title: Exploring a New Simulation Approach to Improve Clinical Reasoning Teaching and Assessment: Randomized Trial Protocol.
abstract: BACKGROUND
  Helping trainees develop appropriate clinical reasoning abilities is a challenging goal in an environment where clinical situations are marked by high levels of complexity and unpredictability. The benefit of simulation-based education to assess clinical reasoning skills has rarely been reported. More specifically, it is unclear if clinical reasoning is better acquired if the instructor's input occurs entirely after or is integrated during the scenario. Based on educational principles of the dual-process theory of clinical reasoning, a new simulation approach called simulation with iterative discussions (SID) is introduced. The instructor interrupts the flow of the scenario at three key moments of the reasoning process (data gathering, integration, and confirmation). After each stop, the scenario is continued where it was interrupted. Finally, a brief general debriefing ends the session. System-1 process of clinical reasoning is assessed by verbalization during management of the case, and System-2 during the iterative discussions without providing feedback.
  
  
  OBJECTIVE
  The aim of this study is to evaluate the effectiveness of Simulation with Iterative Discussions versus the classical approach of simulation in developing reasoning skills of General Pediatrics and Neonatal-Perinatal Medicine residents.
  
  
  METHODS
  This will be a prospective exploratory, randomized study conducted at Sainte-Justine hospital in Montreal, Qc, between January and March 2016. All post-graduate year (PGY) 1 to 6 residents will be invited to complete one SID or classical simulation 30 minutes audio video-recorded complex high-fidelity simulations covering a similar neonatology topic. Pre- and post-simulation questionnaires will be completed and a semistructured interview will be conducted after each simulation. Data analyses will use SPSS and NVivo softwares.
  
  
  RESULTS
  This study is in its preliminary stages and the results are expected to be made available by April, 2016.
  
  
  CONCLUSIONS
  This will be the first study to explore a new simulation approach designed to enhance clinical reasoning. By assessing more closely reasoning processes throughout a simulation session, we believe that Simulation with Iterative Discussions will be an interesting and more effective approach for students. The findings of the study will benefit medical educators, education programs, and medical students.
authors.affiliation: Sainte-Justine Hospital, Department of Neonatology, University of Montreal, Montreal, QC, Canada. thomas@pennaforte.net.
authors.forename: Thomas
authors.identifier: http://orcid.org/0000-0002-1212-6861
authors.initials: T
authors.lastname: Pennaforte
authors.forename: Ahmed
authors.identifier: http://orcid.org/0000-0002-2556-6970
authors.initials: A
authors.lastname: Moussa
authors.forename: Nathalie
authors.identifier: http://orcid.org/0000-0002-0809-6911
authors.initials: N
authors.lastname: Loye
authors.forename: Bernard
authors.identifier: http://orcid.org/0000-0001-5701-9552
authors.initials: B
authors.lastname: Charlin
authors.forename: Marie-Claude
authors.identifier: http://orcid.org/0000-0001-9126-2214
authors.initials: MC
authors.lastname: Audétat
keywords: clinical reasoning; cognitive bias; debriefing; diagnostic errors; dual-process theory; iterative discussions; simulation; verbalization