Clinical reasoning and its challenges at workplace: A qualitative study with novice medical graduates in Sri Lanka

Abstract

Background and rationale: Clinical reasoning is a major determinant of clinical competence among medical professionals (Barrows & Feltovich, 1987). However, even after 40 years of research, diverging opinions still persist on the diagnostic decision making process adopt by medical professionals proving the complexed nature of the phenomenon (Eva, 2004). Aim: This study aims to explore how novice medical graduates working at four main clinical specialties (medicine, surgery, paediatrics and obstetrics & gynaecology) learn and perform clinical reasoning during internship training and the challenges encountered. Theoretical underpinning: Theories of diagnostic decision making range from hypotheticodeductive reasoning described in 1970’s to the dual process theory, discussed recently in the medical education literature (Norman, 2005; Pelaccia, Tardif, Triby, & Charlin, 2011). Proposed methodology: Interpretive paradigm research using phenomenology will be conducted on novice medical graduates working in medicine, paediatric, surgery and obstetrics & gynaecology wards at the North Colombo Teaching Hospital, Ragama, Sri Lanka. The study will be conducted in two phases using purposive sampling (a combined total of 16) with gender balance and equal representation of specialties. During the study each participant will undergo three (3) interviews. The first interview will be on their experience of clinical reasoning as an intern and the challenges faced. The subsequent two interviews are based on audio-recorded patient encounters using the technique of stimulated recall. Two experts from each specialty will review the audio-recordings of patient encounters and determine the relevance of questions to the diagnosis. The interviews will be anonymised and transcribed verbatim. A coding framework will be developed using the five-stage process proposed by Ritchie &Spencer (Analyzing qualitative data, 1994). Thematic analysis of the data will be done using ATLASti. Expected outcomes: The study findings will provide meaningful insights in to organizing and re-structuring medical internship training to facilitate learning and on measures for improving clinical reasoning during undergraduate medical training.