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Innovation and Change in Professional Education 15

Olle ten Cate

Eugène J.F.M. Custers
Steven J. Durning Editors

Principles and
Practice of Case-
based Clinical
Reasoning
Education
A Method for Preclinical Students
Innovation and Change in Professional
Education

Volume 15

Series editor

Wim H. Gijselaers, School of Business and Economics, Maastricht University,

The Netherlands

Associate editors

L.A. Wilkerson, Dell Medical School at the University of Texas at Austin, TX, USA
H.P.A. Boshuizen, Center for Learning Sciences and Technologies,
Open Universiteit Nederland, Heerlen, The Netherlands

Editorial Board

Eugene L. Anderson, Anderson Policy Consulting & APLU, Washington, DC, USA
Hans Gruber, Institute of Educational Science, University of Regensburg,
Regensburg, Germany
Rick Milter, Carey Business School, Johns Hopkins University, Baltimore, MD, USA
Eun Mi Park, JH Swami Institute for International Medical Education,
Johns Hopkins University School of Medicine, Baltimore, MD, USA
SCOPE OF THE SERIES

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Olle ten Cate • Eugène J.F.M. Custers
Steven J. Durning
Editors

Principles and Practice

of Case-based Clinical
Reasoning Education
A Method for Preclinical Students
Editors
Olle ten Cate Eugène J.F.M. Custers
Center for Research and Development Center for Research and Development
of Education of Education
University Medical Center Utrecht University Medical Center Utrecht
Utrecht, The Netherlands Utrecht, The Netherlands

Steven J. Durning
Uniformed Services University of the
Health Sciences
Bethesda, MD, USA

ISSN 1572-1957     ISSN 2542-9957 (electronic)

Innovation and Change in Professional Education
ISBN 978-3-319-64827-9    ISBN 978-3-319-64828-6 (eBook)
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Preface

Probably the most core characteristic of any physician is their clinical reasoning
ability as it touches all aspects of patient care. While this statement is not disputed,
the education to support students in acquiring this ability is far from clear. Clinical
reasoning has been the subject of substantial research to (1) clarify what it actually
is; (2) identify when and why clinical reasoning goes wrong, resulting in errors or
suboptimal care; (3) identify teaching approaches; and (4) recognize models of
assessment. While some medical education scholars question whether clinical rea-
soning can be explicitly taught at all, the literature provides many teaching methods.
None of these are conclusive and every medical school has their own way to support
medical students in their development of clinical reasoning ability.
One area where there is agreement in the medical education community, based
on a body of empirical work, is that clinical experience and a substantial knowledge
base are necessary to reach high levels of clinical reasoning ability. Schools desiring
to optimally prepare students for their clinical experiences face a difficult problem.
How to best train students to think like a doctor? Can they learn taking histories and
conducting physical examinations, formulating differential diagnoses, and propos-
ing management plans before they enter the clinical arena? Integrated curricula,
particularly in a vertical sense, attempt to combine basic science teaching with
patient-based clinical teaching at early stages of the medical curriculum to optimize
this preparation. But what if clinical experience itself is necessary to begin acquir-
ing clinical reasoning ability?
This book describes a teaching method that has been used for over 20 years and
has survived multiple medical curricula in different educational institutions in the
Netherlands and other countries. The method is derived from the primary editor’s
Ph.D. studies on peer teaching in the 1980s at the University of Amsterdam Medical
School.
In the past 10 years, the model has been used to support the modernization of
medical curricula through EU-funded projects in Moldova, Georgia, Azerbaijan,
and Ukraine. The most recent of these projects (MUMEENA or Modernizing
Undergraduate Medical Education in the Eastern Neighboring Area) has led to a
detailed, extensive description of the case-based clinical reasoning (CBCR) method

v
vi Preface

that was first published as a gray-literature English language book and subsequently
translated in the Georgian, Azeri, Ukrainian, and Spanish languages.
This volume was fully revised and expanded, resulting in the current
publication.
The CBCR educational method is one approach to preparing students to think
like doctors before they become engaged in patient care. We do not claim that it is
the only (or even the preferred) method. What we can say is that this method has
served many generations (thousands of medical students) in their preclinical period.
Available student evaluations have been consistently as good as or better than other
preclinical courses. The method can be applied within or added to an existing medi-
cal curriculum, as a core, elective, or extracurricular course.
The book has three parts. For readers interested in general understanding of clini-
cal reasoning education, Part I (Chaps. 1, 2, 3, 4, and 5) will provide food for
thought. For those interested to apply the CBCR method, Part II (Chaps. 6, 7, 8, 9,
and 10) is recommended. Part III (the appendices) provides cases that can be used,
for instance, by educators who wish to try out this method with their learners.
We wish to thank the many individuals who have contributed to the success of
the CBCR method by being involved in the initial design, notably Professor Bert
Schadé from the Academic Medical Center in Amsterdam, or by serving as consul-
tants and by writing cases. For this volume, we thank Drs. Charles Magee, Mary
Kwok, Jeremy Perkins, and Lieke van Imhoff for writing or editing one or more
cases included in the appendix.

