Introduction

Clinical reasoning is one of the core competencies that need to be inculcated in medical students as this skill will be applied throughout their career. The lack of clinical reasoning utilization or inability to apply clinical reasoning has been associated with increased diagnostic error [1] which is one of the causes of preventable harms to patients [2]. Clinical reasoning has been described in literature as a process in which health practitioners observe, collect, and interpret features in patients to come up with a sound diagnosis and appropriate management plan [1,3] and this was the working definition of clinical reasoning for this study. The definition and conceptualization of clinical reasoning differs in clinical reasoning experts from various training backgrounds and professions as they have different ideas on which component was considered relevant to clinical reasoning [4]. Despite its predominant application in clinical years, the development of clinical reasoning begins much earlier during which basic scientific knowledge is obtained, gathered, organized, and stored.

Experts in the medical community agree on the importance of clinical reasoning, however according to surveys done by Rencic et al. in 2017 [5] on clerkship directors in United States medical schools, and Kononowicz et al. in 2020 [6] on international medical education community, reported that most of the respondents did not have explicit longitudinal clinical reasoning curriculum in their centers. Respondents also suggested that clinical reasoning should be introduced early in medical school and not only taught during the clinical years. Among the barriers identified were the lack of faculty expertise to teach clinical reasoning concepts, lack of awareness on the need to have explicit clinical reasoning teaching and the perceived notion that clinical reasoning could not be taught. Faculty development with train-the-trainer program in clinical reasoning was agreed on by majority of the respondents [6] as one of the possible means to overcome the barriers. A qualitative study done by Angus et al. in 2018 [7] in experienced clinical educators shared similar notion, in which clinical reasoning was difficult to teach and might be impossible to teach in some students. This was attributed to the lack of awareness on own clinical reasoning process in experienced educators [7–8].

The teaching of clinical reasoning is advocated to begin early in medical schools, which is from the pre-clinical years [5,8] for students to be able to appreciate and apply basic science knowledge learnt. Pre-clinical and clinical teaching and learning differ as students have a more scheduled and structured teaching during pre-clinical as compared to a more active and independent learning during clinical years [9]. To effectively teach clinical reasoning during pre-clinical years, educators involved need to comprehend and be well-versed in the art of clinical reasoning teaching. Some educators in the pre-clinical years may not be trained in medicine as their first degree leading to different views and perspectives compared to their clinical counterparts. Clinical educators and non-clinical medical education experts have reported a difference in their rank of the educational principles for successful clinical teaching based on a Delphi study [10]. The mismatch between clinical and non-clinical educators may have an impact on the design and development of any faculty development program.

To the best of our knowledge, there are a limited number of qualitative studies on educators’ perception on clinical reasoning, and these have primarily focused on clinical educators in the West. It will be very interesting to explore the perceptions of both pre-clinical and clinical educators on clinical reasoning, especially in an Asian context as culture plays a part in shaping motivation and attitudes that impacts learning [11,12]. It should be noted that Asian students were more dependent on their educators when compared to Western students who were more independent in their learning [13,14]. Strict educators in Asian education environment were shown to have positive association with students’ motivation whereas it showed negative association in Western students, and this may be due to the Asian culture of obedience and respecting elders and those with authority [15]. The culture of uncertainty avoidance in Asian students and the belief that any knowledge should be memorized to be understood might have a negative outcome on the development of critical thinking and clinical reasoning skills [13]. However, most medical institutions in Asia adopts the Western curriculum with minimal cultural adaptation. This study seeks to answer this question: What are the perceptions and understanding of pre-clinical and clinical educators of a Malaysian public medical institution on clinical reasoning? This study aims to explore the pre-clinical and clinical educators’ perception on clinical reasoning, whether there is any difference in the perception between pre-clinical and clinical educators, and between Asian and Western educators.

Methodology

To obtain educators’ perception on clinical reasoning, a semi-structured interview was conducted with chosen pre-clinical and clinical educators from Faculty of Medicine, Universiti Teknologi MARA (UiTM), Malaysia via purposive sampling method. The educators’ list was obtained from the Human Resource Department following which a discussion was done among the researchers to identify suitable educators. The sampling frame included pre-clinical and clinical educators from various disciplines. For pre-clinical, the educators were either medically trained or non-medically trained, teaching basic science subjects or laboratory-based subjects. For clinical educators, the participants were from medical and surgical-based specializations. The selected participants must fulfil the following criteria: 1) more than 5 years teaching experience, and 2) active involvement in teaching and assessment of undergraduate medical students. For pre-clinical educators, teaching involves lecture, problem-based learning (PBL), practical, and tutorial, whereas teaching in clinical years involves bed side teaching, ward rounds, clinic attachment, and multi-disciplinary seminars.

