Clinical Reasoning in Forensic Psychiatry: Concepts, Processes, and Pitfalls

Forensic psychiatrists are often sought by the court of law to provide professional opinion on specific legal matters that have a major impact on the evaluee and possibly society at large. The quality of that opinion and recommendations rely on the quality of the analysis from the assessment results conducted by the psychiatrist. However, the definition and scope of a forensic psychiatric analysis is not clear. While existing literature on forensic psychiatric analysis generally includes organizing information, identifying relevant details, and formulating a set of forensic psychiatric opinions as components, there is no explicit and unified definition of these terms and process. This lack of clarity and guidelines may hinder forensic psychiatry from achieving its goal of providing objective information to the court or other relevant parties. Forensic psychiatric analysis exhibits numerous parallels to clinical reasoning in other fields of medicine. Therefore, this review aims to elaborate forensic psychiatric analysis through the lens of clinical reasoning, which has been developed by incorporating advances in cognitive sciences. We describe forensic psychiatric analysis through three prominent clinical reasoning theories: hypothetico-deductive model, illness script theory, and dual process theory. We expand those theories to elucidate how forensic psychiatrists use clinical reasoning not only to diagnose mental disorders, but also to determine mental capacities as requested by law. Cognitive biases are also described as potential threat to the accuracy of the assessment and analysis. Additionally, situated cognition theory helps elucidate how contextual factors influence risk of errors. Understanding the processes involved in forensic psychiatric analysis and their pitfalls can assist forensic psychiatrists to be aware of and try to mitigate their bias. Debiasing strategies that have been implemented in other fields of medicine to mitigate errors in clinical reasoning can be adapted for forensic psychiatry. This may also shape the training program of general psychiatrists and forensic psychiatrists alike.

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme

There is consensus that clinical reasoning (CR) is crucial for increasing the value of diagnosis, medical decision-making and error reduction. These skills should be developed throughout medical education, starting with undergraduate study. International guidance provides principles for CR curricula but interventions to date, are short term in nature. In this report, we describe the creation of a longitudinal, spiral CR curriculum within a large UK medical school programme (2500 students). A working group drove systematic evidence-based reform of existing structures. We utilised recognised models for curriculum development and mapping, relating learning outcomes to competency frameworks. Application of multiple teaching methodologies, rooted in enquiry-based learning and reported in CR literature, encourage metacognition for information-processing and illness script development. Development of CR is emphasised with recurrent, progressive learning opportunities, each stage purposefully building upon previous experiences. Formative and summative assessment approaches to drive learning, encouraging students’ ability to apply and articulate CR, is constructed via Miller’s Prism of Clinical Competence. Implementation of pedagogy is contingent on faculty development. Whilst many clinicians practice sound CR, the ability to articulate it to students is often a novel skill. Engagement in faculty development was strengthened through cross-institutional recognition of teaching workload and flexibility of delivery. We report lessons learned from the implementation phase and plans for measuring impact.

Diagnostic Reasoning by Master Clinicians: What Distinguishes Them From Their Peers?

Introduction: Master clinicians are a group of physicians recognized in large part for their superior diagnostic reasoning abilities. However, their reasoning skills have not been rigorously and quantitatively compared to other clinicians using a validated instrument.Methods: We surveyed Internal Medicine physicians at the University of Iowa to identify the master clinicians. These master clinicians were administered the Diagnostic Thinking Inventory, along with an equivalent number of their peers in the general population of internists. Scores were tabulated for structure and thinking, as well as four previously identified elements of diagnostic reasoning (data acquisition, problem representation, hypothesis generation, and illness script search and selection). The 2-sample t-test was used to compare scores between the two groups.Results: 17 master clinicians were identified, of whom 17 (100%) completed the inventory. 19 out of 25 randomly-selected internists also completed the inventory (76%). Mean total scores were 187.2 and 175.8 for the Master Clinician (MC) and the Internist (IM) groups respectively. Thinking and structure subscores were 91.5 and 95.71 for MCs, compared to 85.5 and 90.3 for IMs (p-values: 0.0783 and 0.1199, respectively). The mean data acquisition, problem representation, hypothesis generation, and illness script selection subscores for MCs were 4.46, 4.57, 4.71, and 4.46, compared to 4.13, 4.38, 4.45, and 4.13 in the IM group (p-values: 0.2077, 0.4528, 0.095, and 0.029, respectively). Conclusions: Master Clinicians have greater proficiency in searching for and selecting illness scripts compared to their peers. There were no statistically significant differences between the other scores and subscores. These results will help to inform continuing medical education efforts to improve diagnostic reasoning.