Utrecht, The Netherlands Olle ten Cate

Utrecht, The Netherlands Eugène J.F.M. Custers
Bethesda, MD, USA  Steven J. Durning
Contents

Part I Backgrounds of Educating Preclinical Students

in Clinical Reasoning
1 Introduction����������������������������������������������������������������������������������������������    3
Olle ten Cate
2 Training Clinical Reasoning: Historical
and Theoretical Background������������������������������������������������������������������   21
Eugène J.F.M. Custers
3 Understanding Clinical Reasoning from Multiple Perspectives:
A Conceptual and Theoretical Overview����������������������������������������������   35
Olle ten Cate and Steven J. Durning
4 Prerequisites for Learning Clinical Reasoning ������������������������������������   47
Judith L. Bowen and Olle ten Cate
5 Approaches to Assessing the Clinical Reasoning
of Preclinical Students ����������������������������������������������������������������������������   65
Olle ten Cate and Steven J. Durning

Part II The Method of Case-Based Clinical Reasoning Education

6 Case-Based Clinical Reasoning in Practice ������������������������������������������   75
Angela van Zijl, Maria van Loon, and Olle ten Cate
7 Assessment of Clinical Reasoning Using the CBCR Test ��������������������   85
Olle ten Cate
8 Writing CBCR Cases������������������������������������������������������������������������������   95
Olle ten Cate and Maria van Loon

vii
viii Contents

9 Curriculum, Course, and Faculty Development

for Case-Based Clinical Reasoning�������������������������������������������������������� 109
Olle ten Cate and Gaiane Simonia
10 A Model Study Guide for Case-Based Clinical Reasoning������������������ 121
Maria van Loon, Sjoukje van den Broek, and Olle ten Cate

Appendix ���������������������������������������������������������������������������������������������������������� 133

Index������������������������������������������������������������������������������������������������������������������ 205
Editors and Contributors

About the Editors

Olle ten Cate, Ph.D. is a professor of medical education and director of the Center
for Research and Development of Education at University Medical Center Utrecht,
The Netherlands. He was the originator and has been intermittently coordinator of
CBRC courses from 1993 until 1999 in Amsterdam and from 2005 until 2016 in
Utrecht. His research and development interests include curriculum development,
peer teaching, competency-based medical education, clinical reasoning, and many
other areas.

Eugène J.F.M. Custers, Ph.D. is a researcher in medical education at the Center for
Research and Development of Education at University Medical Center Utrecht, The
Netherlands. His primary area of expertise is clinical reasoning, the role of basic
sciences in medical expertise, and illness script development. He also has a special
interest in the history of medical education.

Steven J. Durning, M.D., Ph.D. is professor of medicine and pathology and direc-
tor for the graduate programs in health professions education, the Introduction to
Clinical Reasoning medical school course, and the Long-Term Career Outcome
Study at the Uniformed Services University of the Health Sciences, Bethesda,
Maryland, USA. He holds a Ph.D. in health professions education and is a practic-
ing internist. His research and development interests include clinical reasoning,
assessment, educational theory, peer teaching, and several other areas.

ix
x Editors and Contributors

About the Contributors

Judith L. Bowen, M.D. is professor of medicine in the Division of General Internal

Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon,
USA, where she directs the Education Scholars Program, a longitudinal faculty
development program for clinical teachers. She is a Ph.D. candidate in medical
education at Utrecht University. Her research interests include clinical reasoning
and curriculum with a focus on the impact of transitions of clinical responsibility on
learning diagnostic reasoning.

Gaiane Simonia, M.D., Ph.D. is professor of internal medicine, head of the

Division of Geriatrics, and head of the Department of Medical Education, Research
and Strategic Development at Tbilisi State Medical University, Tbilisi, Georgia. She
was involved as primary initiator of the MUMEENA project of modernizing medi-
cal education in Eastern European countries which included the introduction of
CBCR in curricula in Georgia, Azerbaijan, and Ukraine.

Sjoukje van den Broek, M.D. is an assistant professor at the Unit of Medical
Education, with an adjunct attachment with the Center for Research and Development
of Education, both at University Medical Center Utrecht, The Netherlands. She has
been involved with CBCR from 2010 as consultant and is currently a coordinator of
the CBCR course for second-year medical students. She is also a Ph.D. candidate in
medical education, and she supports, as general secretary, the Ethical Review Board
for Health Professions Education Research of The Netherlands Association for
Medical Education.

Maria van Loon, M.D. worked as a junior teacher at the Center for Research and
Development of Education, University Medical Center Utrecht, The Netherlands.
She was involved with CBCR in 2014 as a consultant and as a coordinator of the
CBCR course for second-year medical students and was actively involved with the
training of medical schools with CBCR in Georgia, Azerbaijan, Ukraine, and Spain.
She now works as a resident in general practice at University Medical Center
Utrecht.

