Scientific Reasoning in Medical Education: A Novel Approach for the Analysis of Epistemic Activities in Clinical Case Discussions

Author(s):

Benedikt Lenzer(presenting / submitting)Christian Ghanem Marc Weidenbusch Martin R. Fischer Jan Zottmann

Conference:

ECER 2017

Network:

Emerging Researchers' Group (for presentation at Emerging Researchers' Conference)

Format:

Poster

Session Information

ERG SES D 02, Interactive Poster Session

Poster Session

Time:

2017-08-21

13:30-15:00

Room:

W3.11

Chair:

Agnieszka Bates

Contribution

A major goal of higher education in a variety of domains such as teacher education, social work, psychology but also physics or biology, incorporates fostering the ability to reason and argue based on scientific knowledge and/or methods of scientific inquiry [1, 2]. This ability is, for instance, crucial to assess evidence in the daily and practical medical work, but it is also a precondition for the selfdirected acquisition of new knowledge. Scientific reasoning and argumentation (SRA) has been described as a compound concept of scientific discovery, scientific argumentation and the understanding of the nature of science [3, 4].

Clinical reasoning can be seen as a specific kind of the SRA process, because the reasoning of physicians incorporates the ability to reason scientifically [2]. These reasoning skills have been investigated for more than 35 years [5]. This study is based on a novel framework of SRA to investigate the reasoning behaviour of medical students in the context of Clinical Case Discussions (CCDs) [6]. This domain-general framework described by Fischer and colleagues is comprised of eight so-called epistemic activities (EAs) and conceptualizes the reasoning process as a potentially nonlinear process.

The present study applies these eight epistemic activites, namely Problem Identificaton (PI), Questioning (Q), Evidence Generation (EG), Evidence Evaluation (EE), Hypothesis Generation (HG), Construction and Redesign of Artefacts (CA), Drawing Conclusions (DC), as well as Communicating and Scrutinizing (CS) to empirically capture single reasoning steps in the complex process of SRA, respectively clinical reasoning.

For the clinical domain, Kind and colleagues described the subset of hypothesizing, experimenting and evidence evaluation as indispensable epistemic activities [7].

It is unclear to what extent these skills are generalizable across domains and how they might be assessed the best. We thus utilized a SRA framework for this study which claims to be domain-general and applied it to a medical education format. This elaborate model with eight detailed epistemic steps proved applicability in the field of teacher education and social work and hereby showed promise for analyses in medical education [8, 9].

The supervised peer teaching format CCD requires students to collaboratively unfold authentic clinical cases and to apply their factual knowledge as well as their reasoning skills to diagnose a patient described in a complex case scenario. The CCD course format is designed to foster epistemic activities, which are crucial for clinical reasoning such as EE or HG

Against this background, we aimed to adapt and apply a coding scheme based on the framework by Fischer and colleagues to analyse the epistemic activities of medical students during CCDs.

Method

Sample We recruited 15 volunteer medical students (age mean: 23.8 years, SD: +/-4.1 years; 53,3% female) of the LMU Munich in the clinical part of their training (3rd to 6th year). Institutional Review Board approval of the protocol and written informed consent of the study participants were obtained. After completion of the study (i.e. participation in all three trial dates) students received a reimbursement of 50 Euro. Clinical Case Discussions A CCD session consisted of three independent internal medicine cases from the “Case Records of the Massachusetts General Hospital” series in the New England Journal of Medicine [10-12] which were worked through in an inquiry-based approach. The CCD format follows an admission , discussion- and summary-sequence and typically lasts 90 to 120 minutes. All three cases were presented in this specified structure similar to the original clinicopathological case discussions [13]. During the admission students got primal information about a patient from the taken anamnesis and the first basic medical tests like an electrocardiogram (ECG) are performed. During the discussion further information and test results were released stepwise per request of the discussants. Eventually, the summary completed the discussion with pathophysiological background information. Participants have full access to digital and analogue media resources at all time during the intervention. In short, the CCD format can be described as a supervised peer-moderated group case discussion where different roles are assigned to the participants: A discussant prepares the presentation beforehand and delivers the case information in the session, a medical student trained in case presentation moderates the discussion; an internal medical resident supervises it. The remaining group of participants takes over the role of the physician at the moment of the patient encounter and as discussants together unfold the diagnostic problem. The discussions were video-recorded and transcribed for further analysis. Coding Scheme: A validated coding scheme for epistemic activities was adapted from the domain of social work [8]. Transcripts were first segmented analogously to the course structure: General topic and sequences in each topic. As smallest divison we defined coding units as subset of sequences. The epistemic activity CA was coded parallel to the other epistemic activities to reflect its coexistent nature if e.g. an explanation was aided by a drawing. Two independent raters reliably coded 10% of the data (Cohen’s κ = 0.781). The remaining data was coded by the first author.

