Table 1 Indicators for clinical reasoning

 Taking the lead in the conversation

8

5

6

7

15

3

‘She allows the patient to talk for too long. It doesn’t become clear to me whether she does so on purpose, to organize everything directly in her head. I do not see that happen. It appears to me that she doesn’t have a clue what to do at this point and she’s waiting for the golden tip to arise.’

‘She allows the patient tell the same story again. She doesn’t give any direction. That’s why I think she doesn’t know what to do with that information.’

‘I think other students would probably allow her to go on talking, and then the story might end with a different subject, for example the adventures of her friend.’

 Recognizing and responding to relevant information

8

3

9

10

5

10

‘Apparently now she’s making a choice; the health problem that occurred four, five weeks ago, that’s the problem she has to get started with. Here she reaches the point that she takes this particular problem from the whole pool of problems. So here clinical reasoning is going on.’

‘Sometimes you think she gets it, but then she’s losing it. She doesn’t proceed to ask questions at a crucial moment, the moment when the patient signals something that makes the story special.’

 Specifying symptoms

4

5

6

12

22

3

‘She knows that she should not be satisfied when a patient mentions “my stools aren’t normal”.’ ‘She knows she has to ask additional questions. Apparently, she doesn’t have the eagerness to continue questioning when it comes to shoulder pain. Apparently, she’s satisfied and she doesn’t realize this by asking more questions about that problem to show differential diagnostic reasoning.’

‘He’s going off track. The patient was dizzy for one day at the start of her period. Well, I wouldn’t want to meet all women who have that once in a while at the start of their period. And now he’s asking about that in depth, while he should go on with her complaining of fatigue.’

 Asking specific questions that point to pathophysiological thinking

10

6

14

3

3

14

‘She asked about stress. So she is thinking of a stomach ulcer, or reflux.’

‘What I notice, is that she’s trying to find out whether there’s a bowel obstruction. At least she appears to be doing that with these questions.’

‘He’s asking the regular questions that belong to the history of pain. He is trying to get a grip on it. Which is proper. But he’s not having a differential diagnosis at this moment.’ ‘She really doesn’t know what she’s talking about. She is simply completing her list.’

 Putting questions in a logical order

3

3

2

2

14

2

‘Why she returns to the hands, while in fact we don’t know the context of the knee problem is totally unclear to me.’

‘Now she’s clustering questions that belong together, questions that indicate heart failure.’

 Checking with the patient

0

3

4

2

2

0

‘This is a question of which you would expect there’s something in it … You can’t accept only “no”, as this patient answered. I would ask her additional questions to be sure it’s really “no”. And to be sure that the patient understands what you mean by that question.’

 Summarizing

1

1

6

1

0

1

‘The way she is summarizing, what she chooses to summarize, which topics she chooses and how she describes them, all this gives me an idea at what point she has arrived in her history taking. It shows what she thinks the problem with this patient may be.’

 Body language

0

1

5

0

0

1

‘When I look at her now, I see a despondent look on her face, expressing: what should I do?’ ‘The look on her face that says, well, what should I be aiming at? What’s the problem I should be analyzing?’

 Patient taking the lead

2

1

3

2

6

1

‘Look, now the patient is taking over. Now she leads the student back to her problems because the student isn’t doing it.’

 Talking at cross-purposes

2

0

4

2

2

1

‘There’s a misunderstanding between the doctor and the patient. The patient is pointing at her skin and mentions pain in her leg, but the student is talking about her knee problem.’ ‘By the way, we don’t know now whether he understands it all, and they talk at the same level. He’s talking about the period before Christmas, and he thinks she describes the symptoms she had when she was first using milk products. But I’m not sure whether she is talking about that period.’

 Repetition

5

1

0

0

0

4

‘With regard to clinical reasoning, he’s gained his information in a more efficient way than the female student. She needed a lot of time. She didn’t realize that she had already gained a lot of information. She allowed the patient to tell the story three times.’

 Data gathered

0

2

0

2

5

2

‘He hasn’t gained enough specific information.’

‘A couple of questions like palpitations, tremors, I’m still missing.’

 Efficiency

12

1

3

0

11

3

‘But only now, after how much time? Eight minutes, she’s getting somewhere.’