Angela van Zijl, M.D. worked as a junior teacher at the Center for Research and
Development of Education, University Medical Center Utrecht. She was involved
with CBCR in 2013 as a coordinator of the CBCR course for second-year medical
students and was actively involved with the training of medical schools with CBCR
in Azerbaijan. At the moment, she is a resident in pediatrics at Gelderse Vallei
Hospital Ede, The Netherlands.
 Part I
Backgrounds of Educating Preclinical
Students in Clinical Reasoning
Chapter 1
Introduction

Olle ten Cate

Clinical reasoning is a professional skill that experts agree is difficult and takes time
to acquire, and, once you have the skill, it is difficult to explain what you actually do
when you apply it—clinical reasoning then sometimes even feels as an easy pro-
cess. The input, a clinical problem or a presenting patient, and the outcome, a diag-
nosis and/or a plan for action, are pretty clear, but what happens in the doctor’s mind
in the meantime is quite obscure. It can be a very short process, happening in sec-
onds, but it can also take days or months. It can require deliberate, painstaking
thinking, consultation of written sources, and colleague opinions, or it may just
seem to happen effortless. And “reasoning” is such a nicely sounding word that doc-
tors would agree captures what they do, but is it always reasoning? Reasoning
sounds like building a chain of thoughts, with causes and consequences, while doc-
tors sometimes jump at a conclusion, sometimes before they even realize they are
clinically reasoning. Is that medical magic? No, it’s not. Laypeople do the same.
Any adult witnessing a motorcycle accident and seeing a victim on the street show-
ing a lower limb in a strange angle will instantly “reason” the diagnosis is a fracture.
Other medical conditions are less obvious and require deep thinking or investiga-
tions or literature study. Whatever presentation, doctors need to have the requisite
skills to tackle the medical problems of patients that are entrusted to their care. No
matter how obscure clinical reasoning is, students need to acquire that ability. So
how does a student begin to learn clinical reasoning? How must teachers organize
the training of students?
Case-based clinical reasoning (CBCR) education is a design of training of pre-
clinical medical students, in small groups, in the art of coping with clinical prob-
lems as they are encountered in practice. As will be apparent from the description

O. ten Cate (*)

Center for Research and Development of Education, University Medical Center Utrecht,
Utrecht, The Netherlands
e-mail: [email protected]

© The Author(s) 2018 3

O. ten Cate et al. (eds.), Principles and Practice of Case-based Clinical
Reasoning Education, Innovation and Change in Professional Education 15,
https://doi.org/10.1007/978-3-319-64828-6_1
4 O. ten Cate

later in this chapter, CBCR is not identical to problem-based learning (Barrows and
Tamblyn 1980), although some features (small groups, no traditional teacher role)
show resemblance. While PBL is intended as a method to arrive at personal educa-
tional objectives and subsequently acquire new knowledge (Schmidt 1983), CBCR
has a focus on training in the application of systematically acquired prior knowl-
edge, but now in a clinical manner. It aims at building illness scripts—mental repre-
sentations of diseases—while at the same time supports the acquisition of a
diagnostic thinking habit. CBCR is not an algorithm or a heuristic to be used in
clinical practice to efficiently solve a new medical problem. CBCR is no more and
no less than educational method to acquire clinical reasoning skill. That is what this
book is about.
The elaboration of the method (Part II and III of the book) is preceded in Part I
by chapters on the general background of clinical reasoning and its teaching.

What Is Clinical Reasoning?

Clinical reasoning is usually defined in a very general sense as “The thinking and
decision -making processes associated with clinical practice” (Higgs and Jones
2000) or simply “diagnostic problem solving” (Elstein 1995).
For the purpose of this book, we define clinical reasoning as the mental process
that happens when a doctor encounters a patient and is expected to draw a conclu-
sion about (a) the nature and possible causes of complaints or abnormal conditions
of the patient, (b) a likely diagnosis, and (c) patient management actions to be taken.
Clinical reasoning is targeted at making decisions on gathering diagnostic informa-
tion and recommending or initiating treatment. The mental reasoning process is
interrupted to collect information and resumed when this information has arrived.
It is well established that clinicians have a range of mental approaches to apply.
Somewhat simplified, they are categorized in two thinking systems, sometimes sub-
sumed under the name dual-process theory (Eva 2005; Kassirer 2010; Croskerry
2009; Pelaccia et al. 2011). Based in the work of Croskerry (2009) and the Institute
of Medicine (Balogh et al. 2015), Fig. 1.1 shows a model of how clinical reasoning
and the use of System 1 and 2 thinking can be conceptualized graphically.
The first thinking approach is rapid and requires little mental effort. This mode
has been called System 1 thinking or pattern recognition, sometimes referred to as
non-analytical thinking. Pattern recognition happens in various domains of exper-
tise. Based on studies in chess, it is estimated that grand master players have over
50,000 patterns available in their memory, from games played and games studied
(Kahneman and Klein 2009). These mental patterns allow for the rapid comparison
of a pattern in a current game with patterns stored in memory and for a quick deci-
sion which move to make next. This huge mental library of patterns may be com-
pared with the mental repository of illness scripts that an experienced clinician has
and that allows for the rapid recognition of a pattern of signs and symptoms in a
1 Introduction 5

Fig. 1.1 A model of clinical reasoning (Adapted from Croskerry 2009)

