Creative Education
2013. Vol.4, No.6A, 42-48
Published Online June 2013 in SciRes (
Copyright © 2013 SciRes.
Clinical Reasoning: Where Do We Stand on Identifying and
Remediating Difficulties?*
Marie-Claude Audétat1,2, Stuart Lubarsky3, Jean-Guy Blais4, Bernard Charlin2
1Department of Family and Emergency Medicine, Faculty of Medicine, University of Montreal,
Montreal, Canada
2Medical Education and Continuin g Professional Devel o pment Center (CPASS), Fac ul ty of Medicine,
University of Montreal, Montreal, Canada
3McGill Center for Medical Education, Faculty of Medicine, McGill University,
Montreal, Canada
4Department of Administration and Education, Faculty of Education, University of M on treal, Montreal, Canada
Received March 2nd, 2013; revised April 4th, 2013; acce p t e d A pr i l 1 2th, 2013
Copyright © 2013 Marie-Claude Audétat et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Ten to fifteen percent of medical trainees have academic difficulties, the majority of which are cognitive
in nature, including clinical reasoning. Many obstacles impede the rapid identification of clinical reason-
ing difficulties in medical learners. This article reviews the literature on detection and remediation of
clinical reasoning difficulties, and offers specific, practical steps for accurately diagnosing and quickly
resolving identified problems with clinical reasoning. Faculties need to become more involved in the de-
velopment and establishment of tools for encouraging direct observation of the development of clinical
reasoning in medical learners, and for strengthening the teachers’ pedagogical competencies.
Keywords: Clinical Reasoning; Remediation; Clinical Reasoning Difficulties; Faculty Development
Clinical Reasoning Is Central to Medical Practice
Clinical reasoning stands at the very core of the medical pro-
fession. Defined as the set of complex thought and deci-
sion-making processes underlying clinicians’ choices and ac-
tions in specific medical problem-solving contexts, clinical
reasoning requires an array of cognitive, metacognitive, emo-
tional, reflective thinking and relational skills (Higgs & Jones,
An abundant literature on clinical reasoning theories and ap-
proaches exists. Recent summary articles that have reviewed
the different approaches have contributed to clarifying the
theoretical viewpoints, as well as their impact on teaching and
evaluating of clinical reasoning (Croskerry, 2009; Eva, 2004;
Nendaz, Charlin, Leblanc, & Bordage, 2005).
To date, several authors have emphasized the importance of
developing specific pedagogical approaches to facilitating the
development of clinical reasoning during medical training.
Building on the work of Kassirer (Kassirer, 1983), Barrows
(Barrows & Pickell, 1991), and others who have incorporated
ideas stemming from cognitive psychology (and more specifi-
cally the organization of knowledge) (Regehr & Norman, 1996;
Tardif, 1992) and even social constructivism (Janssens et al.,
2000), many authors have put forward practical strategies over
the last few years, such as clinical reasoning team-based learn-
ing sessions and specific integrated supervisory strategies for
clarifying reasoning (Audétat & Laurin, 2010b; Belle-
flamme, Boulouffe, Gérard, De Cannière, & Vanpee, 2009;
Borleffs, Custers, Van Gijn, & Ten Cate, 2003; Bowen, 2006;
Chamberland, 1998; Kassirer, 2010; Mc Hugh Schuster, 2000;
Schuwirth, 2002; Struyf et al., 2005; Teherani, O’Sullivan,
Aagaard, Morrison, & Irby, 2007; Windish, 2000; Windish,
price, Clever, Magaziner, & Thomas, 2005; Wolpaw, Papp, &
Bordage, 2009). These strategies generally emphasize the im-
portance of explicitly supporting the early development of
clinical reasoning in authentic clinical contexts (Groves, 2005;
Regehr & Norman, 1996).
