnostic competence with self-explanation prompts and adaptable feedback. Medical Education, 49(10), 993–1003. doi:10.1111/medu.12778Search in Google Scholar PubMed

Ilgen, J. S., Eva, K. W., & Regehr, G. (2016). What’s in a label? Is diagnosis the start or the end of clinical reasoning? Journal of General Internal Medicine, 31(4), 435–437. doi:10.1007/s11606-016-3592-7Search in Google Scholar PubMed PubMed Central

Ilgen, J. S., Humbert, A. J., Kuhn, G., Hansen, M. L., Norman, G. R., Eva, K. W., Charlin, B., Sherbino, J. (2012). Assessing diagnostic reasoning: A consensus statement summarizing theory, practice, and future needs. Academic Emergency Medicine, 19(12), 1454–1461. doi:10.1111/acem.12034Search in Google Scholar PubMed

Kiesewetter, J., Ebersbach, R., Tsalas, N., Holzer, M., Schmidmaier, R., & Fischer, M. R. (2016). Knowledge is not enough to solve the problems - The role of diagnostic knowledge in clinical reasoning activities. BMC Medical Education, 16(1), 1–8. doi:10.1186/s12909-016-0821-zSearch in Google Scholar PubMed PubMed Central

Kuo, Y. F., Adhikari, D., Eke, C. G., Goodwin, J. S., & Raji, M. A. (2017). Processes and outcomes of congestive heart failure care by different types of primary care models. Journal of Cardiac Failure, 24(1), 9–18. doi:10.1016/j.cardfail.2017.08.459Search in Google Scholar PubMed PubMed Central

Kurtzman, E. T., & Barnow, B. S. (2017). A comparison of nurse practitioners, physician assistants, and primary care physicians’ patterns of practice and quality of care in health centers. Medical Care, 55(6), 615–622. doi:10.1097/mlr.0000000000000689Search in Google Scholar

Lafleur, A., Cote, L., & Leppink, J. (2015). Influences of OSCE design on students’ diagnostic reasoning. Medical Education, 49(2), 203–214. doi:10.1111/medu.12635Search in Google Scholar PubMed

Lee, A., Joynt, G. M., Lee, A. K., Ho, A. M., Groves, M., Vlantis, A. C., Ma. R., Coleman, S. C. F., Aun, C. S. (2010). Using illness scripts to teach clinical reasoning skills to medical students. Family Medicine, 42(4), 255–261.Search in Google Scholar

Mamede, S., van Gog, T., Moura, A. S., de Faria, R. M., Peixoto, J. M., Rikers, R. M., & Schmidt, H. G. (2012). Reflection as a strategy to foster medical students’ acquisition of diagnostic competence. Medical Education, 46(5), 464–472. doi:10.1111/j.1365-2923.2012.04217.xSearch in Google Scholar PubMed

Mamede, S., van Gog, T., Sampaio, A. M., de Faria, R. M., Maria, J. P., & Schmidt, H. G. (2014). How can students’ diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases. Academic Medicine, 89(1), 121–127. doi:10.1097/acm.0000000000000076Search in Google Scholar

Moulton, C. A., Regehr, G., Mylopoulos, M., & MacRae, H. M. (2007). Slowing down when you should: A new model of expert judgment. Academic Medicine, 82(10), S109–116. doi:10.1097/ACM.0b013e3181405a76Search in Google Scholar PubMed

Multak, N., Newell, K., Spear, S., Scalese, R. J., & Issenberg, S. B. (2015). A multi-institutional study using simulation to teach cardiopulmonary physical examination and diagnosis skills to physician assistant students. Journal of Physician Assistant Education, 26(2), 70–76. doi:10.1097/jpa.0000000000000021Search in Google Scholar PubMed

National Academies Press; National Academies of Sciences, Engineering, and Medicine. (2015). Improving Diagnosis in Healthcare Retrieved from https://www.nap.edu/catalog/21794/improving-diagnosis-in-health-careSearch in Google Scholar

National Organization of Nurse Practitioner Faculties (NONPF). (2017). Nurse Practitioner Core Competency Content Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/2017_NPCoreComps_with_Curric.pdfSearch in Google Scholar

Olsen, Jeanette & Baisch, Mary Jo (2014). An integrative review of information systems and terminologies used in local health departments. Journal of the American Medical Informatics Association, 21(e1), e20–e27. doi: 10.1136/amiajnl-2013-001714.Search in Google Scholar PubMed PubMed Central

Peixoto, J. M., Mamede, S., de Faria, R. M., Moura, A. S., Santos, S. M., & Schmidt, H. G. (2017). The effect of self-explanation of pathophysiological mechanisms of diseases on medical students’ diagnostic performance. Advances in Health Science Education: Theory, Research, and Practice, 22(5), 1183–1197. doi:10.1007/s10459-017-9757-2Search in Google Scholar PubMed

Raupach, T., Andresen, J. C., Meyer, K., Strobel, L., Koziolek, M., Jung, W., … Anders, S. (2016). Test-enhanced learning of clinical reasoning: A crossover randomised trial. Medical Education, 50(7), 711–720. doi:10.1111/medu.13069Search in Google Scholar PubMed

Sherbino, J., Kulasegaram, K., Howey, E., & Norman, G. (2014). Ineffectiveness of cognitive forcing strategies to reduce biases in diagnostic reasoning: A controlled trial. Canadian Journal of Emergency Medicine, 16(1), 34–40.10.2310/8000.2013.130860Search in Google Scholar PubMed

Sorinola, O. O., Weerasinghe, C., & Brown, R. (2012). Preventable hospital mortality: learning from retrospective case record review. Journal of the Royal Society of Medicine Short Reports, 3(11), 1–10. doi:10.1258/shorts.2012.012077Search in Google Scholar PubMed PubMed Central

Teunissen, P. W., & Bok, H. G. (2013). Believing is seeing: how people’s beliefs influence goals, emotions and behaviour. Medical Education, 47(11), 1064–1072. doi:10.1111/medu.12228Search in Google Scholar PubMed

Tiffen, J., Corbridge, S. J., & Slimmer, L. (2014). Enhancing clinical decision making: Development of a contiguous definition and conceptual framework. Journal of Professional Nursing, 30(5), 399–405. doi:10.1016/j.profnurs.2014.01.006Search in Google Scholar PubMed

Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal of Advanced Nursing, 52(5), 546–553. doi:10.1111/j.1365-2648.2005.03621.xSearch in Google Scholar PubMed

Received: 2018-01-25
Revised: 2018-08-24
Accepted: 2018-08-27
Published Online: 2018-11-02

© 2018 Walter de Gruyter GmbH, Berlin/Boston

Scroll Up Arrow