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Simply, clinical reasoning is the sum of the thinking and decision-making processes associated with clinical practice ... and it enables practitioners to take ... the best judged action in a specific context.1
Every day, clinician teachers witness the shock experienced by new residents when they realize that a clinic is in a constant state of uncertainty. Undifferentiated complaints, diagnostic doubts, the familial, social, and cultural characteristics of the patient and his or her perspective, and the working environment and its imponderables are among the factors that cause residents to “lose their innocence,” as Boshuizen puts it.2 In this context, the ability to make adequate decisions requires a reflexive practice and excellent clinical reasoning skills. For clinician teachers, supervising clinical reasoning offers both a formidable challenge and a unique opportunity to support and promote the development of these skills.
A previous Teaching Moment published in Canadian Family Physician emphasized the importance of direct observation in supervision.3 Although regular clinical supervision keeps our expectations of the time that we actually have to work with residents individually both modest and realistic, the clinical context clearly offers incredible teaching potential. Practical experience plays a determining role in the development of skills, especially if it is accompanied by reflection, during and after, to foster understanding and make room for any necessary adjustments.4
From this perspective, the supervision strategies presented in Table 1 are easy to put into practice, even if you did not observe the consultation, and they do not have to be time-consuming. These strategies will stimulate the development of clinical reasoning skills on a daily basis, calling on both the resident and the supervisor to articulate their thought processes.5,6
The supervisor’s duties and responsibilities point to 2 specific roles: that of a clinician who is responsible for the medical care of patients and that of a teacher who is responsible for helping residents to develop their clinical skills.7 In a pedagogic reasoning process that is very similar to the medical reasoning process, the supervisor starts to look for clues that will enable him or her to develop hypotheses on the quality of the resident’s reasoning process, so that the supervisor can identify the resident’s learning needs. The supervisor can then make a pedagogic diagnosis and choose a specific form of supervision that takes his or her conclusions into account. In this way, supervision becomes a reflective, targeted, dynamic process.8
From our experience of supervision and our discussions with our colleagues who are teachers, we have noted that:
In order to observe the resident’s process and understand it, the supervisor must keep in mind the key steps of the medical reasoning process, as summarized in Box 1.
We have developed a tool* to assist clinician teachers in evaluating the clinical reasoning processes of their residents. This tool targets various times in the supervision process, such as the consultation (direct supervision), the presentation of the case by the resident (case discussion), and manifestations of clinical reasoning best observed at these times. This tool can also be used by the supervisor to document the strengths and weaknesses in the resident’s clinical reasoning, to share his or her observations with the resident, to determine what is standing in the way of effective clinical reasoning, and to pursue clinical reasoning in daily practice using the strategies proposed in Table 1.9 This tool is available at CFPlus.*
Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Allyn Walsh, Teaching Moment Coordinator, at ac.retsacmcm@ahslaw.