Ten to fifteen percent of medical students are identified as
having academic difficulties (Faustinella, Orlando, Colletti, &
Perkowski, 2004; Yates & James, 2006). Although different
models exist in the literature to try to classify the various types
of problems they encounter, there is general agreement that the
main academic difficulties are cognitive in nature, including
clinical reasoning difficulties (Catton et al., 2002; Faustinella et
al., 2004; Hicks et al., 2005; Hu et al., 1989; Kassirer, 2010;
Reamy & Harman, 2006; Smith, Stevens, & Servis, 2007).
In this paper, we review the current literature addressing the
principal challenges related to identification and remediation of
clinical reasoning in medical learners. In the first part, we will
explore the challenges the educators face, according to pub-
lished literature, in diagnosing clinical reasoning difficulties; in
the second part, we will examine the extant research regarding
potential strategies for remediating learners with clinical rea-
soning difficulties. Finally, we will highlight a certain number
of actions that could be implemented to help diagnose clinical
*Declaration of interest: The authors report no declarations of interest.
reasoning difficulties and resolve them quickly and accurately.
We searched the PubMed and MEDLINE databases for arti-
cles whose primary focus was the identification and/or reme-
diation of clinical reasoning difficulties in medical learners.
The research covers the 1995-2011 period. To conduct our
review, we combined the following search terms: “clinical rea-
soning”, ”remedial teaching”, “cl inical competence”, “learning”,
“remediations”, “teaching”, “medical education”, “struggling
medical students”. We also assembled a comprehensive list of
articles written by recognized medical education authors who
have published on related subjects.
Identifying Trainees with Clinical Reasoning
Clinical reasoning difficulties are generally identified late in
medical training (Frellsen, Baker, Papp, & Durning, 2008;
Hauer, Teherani, Kerr, O’Sullivan, & Irby, 2007; Hicks et al.,
2005). Although our review uncovered many reasons to explain
this delay, three in particular were consistently raised and are
worthy of specific mention:
1) Not much attention is given to observing students during
their training years
Clinical teaching during the training years remains, for the
most part, informal, tacit, and haphazard, and is contingent on
the students’ clinical exposure (Chamberland & Hivon, 2005).
Under these circumstances, there are often only limited oppor-
tunities to observe clinical skills during student training, and
particularly during clerkship. The paucity of current reliable,
valid, and feasible assessment tools may also contribute to cli-
nician-educators’ apparent disinclination to directly observe
students’ in-training performance (Hauer et al., 2009). More-
over, feedback is hardly ever based on actual observation of
student interviews with patients (Dudek, Marks, & Regehr,
2005; Hauer, Teherani, Irby, Kerr, & O’Sullivan, 2008; Howley
& Wilson, 2004; Ludmerer, 2000).
2) The challenges of evaluation (including self evaluation)
Documenting and discussing problems with students pose
additional challenges for educators who teach clinical reasoning.
For instance, the final evaluation and the performance supervi-
sor’s opinion are often not consistent (Dudek et al., 2005).
Dudek et al. (2005) point out that supervisors have a hard time
documenting poor clinical performances, largely due to a lack
of tools, of knowledge of what needs to be specifically identi-
fied, and of adequate means of remediation.
Add to this another problem: students are often required to
evaluate their own performance, even though it has been shown
that the correlation between self assessment and real perform-
ance is poor (Eva, Cunnington, Reiter, Keane, & Norman, 2004;
Regehr & Eva, 2006 ).
3) The complexity of clinical reasoning
Clinical reasoning is inordinately complex. Although clini-
cians may have extensive knowledge and experience in a par-
ticular domain, they often have difficulty rendering the basics
of their reasoning processes explicit during teaching. In a simi-
lar vein, clinician educators can quickly identify students with
reasoning difficulties but often struggle to identify specifically
where the problem lies (Audétat, Faguy, Jacques, Blais, &
Charlin, 2011). It may be that they are not familiar with the
underlying cognitive processes. Furthermore, the clinical rea-
soning literature is itself complex, and as a result most clinician
teachers are not well acquainted with it (Dudek et al., 2005;
Kempainen, Migeon, & Wolf, 2003).