Invitations were sent to the prospective participants via official institutional email or personal telephone conversation. Interview date, time and place were scheduled based on the participants’ request. Before the start of each interview session, the author briefed the participants on the details of the Participant Information Sheet (PIS) which included the working definition of clinical reasoning used in this study [1,3], objectives and benefits of the study, as well as the interview process. Written informed consent was then obtained, and participants were assured of their confidentiality. The interview questions consisted of participants’ academic and work background, teaching experience in clinical reasoning, and educational strategies to improve clinical reasoning. The participants were encouraged to share their honest perception to each question posed. The questions were open-ended and adapted from Angus et al., 2018 [7] and Addy et al., 2016 [16]. A comprehensive interview protocol, including the full interview questions and prompts was developed and discussed earlier among the authors. A pilot interview was done with one of the faculty members to see the feasibility and appropriateness of the interview protocol. The interview questions are shown in Table 1.

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Table 1. Interview questions and prompts (adapted from Addy et al., 2016 and Angus et al., 2018).

https://doi.org/10.1371/journal.pone.0320220.t001

The interviews were conducted from 5^th July 2022 to 5^th September 2022 and the entire interview session was digitally audio recorded. Interviews were conducted until a saturation of data was achieved. The average time for the interview session was 26 minutes. Subsequently, the interviews were manually transcribed, and a copy of the transcript was sent to each participant via email to ensure accuracy.

Thematic analysis was chosen as the interview data were inductive in nature, the themes were at semantic level and fell into the essentialist or realist epistemology. The thematic analysis followed a step-by-step process as follows; familiarization with the data, generating initial codes, searching for themes, reviewing the themes, defining and naming themes, and producing the report [17]. The coding was done using Atlas.ti by the first and third author, the themes were identified and checked within and across the interviews of each participant. All the authors reached a consensus on the themes, and exemplar quotes for each theme were extracted.

This study was approved by Universiti Kebangsaan Malaysia (UKM) Research Ethics Committee (UKM/PPI/111/8/JEP-2022-219) and written approval was obtained on 15 April 2022.

Reflexivity statement: All team members came from a diverse background in academics. The first author was a pre-clinical educator where the study was conducted and was an early career researcher and pursuing a doctoral degree in the field of medical education. The first author was responsible for interviewing all the participants who were her colleague. The relationship between the first author and the participants was purely professional. The second and third authors were an otorhinolaryngologist and a medical educator respectively and had considerable amount of experience conducting research in the field of medical education.

Results

Discussion

Referring to the identified themes from the interviews, the perception of clinical reasoning by pre-clinical and clinical educators were almost similar. Even though the educators had diverse academic and working background with some had no experience in clinical work, they emphasized on two important factors: knowledge as the foundation of good clinical reasoning and the role of experience in the evolution of clinical reasoning in an individual. To the best of our knowledge, the literature on pre-clinical and clinical educators’ perception on clinical reasoning in an Asian health education landscape was lacking and these findings showed that educators in Faculty of Medicine, UiTM Malaysia were in agreement with most of the international health educators in terms of important factors in clinical reasoning.

Knowledge was perceived by the participants as the utmost important aspect in clinical reasoning, encompassing basic science, clinical medicine and even knowledge on clinical reasoning itself. According to the participants, the importance of knowledge was not only for the development of clinical reasoning in students, but also in educators. This view on the importance of knowledge aligned widely with clinical reasoning literatures. Both content knowledge and cognitive processes used in problem solving were identified as key components in clinical reasoning [1] and inadequate knowledge could lead to diagnostic error [18]. More crucial than the depth of knowledge was the organization of knowledge for the ease of recalling key concepts during problem-solving [18]. However, a study done by Kiesewetter et al. in 2016 [19] found that knowledge alone was not the only factor in solving clinical cases, instead, it was the goal-directed application of knowledge. They concluded that conceptual and strategic knowledge decreased with an increase in metacognitive knowledge along the course of solving clinical cases. Furthermore, knowledge reorganization was shown to have small but consistent benefits in reducing diagnostic errors when compared to recognition of biases in students [20].