Box 1.1 Illness Script

An illness script is a general representation in the physician’s mind of an ill-
ness. An illness script includes details on typical causal or associated preced-
ing features (“enabling conditions”); the actual pathology (“fault”); the
resulting signs, symptoms, and expected diagnostic findings (“conse-
quences”); and, added to the original illness script definition (Feltovich and
Barrows 1984), the most likely course and prognosis with suitable manage-
ment options (“management”). An illness script may be stored as one compre-
hensive unit in the long-term memory of the physician. It can be triggered to
be retrieved during new clinical encounters, to facilitate comparison and con-
trast, in order to generate a diagnostic hypothesis.

patient with patients encountered in the past (Feltovich and Barrows 1984; Custers
et al. 1998). See Box 1.1.
A mental matching process can lead to an instant recognition and generation of
a hypothesis, if sufficient features of the current patient resemble features of a stored
illness script.
Next to this rapid mental process, clinicians use System 2 thinking: the analytical
thinking mode of presumed causes-and-effects reasoning that is slow and takes
effort and is used when a System 1 process does not lead to an acceptable proposi-
6 O. ten Cate

tion to act. Analytic, often pathophysiological, thinking is typically the approach

that textbooks of medicine use to explain signs and symptoms related to pathophysi-
ological conditions in the human body. Both approaches are needed in clinical
health care, to arrive at decisions and actions and to retrospectively justify actions
taken. The two thinking modes can be viewed on a cognitive continuum between
instant recognition and a reasoning process that may take a long time (Kassirer et al.
2010; Custers 2013). In routine medical practice, the rapid System 1 thinking pre-
vails. This thinking often leads to correct decisions but is not infallible. However,
the admonition to slow down the thinking when System 1 thinking fails and move
to System 2 thinking may not lead to more accurate decisions (Norman et al. 2014).
In fact, emerging fMRI studies seem to indicate that in complex cases, inexperi-
enced learners search for rule-based reasoning solutions (System 2), while experi-
enced clinicians keep searching for cases from memory (System 1) (Hruska et al.
2015).

How to Teach Clinical Reasoning to Junior Students?

It is not exactly clear how medical students acquire clinical reasoning skills
(Boshuizen and Schmidt 2000), but they eventually do, whether they had a targeted
training in their curriculum or not. Williams et al. found a large difference in reason-
ing skill between years of clinical experience and across different schools (Williams
et al. 2011). Even if reasoning skill would develop naturally across the years of
medical training, it does not mean that educational programs cannot improve.
One way to approach the training of students in clinical reasoning is to focus on
things that can go wrong in the practice of clinical reasoning and on threats to effective

Box 1.2 Summary of Prevalent Causes of Errors and Cognitive Biases

Errors (Graber et al. 2005; Kassirer et al. 2010)
–– Lack or faulty knowledge
–– Omission of, or faulty, data gathering and processing
–– Faulty estimation of disease prevalence
–– Faulty test result interpretation
–– Lack of diagnostic verification
Biases (Balogh et al. 2015)
–– Anchoring bias and premature closure (stop search after early
explanation)
–– Affective bias (emotion-based deviance from rational judgment)
–– Availability bias (dominant recall of recent or common cases)
–– Context bias (contextual factors that mislead)
1 Introduction 7

thinking in clinical care. Box 1.2 shows the most prevalent errors and cognitive biases
in clinical reasoning (Graber et al. 2005; Kassirer et al. 2010). See also Chap. 3.
In general, diagnostic errors are considered to occur too often in practice
(McGlynn et al. 2015; Balogh et al. 2015), and it is important that student prepara-
tion for clinical encounters be improved (Lee et al. 2010). In a qualitative study,
Audétat et al. observed five prototypical clinical reasoning difficulties among resi-
dents: generating hypotheses to guide data gathering, premature closure, prioritiz-
ing problems, painting an overall picture of the clinical situation, and elaborating a
management plan (Audétat et al. 2013), not unlike the prevalent errors in clinical
practice as summarized in Box 1.2. Errors in clinical reasoning pertain to both
System 1 and System 2 thinking and cognitive biases causing errors are not easily
amenable to teaching strategies. An inadequate knowledge base appears the most
consistent reason for error (Norman et al. 2017). A number of authors have recom-
mended tailored teaching strategies for clinical reasoning (Rencic 2011; Guerrasio
and Aagaard 2014; Posel et al. 2014). Most approaches pertain to education in the
clinical workplace. Box 1.3 gives a condensed overview.
One dominant approach that clinical educators use when teaching students to
solve medical problems is ask them to analyze pathophysiologically, in other words
to use System 2 thinking. While this seems the only option with students who do not