Identifying Clinical Reasoning Difficulties in Trainees
To shed light on the cognitive processes involved in clinical
reasoning, and specifically the difficulties or pitfalls of reason-
ing in clinical contexts, two major paradigms have been ad-
vanced. These theoretical approaches are decision making
(Chapman & Sonnenberg, 2000; Hunink et al., 2001; Kah-
neman, Slovic, & Tversky, 1982) and problem solving (Bor-
dage & Zacks, 1984; Elstein, Shulman, & Sprafka, 1978; Sch-
midt, Norman, & Boshuizen, 1990).
The decision making approach is concerned with the diagno-
sis and possible errors leading to a misdiagnosis. From this
standpoint, reaching a diagnosis means updating opinion with
imperfect information (the clinical evidence) (Elstein & Sch-
wartz, 2002; Hunink et al., 2001). The standard rule for this kind
of task is Bayes’ theorem. This theorem directs attention to two
major classes of errors in clinical reasoning: errors in assessing
à priori probability and errors in judging the strength of the
evidence. Studies from the decision-making paradigm focus on
errors in both components, like the potential biases resulting
from the use of heuristics. Medical heuristics are mental short-
cuts that are in most cases unconsciously used by clinicians to
facilitate clinical decision making. They can lead to cognitive
errors, such as availability, which is a common bias distorting
hypothesis generation in judging the probability of an event on
the basis of readily recalled similar events, or anchoring, which
occurs when a doctor remains fixed on his first impression of a
case, and fails to adjust hypotheses in light of new data. A
widespread debate exists in the literature on strategies for
avoiding these types of cognitive errors (Croskerry, 2003; Eva
& Norman, 2005; Mamede, Schmidt, & Rikers, 2007; Mitchell,
Russo, & Pennington, 1989).
The problem solving approach views diagnostic reasoning as
a process of hypothesis-testing. The solutions to complex prob-
lems are found by generating a limited number of hypotheses
during the diagnostic process and subsequently using them to
direct the collection of data. Each hypothesis can be used to
predict which elements should be present if that hypothesis
proves to be true. As a result, the diagnostic process is a fo-
cused search for features (findings) predicted by active hy-
potheses. From this perspective, errors that are likely to occur
can, for instance, be related to the difficulty in generating cor-
rect hypotheses, the failure to identify present clinical clues or
data, or the incorrect interpretation of these data (Bordage,
1999; Elstein & Schwartz, 2002).
Errors or difficulties in clinical reasoning can also be contin-
gent on the interpersonal or interactive aspects of the doctor-
patient relationship. From this perspective, examples that can
make clinical reasoning difficult include awkward interpersonal
communication, poor integration of the reasoning of other pro-
fessionals involved and the impact of the patient’s personality
on a negotiated approach to care (Higgs & Jones, 2008).
Clinical reasoning difficulties are often correlated with per-
formance in other domains, such as communication skills or
professionalism (Hauer et al., 2007). This constitutes another
major issue for teachers: identifying difficulties in multiple
Copyright © 2013 SciRes. 43
domains, understanding their intricate interrelationships, and
prioritizing one or the other in a targeted remediation plan.
Remediation of Clinical Reasoning Difficulties
General Findings on Remediation
1) Established pedagogical principles
There is abundant literature on the pedagogical principles
governing remediation in the clinical context (Gallant, Mac-
Donald, & Smith Higuchi, 2006; Hauer et al., 2007; Johnson,
2004; Perin, 2001; Steinert & Lewitt, 1993; Szumacher et al.,
2007). These studies suggest that effective remediation entails
identifying difficulties early in the training curriculum, inform-
ing the students and instituting appropriate remediation meas-
ures. The remediation process should be student-centred and
incorporate a thorough understanding of the student’s difficul-
ties and specific needs. It should be interactive and provided in
a context that has significance for the learner. Lastly, the reme-
diation process must be supported and valued by Faculty per-
sonnel and explicitly defined and guided by a person in charge.
