A Complex Construct: Boiling Down the Clinical Reasoning Process into Directly Observable Behaviors

Current clinical reasoning assessment focuses heavily on outcomes. For example, common tools include checklists of information that should be gathered, lists of differential diagnoses, and whether a supervisor agrees with the next diagnostic or management decision a trainee makes. These approaches appropriately assess whether a learner has reached the appropriate conclusions, but do not provide detailed feedback to improve a learner's clinical reasoning process. Recognizing the complexity of assessment in medical education, NBME used a creative community approach to spark collaborative innovation. Participants in the OSCE for Clinical Reasoning Creative Community have thought in depth about the assessment of clinical reasoning for over two years. In this workshop, presenters will discuss experiences and lessons engaging in research to enhance the formative feedback given to learners and coaches on clinical reasoning skills using simulation-based OSCEs in two areas: hypothesis-driven information gathering (HDIG) and problem representation. HDIG is a synthesis of the subcomponents of hypothesis generation and information gathering, reflecting the iterative and entwined nature of hypothesis generation and information gathering in which each subcomponent feeds back to the other (hypothesis generation leads to information gathering which leads to hypothesis refinement and further information gathering). Through multiple rounds of development and co-production, the community created rubrics that can be used to rate the clinical reasoning process in observed interactions and provide feedback.