Box 1.3 Summary of Recommended Approaches to Teaching Clinical

Reasoning (Guerrasio and Aagaard 2014; Rencic 2011; Posel et al. 2014;
Chamberland et al. 2015; Balslev et al. 2015; Bowen 2006)
Let students
• Maximize learning by remembering many patient encounters.
• Recall similar cases as they increase experience.
• Build a framework for differential diagnosis using anatomy, pathology,
and organ systems combined with semantic qualifiers: age, gender, ethnic-
ity, and main complaint.
• Differentiate between likely and less likely but important diagnoses.
• Contrast diagnoses by listing necessary history questions and physical
exam maneuvers in a tabular format and indicating what supports or does
not support the respective diagnoses.
• Utilize epidemiology, evidence, and Bayesian reasoning.
• Practice deliberately; request and reflect on feedback; and practice
mentally.
• Generate self-explanations during clinical problem solving.
• Talk in buzz groups at morning reports with oral and written patient data.
• Listen to clinical teachers reasoning out loud.
• Summarize clinical cases often using semantic qualifiers and create prob-
lem representations.
8 O. ten Cate

possess a mental library of illness scripts to facilitate System 1 thinking, those

teachers teach something they usually do not do themselves when solving clinical
problems This teaching resembles the “do as I say, not as I do” approach, in part
because they simply cannot express “how they do” when they engaged in clinical
reasoning.
In a recent review of approaches to the teaching of clinical reasoning, Schmidt
and Mamede identified two groups of approaches: a predominant serial-cue
approach (teachers provide bits of patient information to students and ask them to
reason step by step) and a rare whole-task (or whole-case) approach in which all
information is presented at once. They conclude that there is little evidence for the
serial-cue approach, favored by most teachers and recommend a switch to whole-­
case approaches (Schmidt and Mamede 2015). While cognitive theory does support
whole-task instructional techniques (Vandewaetere et al. 2014), the description of a
whole-case in clinical education is not well elaborated. Evidently a whole-case can-
not include a diagnosis and must at least be partly serial. But even if all the informa-
tion that clinicians in practice face is provided to students all at once, the clinical
reasoning process that follows has a serial nature, even if it happens quickly.
Schmidt and Mamede’s proposal to first develop causal explanations, second to
encapsulate pathophysiological knowledge, and third to develop illness scripts
(Schmidt and Mamede 2015) runs the risk of separating biomedical knowledge
acquisition from clinical training and regressing to a Flexnerian curriculum. Flexner
advocated a strong biomedical background before students start dealing with
patients (Flexner 1910). This separation is currently not considered the most useful
approach to clinical reasoning education (Woods 2007; Chamberland et al. 2013).
Training students in the skill of clinical reasoning is evidently a difficult task, and
Schuwirth rightly once posed the question “Can clinical reasoning be taught or can
it only be learned?” (Schuwirth 2002). Since the work of Elstein and colleagues, we
know that clinical reasoning is not a skill that is trainable independent of a large
knowledge base (Elstein et al. 1978). There simply is not an effective and teachable
algorithm of clinical problem solving that can be trained and learned, if there is no
medical knowledge base. The actual reasoning techniques used in clinical problem
solving can be explained rather briefly and may not be very different from those of
a car mechanic. Listen to the patient (or the car owner), examine the patient (or the
car), draw conclusions, and identify what it takes to solve the problem. There is not
much more to it. In difficult cases, medical decision-making can require knowledge
of Bayesian probability calculations, understanding of sensitivity and specificity of
tests (Kassirer et al. 2010), but clinicians seldom use these advanced techniques
explicitly at the bedside.
These recommendations are of no avail if students do not have background
knowledge, both about anatomical structures and pathophysiological processes and
about patterns of signs and symptoms related to illness scripts. When training medi-
cal students to think like doctors, we face the problem that we cannot just look how
clinicians think and just ask students to mimic that technique. That is for two rea-
sons: one is that clinicians often cannot express well how they think, and the second
1 Introduction 9

is simply that the huge knowledge base required to think like an experienced clini-
cian is simply not present in students.
As System 1 pattern recognition is so overwhelmingly dominant in the clini-
cian’s thinking (Norman et al. 2007), the lack of a knowledge base prohibits junior
students to think like a doctor. It is clear that students cannot “recognize” a pattern
if they do not have a similar pattern in their knowledge base. It is unavoidable that
much effort and extensive experience are needed before a reasonable repository of
illness scripts is built that can serve as the internal mirror of patterns seen in clinical
practice. Ericsson’s work suggests that it may take up to 10,000 hours of deliberate
practice to acquire expertise in any domain, although there is some debate about this
volume (Ericsson et al. 1993; Macnamara et al. 2014). Clearly, students must see
and experience many, many cases and construct and remember illness scripts. What
a curriculum can try to offer is just that, i.e., many clinical encounters, in clinical
settings or in a simulated environment. Clinical context is likely to enhance clinical
knowledge, specifically if students feel a sense of responsibility or commitment
(Koens et al. 2005; Koens 2005). This sense of commitment in practice relates to the
patient, but it can also be a commitment to teach peers.
System 2 analytic reasoning is clearly a skill that can be trained early in a cur-
riculum (Ploger 1988). Causal reasoning, usually starting with pathology (a viral
infection of the liver) and a subsequent effect (preventing the draining of red blood
cell waste products) and ending with resulting symptoms (yellow stains in the
blood, visible in the sclerae of the eyes and in the skin, known as jaundice or icterus),
can be understood and remembered, and the reasoning can include deeper biochem-
ical or microbiological explanations (How does it operate the chemical degradation
of hemoglobin? Which viruses cause hepatitis? How was the patient infected?).
This basically is a systems-based reasoning process. The clinician however must
reason in the opposite direction, a skill that is not simply the reverse of this chain of
thought, as there may be very different causes of the same signs and symptoms (a
normal liver, but an obstruction in the bile duct, or a normal liver and bile duct, but
a profuse destruction of red blood cells after an immune reaction). So analytic rea-
soning is trainable, and generating hypotheses of what may have caused the symp-
toms requires a knowledge base of possible physiopathology mechanisms. That can
be acquired step by step, and many answers to analytic problems can be found in the
literature. But clearly, System 2 reasoning too requires prior knowledge. So both a
basic science knowledge base and a mental illness script repository must be
available.
The case-based clinical reasoning training method acknowledges this difficulty
and therefore focuses on two simultaneous approaches (1) building illness scripts
from early on in the curriculum, beginning with simple cases and gradually building
more complex scripts to remember, and (2) conveying a systematic, analytic reason-
ing habit starting with patient presentation vignettes and ending with a conclusion
about the diagnosis, the disease mechanism, and the patient management actions to
be taken.
10 O. ten Cate