2) Limited remediation processes
Beyond these general pedagogical principles, the remediation
process in the frame of the training curriculum is not always
clearly established. There is surprisingly little evidence to guide
“best practices” of remediation in medical education, and it
remains unclear how a lack of competence should be addressed
before promotion. Medical education lags behind other areas of
education in developing robust strategies for remediation.
In a recent article, Hauer et al. (2009) propose a response
model composed of four key elements for implementing a suc-
cessful remediation plan: 1) an initial evaluation using various
evaluation tools to identify the difficulties; 2) an accurate diag-
nosis of the problems and the establishment of an individual-
ized remediation plan; 3) instructions and activities that include
specific clinical activities, feedback and reflective practice; and
4) a reassessment and a skill certification (Hauer et al., 2009).
3) The role of the clinician-educator in remediation
Teaching physicians take on two very specific roles: that of
clinician responsible for the delivery of quality health care to
patients, and that of educator responsible for helping students
develop their clinical competencies, identifying and diagnosing
possible difficulties, and implementing remediation means
(Audétat, Laurin, & Sanche, 2011; Irby, 1994; Kilminster,
Cottrell, Grant, & Jolly, 2007). Due to the realities of the
clinical context, time constraints, and doubts as to the clinician-
teachers’ pedagogical competencies, it is sometimes difficult
for them to take on both roles jointly. It is very tempting for
clinicians to focus on the clinical role at the expense of their
pedagogical responsibilities. In this context, “pedagogical
reasoning”, i.e. the approach that consists of collecting infor-
mation, establishing a pedagogical diagnosis, establishing a
remediation plan, implementing a remediation activity, and
evaluating the results, is often lacking, which may fuel doubts
and potential dissatisfaction on the part of clinician-teachers.
(Audétat et al., 2011; Audétat & Laurin, 2010a; Langlois &
Thach, 2000).
Specific Remediations for Clinical Reasoning Difficulties
There are relatively few descriptions of specific remediation
methods (Chang, Chou, & Hauer, 2008; Saxena, O’Sullivan,
Teherani, Irby, & Hauer, 2009). And there are very few publi-
cations on the effectiveness and validity of remediation plans
dealing with clinical reasoning difficulties.
A few research papers focus on the perception of teachers
with respect to remediation. In general, teachers have reserva-
tions about their actions and consider the process to be pains-
taking (Hauer et al., 2007). Several authors also emphasize the
difficulty of determining which strategy is best suited to a given
problem. They cite the multifactorial nature of difficulties
added to teacher uncertainty with respect to the methods used in
trying to explain it (Hauer et al., 2008; Saxena et al., 2009;
Szumacher et al., 2007).
Winning Strategies Identified
When dealing with reasoning problems, the educator’s focus
should be on helping learners build strong knowledge structures
and representations (e.g., schema, scripts, exemplars, and pro-
totypes) (Bordage, 1994; Charlin, Boshuizen, Custers, & Felt-
ovich, 2007; Norman, 2005; Schmidt & Rikers, 2007).
Some research has shown that integrated teaching of com-
munication techniques and clinical reasoning in a clinical set-
ting significantly fosters the development of clinical reasoning
processes (Evans, Stanley, Mestrovic, & Rose, 1991; Windish
et al., 2005).
Remediation programs based on an integrated approach seem
to provide interesting results. For instance, Chang et al. report
the development of an effective remediation process: a 4th year
student 8-station CPX (clinical performance examination) with
standardized patients helped evaluate clinical reasoning and
communication competencies (Chang et al., 2008). A specific
remediation program was then developed based on the follow-
ing strategies: pedagogical diagnosis, faculty feedback and
targeted supervision. The program included four specific steps:
1) individual review of recorded videos by the students, inter-
view analysis and individualized development of improvement
goals; 2) video review by a Faculty remediation director and
development of an “official” pedagogical prescription (1 - 3
pages signed by the Faculty learning prescription); 3) planning
of video screenings with a supervisor in accordance with the
defined prescriptions; 4) competency strengthening and integra-
tion workshops in small groups, (theoretical contribution,
clinical cases, role playing, analysis and integration). The eva-
luation of the impact of the process with participants shows that
the most relevant elements were: practicing and analysing si-
mulated interviews, learning to manage complex interviews
(multiple diagnoses etc.), getting specific feedback from the su-
pervisor and the Faculty, and having workshop discussions.