Teaching clinical reasoning to undergraduate medical students by illness script method: a randomized controlled trial

Background The illness script method employs a theoretical outline (e.g., epidemiology, pathophysiology, signs and symptoms, diagnostic tests, interventions) to clarify how clinicians organized medical knowledge for clinical reasoning in the diagnosis domain. We hypothesized that an educational intervention based on the illness script method would improve medical students’ clinical reasoning skills in the diagnosis domain. Methods This study is a randomized controlled trial involving 100 fourth-year medical students in Shiraz Medical School, Iran. Fifty students were randomized to the intervention group, who were taught clinical reasoning skills based on the illness script method for three diseases during one clinical scenario. Another 50 students were randomized to the control group, who were taught the clinical presentation based on signs and symptoms of the same three diseases as the intervention group. The outcomes of interest were learner satisfaction with the intervention and posttest scores on both an internally developed knowledge test and a Script Concordance Test (SCT). Results Of the hundred participating fourth-year medical students, 47 (47%) were male, and 53 (53%) were female. On the knowledge test, there was no difference in pretest scores between the intervention and control group, which suggested a similar baseline knowledge in both groups; however, posttest scores in the intervention group were (15.74 ± 2.47 out of 20) statistically significantly higher than the control group (14.38 ± 2.59 out of 20, P = 0.009). On the SCT, the mean score for the intervention group (6.12 ± 1.95 out of 10) was significantly higher than the control group (4.54 ± 1.56 out of 10; P = 0.0001). Learner satisfaction data indicated that the intervention was well-received by students. Conclusion Teaching with the illness script method was an effective way to improve students’ clinical reasoning skills in the diagnosis domain suggested by posttest and SCT scores for specific clinical scenarios. Whether this approach translates to improved generalized clinical reasoning skills in real clinical settings merits further study.

Diagnostic reasoning in internal medicine: a practical reappraisal

The practice of clinical medicine needs to be a very flexible discipline which can adapt promptly to continuously changing surrounding events. Despite the huge advances and progress made in recent decades, clinical reasoning to achieve an accurate diagnosis still seems to be the most appropriate and distinctive feature of clinical medicine. This is particularly evident in internal medicine where diagnostic boundaries are often blurred. Making a diagnosis is a multi-stage process which requires proper data collection, the formulation of an illness script and testing of the diagnostic hypothesis. To make sense of a number of variables, physicians may follow an analytical or an intuitive approach to clinical reasoning, depending on their personal experience and level of professionalism. Intuitive thinking is more typical of experienced physicians, but is not devoid of shortcomings. Particularly, the high risk of biases must be counteracted by de-biasing techniques, which require constant critical thinking. In this review, we discuss critically the current knowledge regarding diagnostic reasoning from an internal medicine perspective.