Summary of the CBCR Method

When applying these principles to preclinical classroom teaching, a case-based

approach is considered superior to other methods (Kim et al. 2006; Postma and
White 2015). Case-based clinical reasoning was designed at the Academic Medical
Center of University of Amsterdam in 1992, when a new undergraduate medical
curriculum was introduced (ten Cate and Schadé 1993; ten Cate 1994, 1995). This
integrated medical curriculum with multidisciplinary block modules of 6–8 weeks
had existed since 10 years, but was found to lack a proper preparation of students to
think like a doctor before entering clinical clerkships. Notably, while all block mod-
ules stressed the knowledge acquisition structured in a systematic way, usually
based on organ systems and resulting in a systems knowledge base, a longitudinal
thread of small group teaching was created to focus on patient-oriented thinking,
with application of acquired knowledge (ten Cate and Schadé 1993). This CBCR
training was implemented in curriculum years 2, 3, and 4, at both medical schools
of the University of Amsterdam and the Free University of Amsterdam, which had
been collaborating on curriculum development since the late 1980s. After an expla-
nation of the method in national publications (ten Cate 1994, 1995), medical schools
at Leiden and Rotterdam universities adopted variants of it. In 1997 CBCR was
introduced at the medical school of Utrecht University with minor modifications
and continued with only little adaptations throughout major undergraduate medical
curriculum changes in 1999, 2006, and 2015 until the current day (2017).
CBCR can be summarized as the practicing of clinical reasoning in small groups.
A CBCR course consists of a series of group sessions over a prolonged time span.
This may be a semester, a year, or usually, a number of years. Students regularly
meet in a fixed group of 10–12, usually every 3–4 weeks, but this may be more
frequent. The course is independent of concurrent courses or blocks. The rationale
for this is that CBCR stresses the application of previously acquired knowledge and
should not be programmed as an “illustration” of clinical or basic science theory.
More importantly, when the case starts, students must not be cued in specific direc-
tions or diagnoses, which would be the case if a session were integrated in, say, a
cardiovascular block. A patient with shortness of breath would then trigger too eas-
ily toward a cardiac problem.
CBCR cases, always titled with age, sex, and main complaint or symptom, con-
sist of an introductory case vignette reflecting the way a patient presents at the clini-
cian’s office. Alternatively, two cases with similar presentations but different
diagnoses may be worked through in one session, usually later in the curriculum
when the thinking process can be speeded up. The context of the case may be at a
general practitioner’s office, at an emergency department, at an outpatient clinic, or
at admission to a hospital ward. The case vignette continues with questions and
assignments (e.g., What would be first hypotheses based on the information so far?
What diagnostic tests should be ordered? Draw a table mapping signs and symp-
toms against likelihood of hypotheses), at fixed moments interrupted with the provi-
sion of new findings about the patient from investigations (more extensive history,
additional physical examination, or new results of diagnostic tests), distributed or
1 Introduction 11

read out loud by a facilitator during the session at the appropriate moment. A full
case includes the complete course of a problem from the initial presentation to fol-
low-­up after treatment, but cases often concentrate on key stages of this course.
Case descriptions should refer to relevant pathophysiological backgrounds and
basic sciences (such as anatomy, biochemistry, cell biology, physiology) during the
case.
The sessions are led by three (sometimes two) students of the group. They are
called peer teachers and take turns in this role over the whole course. Every student
must act as a peer teacher at multiple sessions across the year. Peer teachers have
more information in advance about the patient and disclose this information at the
appropriate time during the session, in accordance with instructions they receive in
advance. In addition, a clinician is present. Given the elaborated format and case
description, this teacher only acts as a consultant, when guidance is requested or
helpful, and indeed is called “consultant” throughout all CBCR education.
Study materials include a general study guide with explanations of the rules,
courses of action, assessment procedures, etc. (see Chap. 10): a “student version” of
the written CBCR case material per session, a “peer teacher version” of the CBCR
case per session with extra information and hints to guide the group, and a full “con-
sultant version” of the CBCR case per session. Short handouts are also available for
all students, covering new clinical information when needed in the course of the
diagnostic process. Optionally, homemade handouts can be prepared by peer teach-
ers. The full consultant version of the CBCR case includes all answers to all ques-
tions in detail, sufficient to enable guidance by a clinician who is not familiar with
the case or discipline, all suggestions and hints for peer teachers, and all patient
information that should be disclosed during the session. Examples are shown in
Appendices of this book.
Students are assessed at the end of the course on their knowledge of all illnesses
and to a small extent on their active participation as a student and a peer teacher (see
Chap. 7).