Research focused on gauging the improvement of clinical
reasoning competencies (with respect to data collection and a
targeted clinical exam related to the patient’s complaint) evalu-
ated the results of a very similar remediation process based on
the same course of action. The exam given at the end of the
four months of the remediation process indicated a 30% im-
provement with respect to the collection of data and 60% with
respect to the clinical exam. The authors highlight the key role
of the targeted exercises on clinical reasoning, the analysis and
structure work provided by the videos and the formative feed-
back (Faustinella et al., 2004).
In general, participants have reported appreciation for the
remediation strategies they underwent, and acknowledged their
effectiveness (Ark, Brooks, & Eva, 2007; Windish et al., 2005).
All schemes require a large investment in terms of time and
Copyright © 2013 SciRes.
Our review has shown that clinician-educators responsible
for identification and remediation of clinical reasoning difficul-
ties in medical learners face a set of important challenges. For
example, precisely identify ing the faulty step(s) along a lear ner’s
clinical reasoning pathway can be a formidable task, particu-
larly for educators with limited familiarity with the current cli-
nical reasoning literature. Even those educators who are well-
versed in the theory of clinical reasoning and teaching method-
ology will attest that, to date, there exists no widely accepted
framework or structured approach to identification and reme-
diation of clinical reasoning deficits.
According to the literature, winning remediation strategies
share the following critical elements: 1) an established peda-
gogical diagnosis, 2) faculty support, 3) a well-defined reme-
diation plan or pedagogical prescription, and 4) the use of
various verbalization and clinical reasoning structuring methods
based on video recorded cases, role playing, standardized pa-
tients and targeted and directed supervision on clinical reason-
Early identification and early support, before the trainee or
student runs into major difficulties, should be regarded as the
gold standard for educational supervision (Evans, Alstead, &
Brown, 2010).
It thus appears crucial to implement a certain number of ac-
tions that will help diagnose clinical reasoning difficulties and
resolve them quickly and accurately. To do so, we suggest that
examining the following issues is critical:
Direct Observation in the Clinical Context
The data stemming from the literature very clearly under-
score the need to directly observe students in their clinical con-
text (Bowen, 2006; Evans et al., 2010; Schuwirth, 2002) with
a view toward identifying and analyzing the clinical reasoning
steps in the setting in which errors or difficulties arise (Groves,
O’Rourke, & Alexander, 2003). They also emphasize the im-
portance of using a variety of tools for detecting specific diffi-
culties and establishing a pedagogical diagnosis and remedia-
tion plan (Chang et al., 2008; Charlin, Bordage, & Van Der
Vleuten, 2003; Charlin, Gagnon, Sibert, & Van der Vleuten,
2002; Faustinella et al., 2004; Hauer, Holmboe, & Kogan, 2010;
Smith, 2008). Students should also be encouraged to participate
in deliberate (i.e., conscious and focused) practice and need to
receive timely feedback on their performance (Ericsson, 2004).
Deeper Understanding of Problems
Considerable work needs to be done to better identify clinical
reasoning difficulties, especially as they manifest in the clinical
context. Therefore, it is necessary to develop not only a deeper
understanding of the problems, but also an ability to better de-
fine them and model them. Disentangling multiple causes is
necessary if we want to initiate appropriate remedial action.
Attempting to understand resident performance without un-
derstanding factors that influence performance is analogous to
examining patient adherence to medication regimens without
understanding the individual patient and his/her environment
(Mitchell M et al., 2005).
