Assessing Clinical Reasoning in Hospice and Palliative Medicine Fellows

Clinical reasoning is essential for hospice and palliative medicine (HPM) fellows, yet structured assessment tools are lacking. The Assessment of Reasoning Tool (ART) has shown positive results for early learners but has not been applied to advanced learners.

We conducted an 18-month mixed-methods study at a single academic center. Seven fellows and seven faculty participated. Faculty used the ART every day during clinical teaching rounds on a fellow's inpatient rotation. Pre- and post-intervention surveys assessed the ART via 4-point Likert scale and free-response questions.

Fellows reported increased feedback on clinical reasoning (2.33 vs. 3.25; p = 0.05) and reflection on cognitive bias (2.67 vs. 2.81; p = 0.02), and no difference in satisfaction with feedback, comfort with clinical reasoning terminology, and time spent on feedback. Faculty reported no difference across all areas. Both groups cited time constraints and a need for clearer guidance on effective use as barriers to using the ART. Qualitative themes highlighted the ART as a diagnostic versus management reasoning tool, limited application to non-symptom-based case scenarios, and persistent faculty discomfort despite training.

This study suggests the ART is feasible for HPM fellowship training and may enhance certain aspects of clinical reasoning assessment for fellows, particularly during early fellowship. However, its broader utility is limited by the absence of faculty-perceived benefit, persistent faculty discomfort with implementation, and the tool's emphasis on diagnostic rather than management reasoning. Further research on effective faculty development and assessment tools tailored to management reasoning would help define the optimal role of the ART in HPM training.