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PRACTICUM LIBRARY. More than one correct answer

Uncertainty as a factor for integration in the evaluation of clinical reasoning and training

Accepting uncertainty allows a better discernment of information and improved decision making and assistance.

Recognizing situations of uncertainty and incorporating them as a variable in the evaluation of clinical reasoning, as well as identifying the barriers that exist for the creation of these evaluations, are emerging as key skills in the context of current clinical practice. Hence, those responsible for training programs are forced to take a step beyond the comfort zone that involves normative knowledge to train future professionals in the management of this uncertainty. According to a study by the University of Calgary (Canada), it is appropriate to assume that it is feasible (and reasonable) to have more than one correct answer.

Madrid, January 1, 2019. In a context in which physicians have access to a huge amount of clinical information and face decisions increasingly more complex, clinical reasoning is imposed as a nuclear competence. To evaluate this ability, pediatricians Suzette Cooke and Jean-François Lemay, of the Canadian University of Calgary, in the province of Alberta, argue that it is essential to start from the fact that uncertainty is part of the equation. Both authors propose two concepts on which medical training plans should rotate: embrace the existence of this uncertainty and recognize that it is totally feasible to have more than one correct answer.

Traditionally, residents' assessment has been based on their handling of basic medical information, their ability to remember data, and how quickly they memorize algorithms. That's why the exams usually comprise multiple-choice or short-answer questionnaires. But how is the ability to make appropriate decisions in contexts without conclusive evidence evaluated? Not even the popular OSCEs  (Objective Structured Clinical Examinations) go far beyond the recognition of patterns. That is why assessment methods should change: "because they do not sufficiently reflect the clinical reasoning processes that are required in actual practice," Cooke and Lemay wrote in the journal Academic Medicine.

Furthermore, "a doctor's tolerance for uncertainty influences his clinical practice," the specialists pointed out. "Doctors who are less tolerant are more likely to order excessive diagnostic tests and additional treatments, which increases health costs and puts patients at risk of adverse effects," they warned. In this sense, there is a gap between the recognized competences for good clinical performance and what is currently being evaluated. This deficit is reflected, for example, in the framework of the medical competences collected in the CanMeds2105 method, developed by the Royal College of Physicians and Surgeons of Canada.

Uncertainty is inherent to clinical reasoning, but the ability to manage it effectively is still a challenge. As a strategy to integrate this "acceptance of uncertainty" in the training of future professionals, Cooke and Lemay have proposed to emphasize the importance of two aspects: the contextual factors and the inherent variability of the human condition. That is, from the age, gender, and social circumstances of the patient, to the recognition of those specific factors that make each person, even under the same conditions, respond differently to the same treatment.

In this sense, the Script Concordance Test is presented as a method that contemplates the two fundamental principles for the evaluation of current clinical reasoning: the performance of tests in a context of uncertainty and respect for the possibility that there may be more than one way to go. The advantages that the SCT offers regarding the speed, agility, and possibility of integrating elements that help to create clinical realism, lead the authors to suggest that their introduction in the training programs can help the students to develop the skills related to the reasoning clinical, as well as to handle uncertainty, adopt better clinical decisions during their training period, and increase their experience.

Obstacles on the road
"Respecting the possibility that there is more than one correct answer reflects the clinical reality and, ultimately, makes the evaluation of clinical reasoning more valid and reliable," the Canadian experts pointed out. However, it is essential to recognize that there are barriers to creating such formative and summative assessments of clinical reasoning. These obstacles include recognizing situations of uncertainty, creating clear frameworks that define progressive levels of clinical reasoning skills, providing evidence of validity to increase the defensive capacity of such evaluations, considering comparative feasibility with other forms of evaluation, and developing strategies to evaluate the impact of these methods on future learning and practice.

The first obstacle is to recognize the situations of uncertainty in clinical medicine on the part of all those involved in the evaluation. This includes candidates, examiners, exam developers, medical schools, program directors, clinical preceptors, certification bodies, and the general public. "In exposing these situations, we accept that gray areas will always exist," Cooke and Lemay emphasized. Next, it is advisable to create a framework for action that allows professionals to select the most relevant medical and contextual aspects in a case, determine which ones predominate, and synthesize their implications in clinical decision making.

Regarding the defensibility of the evaluation method, a unique response has been traditionally sought as a result of consensus, but methods such as the SCT  have demonstrated the potential to consider the responses of a panel of experts to encourage reflection. The same applies to the feasibility of carrying out the SCT, a format attached to clinical reality, which can be administered over 60 to 90 minutes, supports audiovisual content, and incurs minimal costs. In any case, "medical educators have an ethical responsibility to promote the highest capacity for reasoning, both in teaching and evaluation, and to do so in contexts of uncertainty," concluded Cooke and Lemay.



Cooke S, Lemay J.F. Transforming medical assessment: Integrating Uncertainty into the Evaluation of Clinical Reasoning Medical Education. Academic Medicine. 2017 Jun; 92(6):746-751. doi: 10.1097/ACM.0000000000001559.


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