Exploring Differences in Clinical Decisions Between Medical Students and Expert Clinicians

Numerous challenges exist in effectively bridging theory and practice in the teaching and assessment of clinical reasoning, despite an abundance of theoretical models. This study compares clinical reasoning practices and decisions between medical students and expert clinicians using a problem-solving framework from the learning sciences, which identifies clinical reasoning as distinct, observable actions in clinical case solving. We examined students at various training stages against expert clinicians to address the research question: How do expert clinicians and medical students differ in their practices and decisions during the diagnostic process?.

We developed a questionnaire about a pediatric infectious disease case based on the problem-solving framework from the learning sciences to probe clinical reasoning decisions. The questionnaire had four sections: medical history, physical examination, medical tests, and working diagnosis. The questionnaire was administered at Stanford University between January 2019 and June 2023 to collect data from 10 experts and 74 medical students. We recruited participants through maximum variation sampling. We applied deductive content analysis to systematically code responses to identify patterns in the execution of the practices and decisions across the questionnaire.

This research introduces a highly detailed, empirically developed framework that holds potential to bridge theory and practice, offering practical insights for medical instructors in teaching clinical reasoning to students across various stages of their training. This framework involves nine practices, with a total of twenty-nine decisions that need to be made when carrying out these practices. Differences between experts and students centered on ten decisions across the practices: Differential diagnosis formulation, Diagnostic plan and execution, Clinical data reassessment, and Clinical solution review.

We were able to identify nuanced differences in clinical reasoning between students and expert physicians under one comprehensive problem-solving framework from the learning sciences. Identifying key clinical reasoning practices and decision differences could help develop targeted instructional materials and assessment tools, aiding instructors in fostering clinical reasoning in students.