Training principle of the month 3: Clinical reasoning skills are explicitly taught within training

Clinical reasoning is essential for accurate diagnosis. This month, trainees Dr Jenny Merrison-Hort and Dr Sian Copley lead us in exploring this principle. You'll find examples of how to embed clinical reasoning skills into your everyday teaching and/or learning, including a case study from consultant paediatrician Dr Tim Mason, SIM lead for Barnstaple, on how to make the most of simulation.
RCPCH Progress+ Training principle of the month

From children and young people

We asked our RCPCH Epilepsy12 Youth Advocates what this principle meant. Here's what they said:

It is good when you use your skills to help us understand what is going on. For example, a young person with cerebral palsy and limited speech likes it when they are talked to directly and when the consultant emails before with questions and information.

A child with epilepsy liked it when they got a copy of the brain scan which was drawn all over by the doctor to explain what happens.

A young person said about how the doctor used easier words and did a drawing to explain what was going on. 

Working through the information - a consultant's tips by video

Dr Dave Bartle is a consultant neonatologist at the Royal Devon and Exeter NHS Trust, SIM lead in Exeter and TPD for ST4-8 for the South West Peninsula. He notes that:

reasoning is used to work through all of the relevant, and less relevant information, whilst at the same time being aware of confirmation bias or the tendency to interpret new information as confirmation of one's existing beliefs or theories.

Watch Dr Bartle's short video with some useful examples of how clinical reasoning skills can be taught through real life and simulation environments.

Virtual sim: necessity is the mother of invention! - case study

Courtesy of consultant paediatrician Dr Tim Mason, SIM lead for Exeter - @drtimmason (twitter)

Training level: All levels 

Setting: Virtual

What prompted the change? Simulation - or 'sim' - is a technique used to recreate a clinical experience. It is a fantastic way to test and discuss clinical reasoning. However, simulation is also resource-heavy in terms of time, people, space and kit. When we couldn't be physically in the same space because of COVID-19  we used pre-filmed, unscripted simulations filmed with a 360-degree camera to prompt similar learning.  We have used this in local, regional and national teaching so far!

What happened? This led to two distinct projects:

  1. Remote 360 sim - For a session, learners log onto MS Teams separately, have a brief intro then watch the 360 video via a YouTube link (using either phone, laptop or carboard headset) for five to 10 minutes. We then come back together to explore the learners' reactions and how they felt the team worked, and we discuss if they'd seen this in "real life". 
  2. When we could be face to face - we put the videos on VR (virtual reality) headsets (Occulus Go) and follow the same pattern of brief, watching, then debrief chat.

The beauty of 360 video is that the watcher can direct where they want to look (akin to being an active observer) and everyone has their own experience of it (though you can’t alter what's going on). VR headsets are more immersive than a laptop, phone or cardboard headset but all were time, space and cost efficient. 

The debrief was key, and essentially a fantastic way for trainees and teams to analyse how the "team on the screen did" - as well as discuss thoughts and emotions around real world cases. When we did this with junior learners we discussed the medicine behind cases. But with senior learners, processes, emotions and leadership were the main themes.

How did this support training and trainees? A new and engaging teaching occurred rather than stalled during COVID-19. We continue to run remote session as they were well received and can include bigger numbers than standard sim. The VR headset sessions have been popular and could be fit into short periods on night shifts!   

We don't see it as a replacement but an adjunct to standard sim.

Any practical tips? You can do this in your department remotely for free. Contact for the links and I'd be happy to talk you through how to run a session!

Trainee-led MDT - case study

Training level: All levels 

Setting: Inpatients

What prompted the change? A weekly multidisciplinary team (MDT) meeting involved consultant, trainees, dieticians, specialist nurses, pharmacists and biochemistry. Trainees were a constant presence on the ward and had the opportunity to advance their learning by taking a more active role in the MDT.

What happened? Trainees took responsibility for presenting all gastroenterology inpatients to the MDT. Trainees present an overview of each patient and their current situation, recommendations and plans for the week ahead. Consultants and MDT members then add to the discussion. They provide feedback to the trainees on their presentation and summarisation, and also on their clinical reasoning regarding management planning.

How did this support training and trainees? This supports trainees to develop the skills to lead an MDT, which is an invaluable skill. Multidisciplinary feedback gives a range of viewpoints, and the trainee can develop clinical reasoning skills with a wider breadth of knowledge than just the medical viewpoint alone.

Any practical tips? Make trainee participation in MDTs routine and encourage them to lead them. More senior team members can then add points as needed whilst developing the trainees’ clinical reasoning skills. Feedback from other professionals, not just more senior doctors, broadens one's horizons and will help trainees develop a more holistic approach within their clinical reasoning.

Trainee-led clinic - case study

Training level: ST4+

Setting: Outpatients

What prompted the change? Outpatients is an important setting for training, and while it is a huge part of the consultant workload, trainees often spend less time in clinic. It is an underutilised resource in training.

What happened? A weekly registrar led clinic is run in a paediatric gastroenterology department, with a mix of new and review patients. The registrar runs the clinic and sees all patients, with support from the on-call consultant. Investigation and management options are discussed as needed with the consultant, allowing trainees to develop clinical reasoning in the outpatient setting. Their independence increases with their increasing experience throughout their post.  

How did this support training and trainees? Trainees can struggle to get exposure to outpatient management, which is a different skillset to that of inpatient work. This set up allows consultants to teach trainees clinical reasoning around the utility of different investigation and management pathways. Having the clinic as trainee led and presenting cases to the consultant supports the trainee to develop their own clinical reasoning skills, as well as developing time management and leadership skills working in partnership with the outpatient clinic staff.

Any practical tips? Prioritising trainee time in outpatients allows trainees to develop a key skillset needed as a consultant and with planning can be done even with service pressures!

The clinic being trainee-led means trainees actively develop clinical reasoning skills. Doing this clinic regularly means the trainee and trainers see clear progression in clinical reasoning and management skills and independence - and you get real satisfaction seeing how far you have come over the six or 12 months of the post. 

The circular process - a training presentation

Dr Jennifer Hort has created a presentation you can use in your teams, aimed at trainers and trainees, to explore the circular process of clinical reasoning.

Download presentation in PowerPoint or PDF at bottom of this page

Dr Jennifer Hort is a ST4 trainee at the Royal Devon and Exeter NHS trust and Dr Sian Copley is an ST7 PGHAN trainee also based at the Royal Devon and Exeter NHS Trust. They are both RCPCH trainee representatives.

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