Clinical reasoning tests
Mitra Amini
MD MPH
Associate professor of SUMS
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Patient Management Problem (PMP)
Key Feature (KF)
Script Concordance (SC)
Clinical Reasoning Problem (CRP)
Extended Matching (EM)
Comprehensive Integrative Puzzle (CIP)
Symptom Pool (SP)
Patient Management
Problem
• This is a test of clinical problem
solving skill which resemble clinical
situation
• A PMP is usually begins with a clinical
statement concerning the presenting
problem of a patient with a brief
history and examination data
• It is structured in stages; at each
stage the student is asked to make a
decision about patient management,
which he/she considers appropriate
to the situation
• Once a decision is made, further
hidden information is revealed
indicating the results of the
proposed action
• He/she then bases his/her further
decisions on the results revealed
• Mrs Pamela Thompson aged 31 years,
presents at your office complaining
of diarrhea which has been
intermittently present for the past
three months. you have easy access
to hospitals, specialists and
laboratory facilities
• Proceed to section A and select what
action you would take first
• Section A:
• Take detailed history
• Perform detailed physical
examination
• Take brief history while making rapid
assessment of patient
• Perform rapid preliminary
assessment
• Perform office investigation
• Give emergency treatment
• Call in consultant
Key feature
• Not all steps in resolution of a
problem are of equal importance and
the testing time would be better
spend by focusing on the critical
aspects ,key feature
• A key feature is defined as a critical
step in resolution of a problem
Script Concordance
• According to script theory, clinicians
mobilize networks of organized
knowledge, called "scripts", to
process information and progress
toward solutions to clinical problems.
• For example an ear, nose and throat specialist
working with an outpatient suffering from vertigo
is focusing on his or her knowledge of vertigoinducing illnesses. As soon as a new patient comes
into the room, complaining of a cervical mass for
instance, the vertigo knowledge is "washed out"
and networks of knowledge related to cervical
masses are called to mind with direct questions to
ask, physical exams to do or
investigation/treatment options to decide on.
• These knowledge networks are
acquired during clinical training and
refined with each clinical encounter .
They are specifically adapted to the
tasks clinicians commonly perform.
• Health professionals progress toward
solutions to clinical problems with
hypotheses (or management options) and
their related knowledge networks (scripts)
in mind. They actively use them to
constantly make judgments on the effect
that each new piece of information has on
the status of the hypothesis or option
• Script concordance testing (SCT) is based
on the principle that the multiple
judgments made in these clinical reasoning
processes can be probed and their
concordance with those of a panel of
reference experts can be measured. This
provides a tool for assessing clinical
reasoning
• Scenarios are followed by a series of questions,
presented in three parts.
• The first part ("if you were thinking of") contains
a relevant diagnostic or management option.
• The second part ("and then you were to find")
presents a new clinical finding, such as a physical
sign, a pre-existing condition, an imaging study or
a laboratory test result.
• The third part ("this option would become") is a
five-point Likert scale that captures examinees'
decisions.
• The task for examinees is to decide what effect
the new finding has on the status of the option, in
direction (positive, negative or neutral) and
intensity. This effect is captured with a Likert
scale because script theory assumes that clinical
reasoning is composed of a series of qualitative
judgments
Clinical Reasoning
problem
• After reading a brief history,
participants should choose the most
possible diagnosis
• Then they should choose from
patient finding the most probable and
the list probable findings
Extended Matching
Comprehensive
Integrative Puzzle
The CIP is similar to the extended matching
assessment described by Case & Swanson
(1993).
However, it seems to appeal more to
students and teachers because of the fun
in building and solving a ‘matching puzzle’
(like a cross word puzzle
horizontal matching requires an
ability to integrate among disciplines
and the vertical columns depict
knowledge in the various disciplines.
History
a)A 45-year-old man arrived at the
emergency room because of chest
pressure, which began three hours
beforehand while resting. There is no
history of former illnesses for the last
28 years.
• (b) A 28-year-old woman, in her third
month of pregnancy, arrived at the
emergency room because of severe
shortness of breath (dyspnea). She
complains of exertional fatigue from
the beginning of her pregnancy, and
increasing shortness of breath during
the last week.
(c) A 25-year-old man complains of shortness of breath and
dizziness on exertion.Both his grandfather and elder
brother died suddenly at the age of 32 years.
(d) A 75-year-old man arrived at the emergency room
because of 15 minutes of chest pain and sweating,
which began without any prior exertion.The patient
had had a coronary by-pass operation nine years beforehand
and was asymptomatic for nine years.
(e) A 32-year-old woman, with known congenital heart
defect, was hospitalized with a three-week history of
fever, malaise, night sweats and increasing shortness of
breath.
(f ) A 40-year-old woman, suffering for the last three weeks
from flu-like symptoms, complains of continuous anterior
chest pain during the last week.The pain is aggravated
by inspiration, change of posture or swallowing
Symptom pool
• Forward reasoning
• Backward reasoning
• Principle of parsimony