Building a Successful, Socially-Distanced Family Medicine Clerkship in the COVID Crisis

Introduction: In the wake of the COVID-19 pandemic, many family medicine clerkships across the United States are scrambling to provide meaningful medical education in a new clinical environment. Most medical schools have paused or severely limited the direct patient care that has been the core educational requirement of the clinical clerkships. The aim of this study was to develop and evaluate a curricular model that meets the family medicine clerkship learning objectives via telemedicine clinical instruction. Methods: We created a clerkship where all clinical encounters took place by phone or video visits. Students were required to have telemedicine encounters with at least 20 patients over a 4-week clerkship. We also created a telemedicine illness script-writing assignment to prepare students and faculty for these encounters. We evaluated our curriculum by surveying participating students and faculty members. Results: Student surveys revealed that all learning objectives were met during the telemedicine clerkship experience. Students felt they made a difference during the COVID-19 pandemic. Faculty felt that the medical students were helpful and that they were able to provide meaningful clinical instruction. Conclusion: Our study reveals that a family medicine clerkship can be successfully delivered using telemedicine and remote learning techniques. Senior medical students are a valuable resource and can have a meaningful clinical impact while learning more about family medicine. If social distancing precautions continue, this model can be used by other clerkships to continue medical education and provide medical care.

Kimura disease: a case report of a rare illness presenting as a common complaint

Background Kimura is an uncommon inflammatory cause of pediatric head and neck masses due to eosinophilic infiltration of unclear etiology. Kimura can present similarly to infectious lymphadenitis, a much more common pediatric complaint. This case explores the role of anchoring bias when faced with an illness that at first appears to fit a common illness script that led to a delayed diagnosis. Case presentation A 7-year-old boy presented with acute onset of pre-auricular lymphadenopathy and fevers initially thought to be most consistent with infectious cervical lymphadenopathy. Despite treatment with broad spectrum antibiotics and multiple evaluations for underlying abscess requiring surgical drainage, the patient did not improve and remained febrile. Eventually, excisional lymph node biopsy was obtained and a pathologic diagnosis of Kimura disease was made. Conclusions This case illustrates an uncommon pediatric diagnosis which presented similarly to infectious cervical lymphadenitis without additional laboratory features consistent with Kimura. We highlight the role of anchoring bias and care fragmentation leading to repeat imaging and delayed biopsy in the eventual diagnosis of a rare illness.

Applying Metacognition Through Patient Encounters and Illness Scripts to Create a Conceptual Framework for Basic Science Integration, Storage, and Retrieval

Problem: Medical school curriculum continues to search for methods to develop a conceptual educational framework that promotes the storage, retrieval, transfer, and application of basic science to the human experience. To achieve this goal, we propose a metacognitive approach that integrates basic science with the humanistic and health system aspects of medical education. Intervention: During the week, via problem-based learning and lectures, first-year medical students were taught the basic science underlying a disease. Each Friday, a patient with the disease spoke to the class. Students then wrote illness scripts, which required them to metacognitively reflect not only on disease pathophysiology, complications, and treatments but also on the humanistic and health system issues revealed during the patient encounter. Evaluation of the intervention was conducted by measuring results on course exams and national board exams and analyzing free responses on the illness scripts and student course feedback. The course exams and National Board of Medical Examiners questions were divided into 3 categories: content covered in lecture, problem-based learning, or patient + illness script. Comparisons were made using Student t-test. Free responses were inductively analyzed using grounded theory methodology. Context: This curricular intervention was implemented during the first 13-week basic science course of medical school. The main objective of the course, Scientific Principles of Medicine, is to lay the scientific foundation for subsequent organ system courses. A total of 150 students were enrolled each year. We evaluated this intervention over 2 years, totaling 300 students. Outcome: Students scored significantly higher on illness script content compared to lecture content on the course exams (mean difference = 11.1, P = .006) and national board exams given in December (mean difference = 21.8, P = .0002) and June (mean difference = 12.7, P = .016). Themes extracted from students’ free responses included the following: relevance of basic science, humanistic themes of empathy, resilience, and the doctor-patient relationship, and systems themes of cost, barriers to care, and support systems. Lessons learned: A metacognitive approach to learning through the use of patient encounters and illness script reflections creates stronger conceptual frameworks for students to integrate, store, retain, and retrieve knowledge.