title: How is clinical reasoning developed, maintained, and objectively assessed? Views from expert internists and internal medicine interns.
abstract: BACKGROUND
  There is limited understanding of how clinical reasoning is developed, maintained, and objectively assessed. Using the theoretical lens of deliberate practice, we explored physicians' views on clinical reasoning. We compared responses from internists (faculty) and internal medicine interns, to identify potential qualitative and/or quantitative differences in how clinical reasoning is developed and maintained.
  
  
  METHODS
  Participants' free-text comments regarding how clinical reasoning is developed, maintained, and objectively assessed were analyzed. Three investigators coded responses using a constant-comparative, grounded theory approach. We also compared the frequencies of each theme between the 2 groups.
  
  
  RESULTS
  Twenty-two faculty and 17 interns participated in this study. Faculty and intern themes for how clinical reasoning is developed, maintained, and objectively assessed were similar, but quantitative and qualitative differences emerged. Interrater reliability of themes was high (overall kappa: 0.92; range: 0.88-0.98). Only experts (faculty) mentioned the value of teaching for development and maintenance of clinical reasoning. Interns focused on knowledge acquisition activities and use of online resources. Experts and intern participants both struggled with how to best measure clinical reasoning; direct observation was rarely mentioned as a strategy.
  
  
  CONCLUSIONS
  Consistent with our theoretical expectations, we found quantitative and qualitative differences in participants' responses, which have implications for teaching and assessment of clinical reasoning. By capturing the types of activities and their relative frequencies within and between these groups, this work adds to the deliberate practice literature.
authors.affiliation: Professor of Medicine and Pathology, Uniformed Services University.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Durning
authors.forename: Temple
authors.initials: T
authors.lastname: Ratcliffe
authors.forename: Anthony R
authors.initials: AR
authors.lastname: Artino
authors.forename: Cees
authors.initials: C
authors.lastname: van der Vleuten
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Beckman
authors.forename: Eric
authors.initials: E
authors.lastname: Holmboe
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Lipner
authors.forename: Lambert
authors.initials: L
authors.lastname: Schuwirth
mesh_terms: D000328:Adult; D002983:Clinical Competence / Q000592:standards*; D005180:Faculty, Medical / Q000592:standards*; D005260:Female; D017143:Fuzzy Logic; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D007407:Interviews as Topic; D058436:Knowledge Management; D008297:Male; D008875:Middle Aged; D010346:Patient Care Management; D010549:Personal Satisfaction; D010865:Pilot Projects; D018794:Problem-Based Learning / Q000379:methods; D036301:Qualitative Research; D013038:Specialization; D013192:Staff Development / Q000379:methods; D011795:Surveys and Questionnaires
keywords: clinical reasoning; deliberate practice; faculty development; theory-social learning