Important work on associating theory and the realities of
clinical practice needs to be carried out. The development of
specific tools on evaluation and clinical reasoning difficulties
will undoubtedly help clinician-teachers in their task of identi-
fying and diagnosing problems.
Better Pedagogical Equipment
Clinician-teachers intuitively detect global difficulties in
clinical reasoning exhibited by their students, but precise iden-
tification of the problem often remains difficult (Audétat et al.,
2011). They do not feel effective in their remediations and have
reservations about their competencies. Their actions are not
necessarily part of an established pedagogical plan. It thus
seems important to enhance the knowledge of clinician-teachers
and their understanding of the multiple aspects of clinical rea-
soning (Bordage, 2007).
It is also important to acknowledge the dual role of clinician-
teachers (clinical and pedagogical) and to boost their feeling of
pedagogical competency (Evans et al., 2010; Irby, 1992). One
way to do so would be to train them and increase their support
in the clinical reasoning supervision process, but mainly in
pedagogical reasoning with respect to the difficulties identified
with students. Their remediation plans will then be better de-
tailed, and as a result more likely to be effective (Mitchell et al.,
2005; Steinert & Lewitt, 1993; Vaughn, Baker, & De Witt,
More Faculty Support
While the development of valid tools and the appropriate
training of teachers are essential for identifying and remediating
learners with clinical reasoning difficulties, the essential role of
Faculties should not be overlooked.
Most Faculties in the health professions do not provide for-
mal remediation interventions following summative evaluations
(exams, end of training periods) or formative in-training
evaluations. We can thus infer that some students reach the end
of their training still struggling with clinical reasoning. It is
therefore essential that the Faculties establish a framework and
clear procedures for identifying and remediating learners with
clinical reasoning difficulties throughout their training (Smith
et al., 2007).
Based on our review, we advocate taking concrete steps to
involve the Faculty in the pedagogical diagnosis and pedagogi-
cal prescription processes (Chang et al., 2008). Faculties have
the potential to play an important role in offering support and
advice to clinician-teachers for developing appropriate reme-
diation strategies (Catton et al., 2002). It has been noted that
when Faculties a llocate mo re resource s to remedia tion activi ties,
teachers feel supported, more confident and more competent in
their actions. The quality of the remediation process is improved
(Saxena et al., 2009).
In response to these findings, the Family and Emergency
Medicine Department of the University of Montreal has devel-
oped a multidimensional approach consisting of four prongs:
implementing institutional procedures (Hauer et al., 2009) (e.g.
regarding remediation plans and follow-up) (Sanche, Béland, &
Audétat, 2011), introducing clinical teachers to conceptual
frameworks and empirical findings from the literature through
accessible and targeted papers, developing remediation tools
(e.g. a guide to the diagnosis and remediation of different types
of clinical reasoning difficulties) (Audétat et al., 2012), and
teacher-centered faculty development. Altogether this amounts
Copyright © 2013 SciRes. 45
to no less than a cultural (Audétat et al., 2012) and organizational
change (Steinert, 2011) which should help clinician-teachers act
effectively, based on well-grounded educational scripts (Côté &
Bordage, 2012) Arming clinician-tea chers with a strong sense of
“being clinical educators” (Higgs & Mcallister, 2006) should
ultimately improve outcomes for learners.
Many obstacles impede the rapid identification of clinical
reasoning difficulties in medical learners, and more remediation
methods are needed. There is also a need to implement struc-
tured identification and remediation processes for students in
need. Furthermore, Faculties need to become more involved
and encourage the development and establishment of tools that
encourage direct observation of the development of clinical
reasoning and strengthen the teachers’ pedagogical competen-
cies with respect to clinical reasoning per se, clinical supervi-
sion and the pedagogical diagnosis and remediation develop-
ment processes. All this requires considerable time and sub-
stantial pedagogical and financial investment. However, faced
with the reality of observing some students slip through the net
and complete their medical training without being clinically
competent, we suggest that there is an urgent need to commit
ourselves in this direction. Intervening now will undoubtedly
lead in time to improvements in patient care.
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