Searching for Clinical Reasoning in a Dental Curriculum

Clinical reasoning is a complicated cognitive and interactive process that requires competency in application of knowledge and skills of communication, ethics and professionalism. It is unclear how this competency develops during dental education largely because we don't know how students approach problems. Objectives: We explored the clinical reasoning of final-year dental students when they addressed biopsychosocial problems to describe the process of reasoning and the strategies used by students, to explore variations in their clinical reasoning, and to identify educational implications to improve teaching and assessing clinical reasoning. Methods: We asked 18 dental students from different academic standings to think aloud about problems they perceived in 6 clinical vignettes. All interviews were tape-recorded, transcribed, and analyzed both deductively and inductively to explore the reasoning strategies that students used. Results: The clinical reasoning process the students used involved: 1) collecting and evaluating information; 2) identifying and interpreting problems; 3) evaluating options; and finally 4) arriving at a choice for diagnosis and treatment. For each problem, the diagnosis and treatment plan followed a process of recognizing the pattern of a problem and using diagnostic scripts, moving back and forth between hypothesis and information, or moving along the trunk and branches of decision trees. Students used several strategies including conditional reasoning to explore the sources of problems, envision the problems that could arise in the future and evaluate the possible outcomes of interventions. The also used collaborative reasoning to incorporate the opinion of patients and instructors and applied ethical reasoning to address the conflicts of patients' autonomy with beneficence and justice. Finally, they used pragmatic reasoning to approach the problems inherent in the social and political context of the clinic. Conclusions: Evaluating and improving clinical reasoning involved an integrated approach incorporating different types of problems that demand an integrated application of reasoning strategies.