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      Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators


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          Clinical reasoning is fundamental to all forms of professional health practice, however it is also difficult to teach and learn because it is complex, tacit, and effectively invisible for students. In this paper we present an approach for teaching clinical reasoning based on making expert thinking visible and accessible to students.


          Twenty-one experienced allied health clinical educators from three tertiary Australian hospitals attended up to seven action research discussion sessions, where they developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student’s reasoning skills. Data included participants’ written descriptions of the thinking routines they developed and trialed with their students and the transcribed action research discussion sessions. Content analysis was used to summarise this data and categorise themes about teaching and learning clinical reasoning.


          Two overriding themes emerged from participants’ reports about using the ‘making thinking visible approach’. The first was a specific focus by participating educators on students’ understanding of the reasoning process and the second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning.


          We suggest that the making thinking visible approach has potential to assist educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use.

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          Most cited references43

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          Cognitive Load Theory and Complex Learning: Recent Developments and Future Directions

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            Research in clinical reasoning: past history and current trends.

            Research in clinical reasoning has been conducted for over 30 years. Throughout this time there have been a number of identifiable trends in methodology and theory. This paper identifies three broad research traditions, ordered chronologically, are: (a) attempts to understand reasoning as a general skill--the "clinical reasoning" process; (b) research based on probes of memory--reasoning related to the amount of knowledge and memory; and (c) research related to different kinds of mental representations--semantic qualifiers, scripts, schemas and exemplars. Several broad themes emerge from this review. First, there is little evidence that reasoning can be characterised in terms of general process variables. Secondly, it is evident that expertise is associated, not with a single basic representation but with multiple coordinated representations in memory, from causal mechanisms to prior examples. Different representations may be utilised in different circumstances, but little is known about the characteristics of a particular situation that led to a change in strategy. It becomes evident that expertise lies in the availability of multiple representations of knowledge. Perhaps the most critical aspect of learning is not the acquisition of a particular strategy or skill, nor is it the availability of a particular kind of knowledge. Rather, the critical element may be deliberate practice with multiple examples which, on the hand, facilitates the availability of concepts and conceptual knowledge (i.e. transfer) and, on the other hand, adds to a storehouse of already solved problems.
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              The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching.

              To study medical students' views about the quality of the teaching they receive during their undergraduate training, especially in terms of the hidden curriculum. Semistructured interviews with individual students. One medical school in the United Kingdom. 36 undergraduate medical students, across all stages of their training, selected by random and quota sampling, stratified by sex and ethnicity, with the whole medical school population as a sampling frame. Medical students' experiences and perceptions of the quality of teaching received during their undergraduate training. Students reported many examples of positive role models and effective, approachable teachers, with valued characteristics perceived according to traditional gendered stereotypes. They also described a hierarchical and competitive atmosphere in the medical school, in which haphazard instruction and teaching by humiliation occur, especially during the clinical training years. Following on from the recent reforms of the manifest curriculum, the hidden curriculum now needs attention to produce the necessary fundamental changes in the culture of undergraduate medical education.

                Author and article information

                BMC Med Educ
                BMC Med Educ
                BMC Medical Education
                BioMed Central
                30 January 2014
                : 14
                : 20
                [1 ]School of Health Sciences, The University of Melbourne, Melbourne, Australia
                [2 ]Children’s Bioethics Centre, at the Royal Children’s Hospital, Melbourne, Australia
                [3 ]Higher Education Development Centre, University of Otago, North Dunedin, New Zealand
                [4 ]Honorary Senior Fellow of the Centre for Higher Education, University of Melbourne, Melbourne, Australia
                Copyright © 2014 Delany and Golding; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 9 November 2013
                : 27 January 2014
                Research Article

                clinical reasoning,clinical education,diagnostic reasoning,action research,professional development


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