Educational Strategies to Promote Clinical Diagnostic Reasoning: Annotated and Updated


Annotations written by Andrew Parsons, M.D., Joe Rencic, M.D., and Judith Bowen, M.D., Ph.D.
Edited by Raja-Elie Abdulnour, M.D.

Fifteen years after its publication, this 2006 landmark article continues to bestow knowledge and guidance to both teachers and learners of clinical reasoning. Increased emphasis on reasoning skills in medical education and key research developments prompted our desire to update this information. Therefore, we have annotated this article to address some of these developments:

  • Current research on clinical reasoning that expands theoretical lenses to include sociocultural theories as well as cognitive science. Notably, the personal histories that clinicians and patients bring to each encounter play a significant role in implicit bias.
  • A greater recognition that diagnosis is co-created by the patient and the diagnostic team, which can include a broad array of health care professionals and an understanding that problem representations activate interactive and continuous analytic and nonanalytic reasoning processes.
  • A call for clinical teachers to observe learners and provide formative feedback as part of an “educational alliance,” whereby a transactional delivery of feedback shifts to a conversation aimed at improving learning.
  • New resources to help clinical teachers facilitate learning, including emerging innovative technologies.

 Andrew Parsons, MD, MPH, is an assistant professor of medicine and public health at the University of Virginia (UVA) where he practices as an internal medicine hospitalist. As the Director of Clinical Competency for UVA School of Medicine, he oversees the clinical reasoning curriculum and a comprehensive coaching program focused on longitudinal clinical skill development, assessment, and remediation for medical students. He also serves as director of a GME-wide clinical reasoning coaching program and Associate Section Head for Education in Hospital Medicine.

 Joseph John Rencic MD, is a Professor of Medicine at Boston University and a hospitalist in the Division of General Internal Medicine. His research seeks to improve health professionals’ clinical reasoning and enhance their diagnostic accuracy and treatment decisions, with the ultimate goal of reducing medical errors and improving patient outcomes. He is co-editor of Teaching Clinical Reasoning, the 7th book in the American College of Physicians Teaching Medicine series collection. In addition to his scholarship, Dr. Rencic is the Director of Clinical Reasoning Education, the co-course Director of Doctoring 2, and a member of the Academy of Medical Educators at the Boston University School of Medicine. He also serves as Acting Internship Director for the fourth-year internal medicine rotation at Boston Medical Center.

 Judith L. Bowen, MD, PhD, is Professor of Medicine and Associate Dean for Curriculum at the Washington State University Elson S. Floyd College of Medicine. She earned her MD at Dartmouth and her PhD in health professions education at the UCSF/University of Utrecht (The Netherlands) joint program. She completed her internal medicine residency at Virginia Mason Hospital in Seattle. Dr. Bowen’s contributions to clinical diagnostic reasoning include more than 20 years supporting faculty development for educators, and clinical reasoning education for internal medicine residents and nurse practitioner candidates. With expertise in clinical practice and medical education, Dr. Bowen frequently translates medical education research into practical applications for clinician educators. Most recently, she is developing, implementing, and studying a pre-clerkship clinical reasoning curriculum designed to prepare medical students with habits of critical inquiry and knowledge building. Dr. Bowen’s research explores the impact of health system discontinuity—clinical reasoning transitions before the diagnosis is known—on learning and improving diagnostic acumen.

 Raja-Elie Abdulnour, MD, is co-developer and lead editor of NEJM Healer and Director of Educational Innovation at NEJM Group. He also serves as Assistant Professor of Medicine at Harvard Medical School and faculty member in Pulmonary & Critical Care Medicine at Brigham and Women’s Hospital.

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