Students’ educational needs for clinical reasoning in first clerkships

Transition to the clinical phase (4)

‘Textbooks aren’t always useful, because they start from diseases, not symptoms.’ R1;F1

‘During the preclinical phase we followed the course on communication skills, but the focus was on the technique of conversation, not so much on the generation of differential diagnoses.’ R3;F2

Teaching methods (17)

‘You can’t exclusively learn from textbooks, you’ve got to witness it yourself. I think the combination is strong.’ R2;F1

‘You just have to say something, because you’re in a group of 12 students. […] When the teacher asks a question he looks you in the eyes. So, I think that it has an effect on me.’ F2;R1

Learning climate (10)

‘It does make a difference. You are just one of the almost 40 clerks, interns and residents. As the most junior one you don’t have a lot of credit.’ R1;F3

Student (9)

‘And then you realize—if I forget to ask something now, it may be overlooked entirely. It feels much more my own responsibility.’ R1;F2

‘[…] so I focus on the hassles and spend hours in the library rather than doing that what matters most: participating in the clinic’ R2;F2

‘I come to drag up the story after the patient has been seen by so many doctors, residents and interns. So I finish off quickly in order to wrap up my presentation as soon as possible. I’m not going to bother this patient needlessly.’ R1;F1

Teacher (13)

‘To have a physician on your side who observes your history-taking or physical examination and puts you back on track when you stray off. Getting feedback afterwards is really different from getting direct feedback.’ R4;F3

‘We barely see our teacher.’ R2;F3

‘When we want to see her we have to go to the operating rooms. Then it’s clear that teaching junior clerks is not her priority and more an obligation.’ R3;F3

Patient (9)

‘Don’t you have patients who blurt out their assumed diagnosis without me having asked them a single question about it?’ R1;F3

‘Yes.’ R7;F3

‘That’s the major problem. […] You aren’t taking a history, you are listening to a patient’s story.’ R3;F3

‘By telling patients in advance: ‘I’m a junior clerk, that means I’m in training, could you hold back your diagnosis so I can try to figure it out myself’. That works really well.’ R6;F3

Strategies in clinical reasoning (13)

‘I noticed my differential diagnosis came afterwards. I started connecting the dots: ‘these symptoms are linked with these diseases’. I think it’s hard to come up with possible diagnoses during my history-taking.’ R5; F3