Summary
Drawn from the expertise of Verity Schaye, MD, MHPE, this reading guide provides an overview of the state of the science of teaching clinical reasoning to medical learners. If you are faculty or a trainee, this is for you.
For a guided summary of these resources from Dr. Schaye, watch her presentation for Sketchy, “Teaching clinical reasoning in the age of generative AI."
For more from Dr. Schaye, watch her CODEX webinar, "Artificial Intelligence-Based Assessment to Enhance Internal Medicine Resident Clinical Reasoning Practices."
The Sticky Problem of Diagnostic Errors
Rates of diagnostic errors have not improved in the last 10 years. Diagnosis is a complex process involving cyclical interactions between patients and the healthcare team. In the majority of cases, diagnostic errors involve individual clinicians making cognitive errors. In response to this, an increasing number of medical schools have integrated a dedicated curriculum on clinical reasoning.
- Improving Diagnosis in Health Care. National Academies of Sciences, Engineering, and Medicine. 2015. Washington, DC: The National Academies Press.
- Diagnostic Error in Internal Medicine. Graber ML, Franklin N, Gordon R. Diagnostic Error in Internal Medicine. Arch Intern Med. 2005;165;(13):1493-1499.
- Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors. Rencic J, Trowbridge RL, Fagan M, et al. J Gen Intern Med. 2017.
Evidence-Based Best Practices to Teach Clinical Reasoning
What works to improve clinical reasoning?
Strategies that promote knowledge organization:
- Prototypes of disease presentation and management
- Mental abstraction (problem representation into acute vs chronic, focal vs diffuse)?)
- Diagnostic and management schemas (ways to move from a symptom to potential diagnoses and management based on pathophysiology)
Strategies that promote structured reflection on both the diagnostic and management steps and shared/distributed cognition:
- Diagnostic timeouts/management pause
- Working in diagnostic teams
- Diagnostic Schemas: Form and Function. Cammarata M & Dhaliwal G. J Gen Intern Med. 2023.
- Theory-guided teaching: Implementation of a clinical reasoning curriculum in residents. Schaye V, Eliasz KL, Janjigian M, Stern DT. Med Teach. 2019.
- Educational strategies to promote clinical diagnostic reasoning. Bowen J. NEJM. 2006.
- The future of teaching management reasoning: important questions and potential solutions. Abdoler EA, Parsons AS, Wijesekera TP. Diagnosis (Berl). 2022.
Documentation and Clinical Reasoning
Documentation also serves an important role for clinicians to develop and demonstrate clinical reasoning. These articles illustrate best practices for teaching clinical documentation in residency curriculum and in clinical care, including describing a justified differential diagnosis and iterating the use of progress notes.
- A synthesized differential diagnosis is associated with fewer diagnostic errors compared to an inventorial list. Sheline EK, Leonard J, Helmuth R, et al. Diagnosis (Berl). 2025.
- Writing Is Thinking: Implementation and Evaluation of an Internal Medicine Residency Clinical Reasoning and Documentation Curriculum. Richardson KM, Cristiano JA, Schafer KR, Shen E, Burns CA. Med Sci Educ. 2022.
- Point-counterpoint: Time to wash away the SOAP note-Or merely rinse it?. Rodman A, Schaye V, Hofmann H, Airan-Javia SL. J Hosp Med. 2023.
Verity Schaye, MD, MHPE
Assistant Dean for Education in the Clinical Sciences, Office of Medical Education
Assistant Director of Curricular Innovation, Institute for Innovations in Medical Education
Associate Professor of Medicine, NYU Grossman School of Medicine
Dr. Schaye’s work focuses on the integration of technology and artificial intelligence in the teaching and assessment of clinical reasoning, and she has been grant-funded by the NBME Stemmler fund to support this work focusing on AI assessment of clinical reasoning documentation. Recently, she was selected as a National Academy of Medicine Scholar in Diagnostic Excellence focusing on developing an AI-based diagnostic performance feedback system.