Expected Outcomes

Transcripts were segmented into 3346 coding units with a distribution of 50% on admission, 41% on discussion and 9% on case summary. Overall, participants predominantly engaged in the epistemic activities EG, 34%, CS, 26.2%, Q, 22.4% and EE, 12.4%. HG, DC and PI only summed up to 2.5%, 1.1% and 0.8%, respectively. Out of all epistemic activities, 30.1% were supported by CA. Finally, we found the moderator-role to be a driver of EG, CS and Q in the case discussions, whereas students engaged mostly in EE, HG, DC and PI. Interestingly, EE and HG as identified by Kind (2013) as crucial for clinical reasonig are pursued mainly on the side of the student discussants. This underlines that CCDs are an appropriate format to teach clinical reasoning skills to medical students. Also, the successful transfer of a SRA coding scheme from social work to medical education supports the notion of a cross-domain validity of epistemic activities. Subsequently, this suggests that the SRA framework by Fischer et al. (2014) [6] and the according coding scheme provide useful analytical tools for investigating clinical reasoning processes in medical education. Further research needs to clarify the complex interactions between epistemic activities and the reasoning behaviour of the participants in the collaborative CCD format. Beyond that, we also intend to find ways to improve the assessment and analysis of epistemic activities by comparing the data of studies from different domains [8] where the SRA framework was successfully applied.

References

1. Bao, L., et al., Learning and scientific reasoning. Science, 2009. 323(5914): p. 586-587. 2. Barz, D.L. and A. Achimas-Cadariu, The development of scientific reasoning in medical education: a psychological perspective. Clujul Med, 2016. 89(1): p. 32-7. 3. Engelmann, K., B.J. Neuhaus, and F. Fischer, Fostering scientific reasoning in education–meta-analytic evidence from intervention studies. Educational Research and Evaluation, 2016: p. 1-17. 4. Ouellette, D.L., Zottmann, J., Bolzer, M., Fischer, F., & Fischer, M. R., Investigating the Interplay of Epistemological Beliefs and Scientific Reasoning and Argumentation., in Forschendes Lernen: Wissenschaftsforschung Jahrbuch, H.P. H. A. Mieg, Editor. 2016, H. Laitko: Berlin. p. 71-86. 5. Elstein, A.S., Thinking about diagnostic thinking: a 30-year perspective. Advances in Health Sciences Education, 2009. 14(1): p. 7-18. 6. Fischer, F., et al., Scientific Reasoning and Argumentation: Advancing an Interdisciplinary Research Agenda in Education. Frontline Learning Research, 2014. 2(3): p. 28-45. 7. Kind, P.M., Establishing Assessment Scales Using a Novel Disciplinary Rationale for Scientific Reasoning. Journal of Research in Science Teaching, 2013. 50(5): p. 530-560. 8. Ghanem, C., Kollar, I., Fischer, F., Lawson, T.R., Pankofer, S.. How do Social Work Novices and Experts Solve Professional Problems? A Micro-Analysis of Epistemic Activities and the Use of Evidence. European Journal of Social Work, 2016. 9. Csanadi, A., I. Kollar, and F. Fischer, Scientific Reasoning and Problem Solving in a Practical Domain: Are Two Heads Better Than One? 10. Kotton, D.N., V.V. Muse, and M. Nishino, Case 2-2012. New England Journal of Medicine, 2012. 366(3): p. 259-269. 11. Marks, P.W. and L.R. Zukerberg, Case 30-2004. New England Journal of Medicine, 2004. 351(13): p. 1333-1341. 12. Uyeki, T.M., A. Sharma, and J.A. Branda, Case 40-2009. New England Journal of Medicine, 2009. 361(26): p. 2558-2569. 13. Harris, N.L., Case Records of the Massachusetts General Hospital — Continuing to Learn from the Patient. New England Journal of Medicine, 2003. 348(22): p. 2252-2254.

Author Information

Benedikt Lenzer (presenting / submitting)

Ludwig-Maximilians-Universität, Munich, Germany

Institut für Didaktik und Ausbildungsforschung in der Medizin, Klinikum der Universität München

Munich

Christian Ghanem

Munich Center of the Learning Sciences, Ludwig-Maximilians-Universität München, Munich, Germany.

Marc Weidenbusch

Institut für Didaktik und Ausbildungsforschung in der Medizin, Klinikum der Universität München, Munich, Germany; Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.

Martin R. Fischer

Institut für Didaktik und Ausbildungsforschung in der Medizin, Klinikum der Universität München, Munich, Germany

Jan Zottmann