Faculty of Education - Theses
Permanent URI for this collection
Search Results
1 - 1 of 1
-
ItemDiagnostic reasoning teaching : an analysis of expert teacher behaviour in a clinical setting( 2008)Clinical reasoning is a cognitive process that uses data collected from and about a patient to make a diagnosis and develop and implement a therapeutic plan. Clinical reasoning may be usefully divided into diagnostic and therapeutic reasoning. Diagnostic reasoning is a problem solving task of categorization where information from the patient interview, physical examination and investigations are used formulate diagnostic hypotheses (a differential diagnosis) and eventually (and ideally) a single diagnosis. Therapeutic reasoning derives a therapeutic plan from the diagnosis and the wishes of the patient and implements the plan in the context of specific measurable outcomes. The diagnostic reasoning processes of novices and experts have been extensively evaluated. A variety of reasoning strategies have been identified including causal, probabilistic, deterministic and hypothetico-deductive reasoning and pattern recognition. Clinicians use, at different times and with different patient problems, any or all of these strategies. Novices are more likely to use causal and hypothetico-deductive reasoning whereas experts are more likely to apply pattern recognition. The quality and fidelity of the diagnostic reasoning process is also (and substantially) influenced by the knowledge organization of the clinician. Novices are more likely to have their knowledge organized as prototypes and instance scripts which rely on bioscience knowledge and less clinical experience whereas experts use illness scripts and semantic networks which are rich in data collected from their previous experience and relies little on bioscience knowledge. The teaching of diagnostic reasoning changed substantially with the implementation of problem-based learning (PBL) curricula by medical schools from the late 1960s onwards. PBL employs the principles of adult learning theory and hypothetico-deductive reasoning to explore clinical cases in the bioscience years of the medical course. The implementation of PBL curricula resulted in greater student and teacher satisfaction but there is little evidence that the knowledge and skills of the students are different to traditional more didactic curricula. A small body of evidence suggests that students of PBL courses have better diagnostic reasoning skills. The teaching of diagnostic reasoning in the clinical years of a medical course is less well understood. Traditional patient-based discussions at the bedside or in a tutorial room have been the mainstay of clinical education for many years. The effectiveness of this style of this traditional "bedside" clinical teaching to teach diagnostic reasoning has not been evaluated but many recommendations about teaching and learning styles have been published. In order to examine the teaching of diagnostic reasoning by expert clinician teachers a model of novice diagnostic reasoning was developed from the literature which was used as a framework for analysis. In this model three phases of novice diagnostic reasoning were identified - data acquisition, problem representation and hypothesis generation and refinement. The study presented in this thesis examined teacher behaviour in six seminaturalistic "bedside" tutorials designed to promote diagnostic reasoning discussions. Each tutorial was led by an expert teacher, who had won the teacher of the year award (determined by student vote), with a group of medical students in their first clinical year and an experienced simulated patient. The simulated patient delivered a script that was deliberately diagnostically inconclusive. Each session was videotaped and analysed using Studiocode (video analysis software). The coding first attributed each utterance to the teacher, a student or the patient. The teacher utterances were then sub-coded to the phases of the novice diagnostic reasoning process (data acquisition, problem representation and hypothesis generation/refinement). Teacher utterances in each phase of the novice diagnostic reasoning model were examined to identify illustrative examples of teaching behaviours consistent with excellent teachers (derived from the previous literature) including requests, direct instruction, questioning/probing, scaffolding, modeling and feedback. Finally, in the hypothesis generation and refinement phase of each tutorial, teacher utterances were further examined for illustrative examples of the teaching of causal, probabilistic, deterministic and hypothetico-deductice reasoning and pattern recognition. Six expert teachers participated in the tutorials (3 physicians and 3 surgeons, 4 male and 2 female). The teachers, on average, spoke for 56% (range 43-64%) of the tutorial (average length 56 minutes). Physicians and surgeon talk proportions were not different (56% vs 56%). Of the teacher utterances 55% were coded to the hypothesis generation/refinement phase, 31% to the data acquisition phase and 3% to the problem representation phase. During the data acquisition and hypothesis generation/refinement phases of the tutorial illustrative examples of direct instruction, questioning/probing, scaffolding, modeling and feedback were identified in the teacher utterances. In the problem representation phase only illustrative examples of direct instruction, modeling and feedback were identified. In the hypothesis generation and refinement phase illustrative examples of the teaching of causal, probabilistic and hypothetico-deductive reasoning and pattern recognition course but not deterministic reasoning were identified in the teacher utterances. This study examined the behaviour of expert teachers in semi naturalistic tutorials designed to promote the teaching of diagnostic reasoning. In these tutorials the teacher typically spoke for more than half of the tutorial. The teacher utterances were coded into all three phases of the novice diagnostic reasoning model but least time was spent in the problem representation phase. Illustrative examples of excellent teaching behaviour were identified in most of the phases of the novice diagnostic reasoning process. Illustrative examples of most diagnostic reasoning types were identified in the tutorials. The results of this study would suggest that further research is required to determine the "optimum" teacher talk time in a clinical (and other) tutorial and the effectiveness of teaching about the problem representation phase of diagnostic reasoning.