Evaluation of Forward Clinical Reasoning among Pediatrics Residents in a Third Level Hospital

Abstract

Background: In forward reasoning, the physician makes inferences according to data obtained during history taking as well as from physical examination findings, strengthening a hypothesis until a diagnosis is reached.

Objective: Evaluating the differences in forward clinical reasoning among groups with different levels of clinical experience in pediatrics (students, general practitioners accepted to start residence (GPASR) in pediatrics, and residents) with special interest in the initial diagnostic hypothesis.

Methods: Two clinical cases were designed, one depicted an infrequent disease and the other one a frequent disease. Each case had a clinical vignette followed by 5 sequenced multiple choice questions focused on history data, physical exam, complementary studies, diagnosis, and treatment). Each diagnosis had a specific option in each question. The strongest information regarding the correct diagnosis was included as an answer option in the first question. The clinical vignettes were projected followed by the questions. The participants answered the questions immediately on an answering sheet in order to prevent modifications to previously given answers.

Results: Clinical cases were answered by 154 participants, including 69 (44.8%) students, 38 (24.7%) GPASR, and 47 (40.5%) pediatric residents from the same hospital. The proportion of correct diagnosis was different between groups for the frequent disease (students vs. GPASR and residents OR = 0.484, 95% CI: 0.235 - 0.997; residents vs. students and GPASR OR = 3.5, 95% CI: 1.67 - 7.29) but not for the rare disease. The proportion of correct diagnosis was higher when the first question was correctly solved in all groups for the rare disease (OR = 62; 95% CI: 19.32 - 198.89) and the frequent disease (OR = 9.96; 95% CI: 4.36 - 22.71).

Conclusion: Forward reasoning in pediatrics improved through the academic level, for the common disease but not for the uncommonly seen disease; the main factor associated with the correct diagnosis is the initial diagnostic hypothesis.