Clinical reasoning teaching and learning in the undergraduate primary care medical education

Problem

Clinical reasoning (CR) in medical education is taught and learned in various settings, including primary care. CR is known to be context and case-specifics. Still, little studies have described teaching and learning CR in the primary care setting. Using the lens of transformative learning (TL) theory, this systematic review aimed at answering the question, “what educational activities were described in the international literature on clinical reasoning in undergraduate primary care medical education?” It also sought to explore the underlying theoretical underpinnings of CR educational activities during clinical clerkship, stakeholders’ involvement in the process and challenges surrounded CR educational activities, including strategies to overcome these challenges.

Approach

With the assistance of an information specialist and correspondence with two experts in the field of CR, we searched five databases and other sources using a combination of keywords - "clinical reasoning" and its related terminologies, "primary health care", and "undergraduate medical education". We screened articles based on empirical studies published in the English language between January 2010 to August 2020. We used single-blinded review management software Rayyan to make independent decisions about study selections. We conducted meta-synthesis (Thomas & Harden, 2008) to all the included articles and assessed each study’s quality using a Critical Appraisals Skills Program (CASP) UK checklists.

Findings

From 4515 records of records identified, we included 29 for final synthesis. We organised the themes based on the review questions. Themes for educational activities involved the sequence of a) task first or b) patient contact. Theoretical underpinnings were related to a) systems of care and b) learning theories. Barriers to CR learning were in the forms of a) context, b) consignment and c) community. The roles of clinician teachers and patients were critical. Clinician teachers' roles were a) fortifier, b) mediator, c) connoisseur and d) monitor. Patients roles emerged through a matrix of a) self- society and b) Passive - active. Outcomes were organised around ten steps of TL. This analysis segment highlighted that reflective assignment, teaching point, mid-point review, and CR teaching tool/method were useful in transforming teaching and learning. However, sub-optimal task fidelity, inadequate supervision, contradictory feedback, insufficient role-modelling and temporality of effects were all setbacks to transformational learning of CR in this context.

Consequences

This review has made apparent essential knowledge about clinical reasoning in undergraduate primary care medical education in the form of meanings made about CR nature and its practice within the reviewed studies. However, there are still too few studies to comprehend this topic thoroughly. This review may serve as an impetus to practitioners and educators for further research in this area.