Experience perceived as another important aspect by the participants, as clinical reasoning improved with exposure and time. Despite pre-clinical educators not having patient encounters, they recognized the importance of experience in developing clinical reasoning. This may be credited to the exposure to various clinical cases that they encountered during the preparation of teaching and assessment sessions that made them more familiar with the concept of clinical reasoning. This perception showed that the educators were aware of their own clinical reasoning development unlike the findings by Angus et al. in 2018[7], where experienced educators might have lacked the awareness of their own clinical reasoning development. The importance of experience also aligned with the concept of dual process theory (DPT) which posits two types of reasoning systems: System 1 and System 2 [21]. System 1 was an intuitive and unconscious approach or also known as non-analytical whereas System 2 was more analytical, conscious, and deliberate [21,22]. System 1 approach was used mostly by experts as experience over time would make the pattern recognition of similar diseases easier [21]. The role of experience could be used to inculcate clinical reasoning in students, as exposure to simple and complex clinical problems during teaching sessions would provide them with the essential experiences needed [23]. This exposure would direct the students to develop their own illness scripts of different diseases and together with deliberate practice in comparing and contrasting diseases, clinical reasoning could be strengthened [24].

Clinical reasoning itself was viewed by participants as a skill, thus it was something that can be taught. Clinical reasoning was classified under procedural knowledge, similar as blood pressure measurement and other clinical skills. The development of procedural knowledge involved the crucial steps of coaching, constructive feedback, and deliberate practice [1]. All the participants in this study held a positive view that clinical reasoning could be taught, but with its own difficulties. This view was shared by Angus et al. in 2018[7], in which the participants of a qualitative study admitted that clinical reasoning was not easy to teach. The perception that clinical reasoning cannot be taught was seen in some participants of surveys done by Rencic et al. in 2017 [5] and Kononowicz et al. in 2020[6].

Previously, three forms of barriers and challenges in teaching clinical reasoning were identified which were content, environment and expert or teacher factors [8]. In this current study, three form of difficulties in teaching clinical reasoning were identified: educator, institution, and student factor. Participants viewed the high workload, lack of personal understanding, and disconcerted goals or mismatched expectations on clinical reasoning among educators as the difficulties that stemmed from the educators’ side. To be able to teach clinical reasoning meaningfully, educators need to have the same understanding on definition and concepts of clinical reasoning [25] and a common goal. It was shown that clinical teachers had many roles, worked in a demanding and complex environment, and they were not given the proper orientation or preparation before assuming their tasks [26]. Pre-clinical educators also had a myriad of tasks unrelated to teaching and research such as administrative tasks which took a toll on them and could negatively impact their abilities to fulfil assigned tasks. There’s a need for the educators to have the same understanding, goal, and outlook on the teaching of clinical reasoning and this could be achieved by uniformed training.

Students’ timetable, insufficient manpower and multiple campuses were perceived as the difficulties that arose from the institution’s side. The medical curriculum in the place of this study consisted of many core subjects and there were also some additional subjects deemed necessary by the university for the students to learn in their pre-clinical years, further reducing the time for self-directed learning. In many Asian educational systems, significant emphasis was placed on assessments and rote memorization, which often leads to student timetables being filled with lectures and classes. Some of the senior educators had resigned from the public service and worked in the private sector due to a variety of factors; be it for financial gains or self-fulfilment, thus creating a void in the public medical institution. Higher number of educators who were experts in their respective fields need to be recruited to reduce the burden and prevent burnout amongst educators. To accommodate the large number of students and making sure each student had maximum clinical exposure, Faculty of Medicine UiTM had multiple campuses targeting different health education aspects such as urban and rural health. Even though this arrangement did help with students’ educational needs, it posed as a difficulty in terms of logistics to students and educators.

Gradual change in the curriculum, such as implementing curriculum structured on clinical representation rather than system-based [1], or even spiral curriculum [22] could be beneficial to address the issue of student timetable. Lack of curricular time was cited as a significant barrier in implementing clinical reasoning curriculum [5,6] and institution could integrate the teaching and learning clinical reasoning to be more explicit in existing curriculum along the years [27]. The institution’s role was beyond curriculum, as policies and matters related to the well-being of educators was also under its purview, and this included the appointment of more qualified manpower. The issue of educators resigning from public medical institutions and the logistics implication from multiple campuses were beyond the scope of the institution and needed reform from higher governance. However, the current study did highlight these difficulties and it was hoped that it brought awareness for the institution to engage the relevant parties for further discussion.

Students were perceived to have less than desirable critical thinking skills that hindered them from knowledge application. Participants perceived students with high critical thinking skill, asking the right questions and always explaining their train of thoughts as having the desirable qualities to instil clinical reasoning. Achieving this may require a change in the curriculum and teaching and learning modalities towards more active learning approach.

As teaching clinical reasoning proved to be a challenge in pre-clinical and clinical years, participants believed that educators would benefit from training in clinical reasoning. They believed that educators need to really understand and be proficient in clinical reasoning themselves before imparting it to students. Unfortunately, train-the-trainer programs in clinical reasoning were not readily available in most medical institution, and these programmes were deemed necessary by most of the respondents surveyed by Kononowicz et al. in 2020 [6]. Existing train-the-trainer programs were mostly targeted for clinical educators [28,29] and not tailored for pre-clinical educators. Feedback from these programs were mostly positive, with participants perceiving an increase in their confidence level and committing to changes in teaching clinical reasoning [29]. A train-the-trainer program curated and developed for both pre-clinical and clinical educators might be the solution.