Essential Features of CBCR Education

While a summary is given above, and a detailed procedural description is given in

Part II, it may be helpful to provide some principles to help understand some of the
rationale behind the CBCR method.

 witching Between System-Oriented Thinking and Patient-­

S
Oriented Thinking

It is our belief that preclinical students must learn to acquire both system-oriented
knowledge and patient-oriented knowledge and that they need to practice switching
between both modes of thinking (Eva et al. 2007). In that sense, our approach not
12 O. ten Cate

only differs from traditional curricula with no training in clinical reasoning but also
from curricula in which all education is derived from clinical presentations (Mandin
et al. 1995, 1997).
By scheduling CBCR sessions spread over the year, with each session requiring
the clinical application of system knowledge of previous system courses, this prac-
tice of switching is stimulated. It is important to prepare and schedule CBCR cases
carefully to enable this knowledge application. It is inevitable, because of differen-
tial diagnostic thinking, that cases draw upon knowledge from different courses and
sometimes knowledge that may not have been taught. In that case, additional infor-
mation may be provided during the case discussion. Peer teachers often have an
assignment to summarize relevant system information between case questions in a
brief presentation (maximum 10 min), to enable further progression.

 anaging Cognitive Load and the Development of Illness

M
Scripts

Illness scripts are mental representations of disease entities combining three ele-
ments in a script (Custers et al. 1998; Charlin et al. 2007): (1) factors causing or
preceding a disease, (2) the actual pathology, and (3) the effect of the pathology
showing as signs, symptoms, and expected diagnostic findings. While some authors,
including us, add (4) course and management as the fourth element (de Vries et al.
2006), originally the first three, “enabling conditions,” “fault,” and “consequences,”
were proposed to constitute the illness script (Feltovich and Barrows 1984). Illness
scripts are stored as units in the long-term memory that are simultaneously activated
and subsequently instantiated (i.e., recalled instantly) when a pattern recognition
process occurs based on a patient seen by a doctor. This process is usually not delib-
erately executed, but occurs spontaneously. Illness scripts have a temporal nature
like a film script, because of their cause and effect features, which enables clinicians
to quickly take a next step, suggested by the script, in managing the patient. “Course
and management” can therefore naturally be considered part of the script.
A shared explanation why illness scripts “work” in clinical reasoning is that the
human working memory is very limited and does not allow to process much more
than seven units or chunks of information at a time (Miller 1956) and likely less than
that. Clinicians cannot process all separate signs and symptoms, history, and physi-
cal examination information simultaneously—that would overload their working
memory capacity, but try to use one label to combine many bits of information in
one unit (e.g., the illness script “diabetes type II” combines its enabling factors,
pathology, signs and symptoms, disease course, and standard treatment in one
chunk). If necessary, those units can be unpacked in elements (Figs. 1.1 and 1.2).
To create illness scripts stored in the long-term memory, students must learn to
see illnesses as a unit of information. In case-based clinical reasoning education,
1 Introduction 13

Fig. 1.2 One information chunk in the working memory may be decomposed in smaller chunks
in the long-term memory (Young et al. 2014)

students face complete patient scripts, i.e., with enabling conditions (often derived
from history taking) to consequences (as presenting signs and symptoms). Although
illness scripts have an implicit chronology, from a clinical reasoning perspective,
there is an adapted chronology of (a) consequences → (b) enabling conditions → (c)
fault and diagnosis → (d) course and management, as the physician starts out
observing the signs and symptoms, then takes a history, performs a physical exami-
nation, and orders tests if necessary before arriving at a conclusion about the “fault.”
To enable building illness script units in the long-term memory, students must start
out with simple, prototype cases that can be easily remembered. CBCR aims to
develop in second year medical students stable but still somewhat limited illness
scripts. This still limited repository should be sufficient to quickly recognize the
causes, symptoms, and management of a limited series of common illnesses, and
handle prototypical patient problems in practice if they would encounter these, reso-
nating with Bordage’s prototype approach (Bordage and Zacks 1984; Bordage
2007). See Chap. 3. The assessment of student knowledge at the end of a CBCR
course focuses on the exact cases discussed, including, of course, the differential
diagnostic considerations that are activated with the illness script, all to reinforce
the same carefully chosen illness scripts. The aim is to provide a foundation that
enables the addition in later years of variations to the prototypical cases learned, to
enrich further illness script formation and from there add new illness scripts. We
believe that working with whole, but not too complex, cases in an early phase in the
medical curriculum serves to help students in an early phase in the medical curricu-
lum to learn to recognize common patterns.
14 O. ten Cate

