Clinical reasoning education in undergraduate medicine: a mixed-methods study

Abstract

Introduction

Clinical reasoning is a core competency in medical education, yet its development depends on instructional, curricular, and institutional factors that are rarely evaluated simultaneously. This study aimed to assess clinical reasoning competencies and to explore the educational and institutional conditions that may influence their development.

Materials and methods

An explanatory sequential mixed-methods study was conducted in a medical school in Chile. Twenty-two sixth-year medical students completed the Practicum Script assessment evaluating hypothesis generation, hypothesis argumentation, and knowledge application. Additionally, 106 students and faculty completed the Factors for Clinical Reasoning Teaching and Learning Scale (FEARC), assessing educational strategies, institutional/curricular factors, and microsystem learning conditions. Semi-structured interviews explored contextual influences on clinical reasoning education.

Results

Students demonstrated high concordance with expert benchmarks in hypothesis generation (75.8%) and knowledge application (98.5%), but descriptively lower performance in hypothesis argumentation (38.7%). Exploratory factor analysis suggested a three-factor solution within the FEARC instrument explaining 58.8% of variance. Faculty rated educational strategies and microsystem conditions more positively than students, whereas students rated institutional/curricular factors more favorably. Qualitative findings highlighted curriculum integration, faculty development, structured feedback, psychological safety, and authentic clinical experiences as key influences on clinical reasoning development.

Conclusion

Students showed lower performance in hypothesis argumentation than in hypothesis generation and knowledge application. Clinical reasoning education was influenced by interactions among instructional strategies, curricular organization, faculty development, and supportive learning environments. These findings support multilevel institutional approaches that integrate competency assessment with evaluation of the educational conditions shaping clinical reasoning development.