In teaching clinical reasoning, participants agreed that it should be taught as early as possible; even during the first year of the pre-clinical phase, incorporated in various teaching and learning modalities with educators having a significant role. This viewpoint was also shared by the participants in the survey done by Rencic et al. in 2017 [5], in which the respondents viewed that clinical reasoning should be taught in all phases of medical education. Early introduction to clinical reasoning might make the pre-clinical students appreciate the importance of basic science subjects [8,30]. However, not all aspects of clinical reasoning should be taught in the early years, as the content and approach need to be tailored to the maturity and knowledge level of the students [24,25]. In view of early introduction to clinical reasoning, pre-clinical educators should be equipped with the appropriate knowledge on clinical reasoning, and this made the need to have a train-the-trainer program much more important.

To enhance the teaching of clinical reasoning, it should be incorporated into various teaching and learning methods, preferably in an active learning setting. Bedside teaching, problem-based learning and virtual patients were some of the methods in which clinical reasoning should be taught [6]. Blended learning strategies encompassing active and collaborative learning principles such as case-based discussion and flipped classroom were useful for students to discuss, apply and reflect on their learning [30]. Participants in this study were not particularly agreeable with lectures or didactic teaching as an effective mode to teach clinical reasoning and this view was also shared in a survey by Kononowicz et al. in 2020 [6].

Interestingly, clinical educators in the current study pointed out the role that technological advances could play such as gamification and simulation in the teaching of clinical reasoning. This view however was not shared by the pre-clinical educators. This difference in view could be due to the way pre-clinical years were taught; student timetable had mostly lectures and less opportunity to incorporate simulation. Pre-clinical educators in this study institution needed to deliver the learning objectives identified for each topic in a specified time frame, giving rise to compressed lecture laden with information. This echoed the findings by Findyartini et al. in 2016 [13] in which Asian academics emphasized on the importance of content expertise and the process of knowledge transfer.

Whereas in clinical years, the use of simulation in clinical skills lab was quite substantial to provide the students with a safe environment to solve clinical cases. Students have been utilizing clinical skill laboratory to practice procedural knowledge such as blood pressure measurement and insertion of nasogastric tubes under the supervision of clinical educators. The nature of procedural knowledge that was predominant in clinical years also played a part in clinical educators’ agreement on the benefits of technological advances. The use of virtual patient was shown to improve clinical reasoning skills in students as it could complement case-based discussion, more so if the number of cases in the hospital were limited [31]. It also provided students with a safe environment in which making a diagnostic or management mistake was not harmful, thus prompting clinical educators to utilize these advances. The pre-clinical educators need protected time to allow for more creativity in incorporating technological advances to inculcate clinical reasoning in their teaching.

Participants in this study also agreed that being an educator was a significant responsibility and should be honoured by giving their utmost dedication in teaching. They were responsible for the cognitive aspect or imparting knowledge to students. Apart from that, they needed to be equipped with the soft skills to enhance teaching. Educators needed to be a coach; to be a role model, to motivate and to give feedback, and these attributes might be one of the important roles of an educator [32]. A review done by Sutkin et al. in 2008 [33] found that non-cognitive attributes were perceived as characteristics of good clinical teachers compared to cognitive attributes. This showed the vast role that educators undertook as a mentor, role model, facilitator, and others.

This study had its own limitation in which the study was conducted in a single centre and the findings obtained were specific to this medical faculty, and it may not be suitable to be generalized to other medical institutions. It is of interest to see the perception of pre-clinical and clinical educators of other public and private medical institution in Malaysia on clinical reasoning and to compare it with the perception of educators in other parts of Asia and elsewhere. To really retest and refine the findings in this study, perhaps a quantitative study on faculty development needs on the rest of the educators would be ideal and should be done in the near future.

Conclusion

Pre-clinical and clinical educators had somewhat similar perception and understanding on clinical reasoning, the only difference was on the perceived role of technological advances in aiding the teaching and learning of clinical reasoning. As they perceived that clinical reasoning can be taught albeit its difficulties, a train-the-trainer programme tailored for pre-clinical and clinical educators could be of assistance in inculcating clinical reasoning in various teaching and learning modalities. Promoting the teaching of clinical reasoning was the concerted efforts by the institution, educators, and students; and the importance of understanding clinical reasoning by these stakeholders were undeniable.

Supporting information