 ducational Philosophies: Active Reasoning by Oral

E
Communication and Peer Teaching

A CBCR education in the format elaborated in this book reflects the philosophy that
learning clinical reasoning is enhanced by reasoning aloud. The small group
arrangement, limited to no more than about 12 students, guarantees that every stu-
dent actively contributes to the discussion. Even when listening, this group size
precludes from hiding as would be a risk in a lecture setting.
Students act as peer teachers for their fellow students. Peer teaching is an
accepted educational method with a theoretical foundation (ten Cate and Durning
2007; Topping 1996). It is well known that taking the role of teacher for peers
stimulates knowledge acquisition in a different and often more productive way than
studying for an exam (Bargh and Schul 1980). Social and cognitive congruence
concepts explain why students benefit from communicating with peers or near-­
peers and should understand each other better than when students communicate
with expert teachers (Lockspeiser et al. 2008). The peer teaching format used in
CBCR is an excellent way to achieve active participation of all students during
small group education. An additional benefit of using peer teachers is that they are
instrumental in the provision of just-in-time information about the clinical case for
their peers in the CBCR group, e.g., as a result of a diagnostic test that was proposed
to be ordered.
Case-based clinical reasoning has most of the features that are recommended by
Kassirer et al.: “First, clinical data are presented, analyzed and discussed in the
same chronological sequence in which they were obtained in the course of the
encounter between the physician and the patient. Second, instead of providing all
available data completely synthesized in one cohesive story, as is in the practice of
the traditional case presentation, data are provided and considered on a little at a
time. Third, any cases presented should consist of real, unabridged patient material.
Simulated cases or modified actual cases should be avoided because they may fail
to reflect the true inconsistencies, false leads, inappropriate cues, and fuzzy data
inherent in actual patient material. Finally, the careful selection of examples of
problem solving ensures that a reasonable set of cognitive concepts will be covered”
(Kassirer et al. 2010). While we agree with the third condition for advanced stu-
dents, i.e., in clerkship years, for pre-clerkship medical students, a prototypical ill-
ness script is considered more appropriate and effective (Bordage 2007). The CBCR
method also matches well with most recommendations on clinical reasoning educa-
tion (see Box 1.3).
Chapter 4 of this book describes six prerequisites for clinical reasoning by medi-
cal students in the clinical context: having clinical vocabulary, experience with
problem representation, an illness script mental repository, a contrastive learning
approach, hypothesis-driven inquiry skill, and a habit of diagnostic verification. The
CBCR approach helps to prepare students with most of these prerequisites.
1 Introduction 15

Indications for the Effectiveness of the CBCR Method

The CBCR method finds its roots in part in problem-based learning (PBL) and other
small group active learning approaches. Since the 1970s, various small group
approaches have been recommended for medical education, notably PBL (Barrows
and Tamblyn 1980) and team-based learning (TBL) (Michaelsen et al. 2008). In
particular PBL has gained huge interest in the 1980s onward, due to the develop-
mental work done by its founder Howard Barrows from McMaster University in
Canada and from Maastricht University in the Netherlands, which institution
derived its entire identity to a large part from problem-based learning. Despite sig-
nificant research efforts to establish the superiority of PBL curricula, the general
outcomes have been somewhat less than expected (Dolmans and Gijbels 2013).
However, many studies on a more detailed level have shown that components of
PBL are effective. In a recent overviews of PBL studies, Dolmans and Wilkerson
conclude that “a clearly formulated problem, an especially socially congruent tutor,
a cognitive congruent tutor with expertise, and a focused group discussion have a
strong influence on students’ learning and achievement” (Dolmans and Wilkerson
2011). These are components that are included in the CBCR method.
While there has not been a controlled study to establish the effect of a CBCR
course per se, compared to an alternative approach to clinical reasoning training,
there is some indirect support for its validity, apart from the favorable reception of
the teaching model among clinicians and students over the course of 20 years and
different schools. A recent publication by Krupat and colleagues showed that a
“case-based collaborative learning” format, including small group work on patient
cases with sequential provision of patient information, led to higher scores of a
physiology exam and high appreciation among students, compared with education
using a problem-based learning format (Krupat et al. 2016). A more indirect indica-
tion of its effectiveness is shown in a comparative study among three schools in the
Netherlands two decades ago (Schmidt et al. 1996). One of the schools, the
University of Amsterdam medical school, had used the CBCR training among sec-
ond and third year students at that time (ten Cate 1994). While the study does not
specifically report on the effects of clinical reasoning education, Schmidt et al. show
how students of the second and third year in this curriculum outperform students in
both other curricula in diagnostic competence.

CBCR as an Approach to Ignite Curriculum Modernization

Since 2005, the method of CBCR has been used as leverage for undergraduate med-
ical curriculum reform in Moldova, Georgia, Ukraine, and Azerbaijan (ten Cate
et al. 2014). It has proven to be useful in medical education contexts with heavily
lecture-based curricula—likely because the method can be applied within an exist-
ing curriculum, causing little disruption, while also being exemplary for
16 O. ten Cate

recommended modern medical education (Harden et al. 1984). It stimulates integra-

tion, and the method is highly student-centered and problem-based. While observ-
ing CBCR in practice, a school can consider how these features can also be applied
more generally in preclinical courses. This volume provides a detailed description
that allows a school to pilot CBCR for this purpose.

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