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On the development of competence in solving clinical problems; Can it be taught? Or can it only be learned?

By S.P.J. Ramaekers


For students, the transition from preclinical to clinical learning can be both exciting and worrying. Prior research into the ‘shock of practice’ has shown that many of the students’ difficulties relate to their organisation of knowledge and result from a lack of experience in applying knowledge in real practice situations. This thesis concerns the design and effectiveness of an extensive course in veterinary medicine, intended to bridge the gap between theory and practice. Following a design-based research methodology, the studies in this thesis aim to reveal when and how particular features of the educational design affect the development of competence in solving clinical problems. The main research questions are directed towards: optimal case design, optimal student support from their teachers, the effectiveness of the instructional formats, and assessment of progress in solving clinical problems. The first and last study in this thesis focus on the course design and its effectiveness with regard to the development of competence in solving clinical problems. A proof-of-concept study first revealed how the key features of the course design match with current insights about learning to solve clinical problems. The last study confirmed the effectiveness of the design in practice, showing progress in terms of a) improved performances on the assessment of clinical judgements and decisions, b) observed advancements in the approach of clinical cases, and c) the progress students perceived in their problem solving ability. The second study zooms in on optimisation of the case design with regard to the complexity and authenticity of cases. In line with cognitive load theory, just-in-time provision of case information is used to adjust real-practice cases to a level students can handle and improve upon. The study confirmed that in problem solving tasks information characteristics such as the problem demarcation, information ambiguity or structure affect case complexity and cognitive requirements. To reduced cognitive load during task execution, it is recommended to provide students beforehand with sufficient information, at a level of functional fidelity. The third study explores the impact of just-in-time provision of case information on teacher and student behaviour in the problem solving process. Triangulation of observations of clinical tutorials, stimulated recall interviews and student questionnaires revealed that providing clarity on teacher roles and expectations, delayed scaffolding, and facilitation of reflection and feedback are conditional for student learning and motivation, whereas concurrent scaffolding proved counterproductive. The fourth study concerns the development of a test on solving clinical problems in veterinary medicine, and establishing its methodological qualities. The script concordance test format is designed to assess in a large number of authentic cases making decisions under uncertainty. From a substantive appraisal of the cases and items it was concluded that the test validly represents the problems, decisions and uncertainties of clinical practice. In spite of the uncertainties included in the test, the reliability (generalisability) of the test and its results could be evaluated and proved to meet measurement criteria. The strength of the results on the test signified that the progress students made in this course was substantial

Publisher: Utrecht University
Year: 2011
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