The development of clinical reasoning in veterinary students

Clinical reasoning is the skill used when veterinary surgeons make a decision regarding the diagnosis, treatment plan or prognosis of a patient. Despite its necessity and ubiquity within clinical practice, very little is known about the development of clinical reasoning during undergraduate training. Even less is understood about how veterinary schools should be helping students improve this skill. The aim of the research presented within this thesis was to, firstly, examine the development of clinical reasoning ability within veterinary students and, secondly, to investigate possible methods to aid this process. The University of Nottingham School of Veterinary Medicine and Science (SVMS) was used as a case study for this research. In study one, focus groups and interviews were conducted with SVMS staff, students and graduates to investigate the development of clinical reasoning. A curriculum document content analysis was also performed. The findings suggested that clinical reasoning development is not optimal, with alumni facing a steep learning curve when entering practice. These results were used to design study two, in which a simulated consultation exercise utilizing standardised clients was created and implemented for final year students. The success of the simulation was measured using both quantitative and qualitative methods – all of which supported the use of the session for clinical reasoning development. The final study, also building on the findings of study one, aimed to improve the accessibility of veterinary surgeons’ decision-making processes during student clinical extramural studies placements (CEMS). A reflective Decision Diary was created and trialled with third and fourth year SVMS students. Diary content analysis showed the study aim was met, triangulated by survey and focus group findings. During the research, wider issues relating to clinical reasoning integration into veterinary curricula were unearthed. These included low student awareness of the subject and the misalignment between the skill learnt during training and the skill required when in practice. Several recommendations have been made to improve the design of the undergraduate curriculum in relation to clinical reasoning

An investigation into the clinical reasoning development of veterinary students

Clinical reasoning is a fundamental skill for veterinary clinicians and a competency required of graduates by the Royal College of Veterinary Surgeons. However, it is unknown how veterinary students develop reasoning skills and where strengths and shortcomings of curricula lie. This research aimed to use the University of Nottingham School of Veterinary Medicine and Science (SVMS) as a case study to investigate the development of clinical reasoning among veterinary students. The analysis was framed in consideration of the taught, learned, and declared curricula. Sixteen staff and sixteen students from the SVMS participated separately in a total of four focus groups. In addition, five interviews were conducted with recent SVMS graduates. Audio transcriptions were used to conduct a thematic analysis. A content analysis was performed on all curriculum documentation. It was found that SVMS graduates feel they have a good level of reasoning ability, but they still experience a deficit in their reasoning capabilities when starting their first job. Overarching themes arising from the data suggest that a lack of responsibility for clinical decisions during the program and the embedded nature of the clinical reasoning skill within the curriculum could be restricting development. In addition, SVMS students would benefit from clinical reasoning training where factors influencing ‘‘real life’’ decisions (e.g., finances) are explored in more depth. Integrating these factors into the curriculum could lead to improved decision-making ability among SVMS graduates and better prepare students for the stressful transition to practice. These findings are likely to have implications for other veterinary curricula

The development of clinical reasoning in veterinary students

Clinical reasoning is the skill used when veterinary surgeons make a decision regarding the diagnosis, treatment plan or prognosis of a patient. Despite its necessity and ubiquity within clinical practice, very little is known about the development of clinical reasoning during undergraduate training. Even less is understood about how veterinary schools should be helping students improve this skill. The aim of the research presented within this thesis was to, firstly, examine the development of clinical reasoning ability within veterinary students and, secondly, to investigate possible methods to aid this process. The University of Nottingham School of Veterinary Medicine and Science (SVMS) was used as a case study for this research. In study one, focus groups and interviews were conducted with SVMS staff, students and graduates to investigate the development of clinical reasoning. A curriculum document content analysis was also performed. The findings suggested that clinical reasoning development is not optimal, with alumni facing a steep learning curve when entering practice. These results were used to design study two, in which a simulated consultation exercise utilizing standardised clients was created and implemented for final year students. The success of the simulation was measured using both quantitative and qualitative methods – all of which supported the use of the session for clinical reasoning development. The final study, also building on the findings of study one, aimed to improve the accessibility of veterinary surgeons’ decision-making processes during student clinical extramural studies placements (CEMS). A reflective Decision Diary was created and trialled with third and fourth year SVMS students. Diary content analysis showed the study aim was met, triangulated by survey and focus group findings. During the research, wider issues relating to clinical reasoning integration into veterinary curricula were unearthed. These included low student awareness of the subject and the misalignment between the skill learnt during training and the skill required when in practice. Several recommendations have been made to improve the design of the undergraduate curriculum in relation to clinical reasoning

Comparison of microbial community assays for the assessment of stream biofilm ecology

We investigated a range of microbiological community assays performed on scrapes of biofilms formed on artificial diffusing substrates deployed in 8 streams in eastern Scotland, with a view to using them to characterize ecological response to stream water quality. The assays considered were: Multiplex Terminal Restriction Fragment Length Polymorphism or M-TRFLP (a molecular method), Phospholipid Fatty Acid or PLFA analysis (a biochemical method) and MICRORESP™ (a physiological method) alongside TDI, diatom species, and chlorophyll a content. Four of the streams were classified as of excellent status (3–6 μg/L Soluble Reactive Phosphorus (SRP)) with respect to soluble P content under the EU Water Framework Directive and four were of borderline good/moderate or moderate status (43–577 μg/L SRP). At each site, 3 replicates of 3 solute diffusion treatments were deployed in a Latin square design. Solute diffusion treatments were: KCl (as a control solute), N and P (to investigate the effect of nutrient enrichment), or the herbicide isoproturon (as a “high impact” control, which aimed to affect biofilm growth in a way detectable by all assays). Biofilms were sampled after 4 weeks deployment in a low flow period of early summer 2006. The chlorophyll a content of biofilms after 4 weeks was 2.0 ± 0.29 mg/m2 (mean ± se). Dry matter content was 16.0 ± 13.1 g/m2. The M-TRFLP was successfully used for generating community profiles of cyanobacteria, algae and bacteria and was much faster than diatom identification. The PFLA and TDI were successful after an increase in the sample size, due to low counts. The MICRORESP™ assays were often below or near detection limit. We estimated the per-sample times for the successful assays as follows: M-TRFLP: 20 min, PLFA 40 min, TDI 90 min. Using MANOVA on the first 5 principal co-ordinates, all the assays except MICRORESP™ showed significant differences between sites, but none of the assays showed a significant effect of either initial stream trophic status (as classified by the EU Water Framework Directive using chemical standards for soluble P), or of the diffusing solute treatment. Multiple Procrustes analysis on the ordination results showed that the diatom and M-TRFLP data sets hold distinct, though as yet unexplored, information about the ecological factors affecting stream biofilms. The diatom data were subjected to principal components analysis, to identify which taxa were more strongly influenced by site variables, trophic status or treatment effects. These were Acnanthes lanceolata, A. minutissimma, Nitzchia spp., Coccineis spp. and Navicula spp. Further experimentation and data analysis on a larger number of sites, to identify specific M-TRFLP bands that could be used as indicators linked to specific taxa, are desirable. Results highlight the need for a multifactorial approach to understanding controls on stream ecology