Free communications-14th Asia Pacific Medical Education Conference 2017: Using phenomenology to understand how novice medical graduates learn clinical reasoning in practice

Background: Clinical reasoning is central to the process of making effective diagnostic and management decisions in health care and is essentially considered as a core competence in clinical practice. The field has been researched for nearly four decades giving rise to numerous theories to describe the nature and process of clinical reasoning. However diverging schools of thought still persist and the field continues to be researched by many. This study aimed at exploring how novice medical graduates learn clinical reasoning during internship training and the challenges encountered.
Methodology: A qualitative research using phenomenology was conducted with the participation of novice medical graduates working in North Colombo Teaching Hospital, Ragama, Sri Lanka. A maximum variation sampling method was used to make representations from the four main clinical disciplines namely medicine, paediatric, surgery and obstetrics & gynaecology, and gender groups. Sixteen intern medical officers were recruited accordingly. A semi-structured in-depth interviews were conducted with each individual. The duration of interviews varied between 40 to 60 minutes. The audio records of the interviews were transcribed verbatim. A coding framework was developed using the five - stage process proposed by Ritchie & Spencer (1994). Thematic analysis of data was performed using ATLAS - ti.
Results: The participants conceptualized clinical reasoning as transitional and dynamic process which develops over time with their practice. The approach is dependent on individuals. A deductive approach appeared to be preferred as method of adapting to workplace culture and as a safety measure. However, it may be more susceptible to making error. The main drivers of learning reasoning include to emulate senior doctors, to meet the expectations, to meet the demands of workplace, encouragement by words of wisdom of superiors. Learning of clinical reasoning is facilitated by seeing the same patient frequently, self-reflection, fragmentation of complex clinical dilemmas, safe environments to make mistakes, being patient centered, gaining experience over time and the ‘instinct’. The sources of learning reasoning are multiple and include personnel, processes and environment. Postgraduate trainees appeared to be the most impactful personnel. However, senior doctors, medical students, peers, nurse and patients are identified as useful personnel. Learning reasoning from supervisors and peers is largely implicit. Ward rounds are the key process but referrals of patients, using templets, and compliance with protocols (formal and informal) have also been identified. Personal attitudes like being companionate and caring not only towards patients but also towards near-peers, peers and nurses provides more opportunities for learning reasoning. Workload appears to be the main barrier for learning reasoning. Moreover, learning reasoning may be demotivated by poor self- satisfaction on work constantly changing management regimes, limited interactions with experts, breeches of team dynamics and poor feedback.

Conclusions Intern house officers possess a sound and somewhat diverse understanding of the concept clinical reasoning. They attempt to adopt different strategies. However, their learning and use of clinical reasoning is affected by personal, interpersonal and environmental factors which may leads to the strategy of conformity.