Evaluation of an online learning tool to improve medical students' clinical reasoning skills

Background: Evidence suggests that problems in clinical reasoning skills – the thought processes required to make clinical decisions – are the leading cause of diagnostic errors, which can lead to significant patient harm. Theories of learning and clinical reasoning have indicated online patient simulations (OPS) could be a novel approach to improving medical students’ clinical reasoning skills. However, little is known about their impact on clinical reasoning. Methods: I conducted a systematic literature review to explore the effectiveness of OPS. Informed by my review and theory, I co-developed eCREST (electronic Clinical Reasoning Skills Educational Simulation Tool). I assessed the feasibility, acceptability and potential impact of eCREST at three UK medical schools with a feasibility randomised controlled trial (RCT). I explored how students reasoned when using eCREST and what factors influenced reasoning, using a Think Aloud and interview approach with 16 medical students. Results: My systematic review found OPS may be effective at improving medical students’ clinical reasoning skills but the few studies available lacked methodological rigour, so these results should be treated with caution. Uptake and retention in the feasibility trial was acceptable and provided evidence to support a definitive RCT. Impact data suggested eCREST may improve clinical reasoning skills - the intervention group were significantly more likely to gather essential information from the ‘patient’ than controls (OR = 1.4; 95% CI 1.1-1.7, n = 148). Qualitative findings suggested that students use a variety of data gathering strategies and eCREST helped students to structure their data gathering and stay open-minded about diagnosis. Students’ knowledge, confidence and engagement with eCREST also influenced these strategies. Conclusions: Tools like eCREST can improve reasoning skills by helping students to gather essential information and potentially reduce future missed diagnostic opportunities. Evaluations of such tools are now needed within medical curricula, using validated outcome measures to determine effectiveness