Steps to improve the teaching of clinical reasoning in dermatology: A scoping review and proposal

Clinical reasoning (CR) is an area of active interest since faults in the diagnostic process can result in errors and possibly delays in care or even patient harm. The purpose of this scoping review was to collect information from the medical literature on approaches utilized to teach and assess CR in dermatology, identify gaps, and prepare a proposal on how to enhance the speciality's ability to develop trainee CR skills. We conducted a review of the published literature (1990-2020) from four databases. The initial search yielded 780 papers, and 42 relevant CR publications met inclusion criteria. Demographic, thematic content, theoretical frameworks, continuum of authenticity, competency/milestone, and assessment/educational intervention data were recorded by two screeners. Trainees at different educational levels from 17 different countries have been assessed in the dermatology literature. Most publications were of a single intervention, appeared underpowered, and had small sample sizes. Only two publications examined work-based assessments (use real patients/stimuli). Knowledge-based studies were the dominant theoretical framework with no studies exclusively focused on process-based CR interventions. Simulation was well represented with 23 (55%) investigations. Rigorous studies that examine CR teaching and assessment in dermatology are lacking. Evidence-based best practices for use of work-based assessments, especially direct observation, need to be developed/adapted for dermatology and validated. Dermatology training programs would benefit from longitudinal data on trainee CR development, process-based CR educational programs, metacognition CR exploration specific to skin disease diagnosis, and studies that yield practical recommendations on how to structure multi-faceted assessments that assess CR.