journal club. Students received journal articlesahead of sessions and completed a short pre-testquiz on the article prior to class. An online criticalassessment worksheet (CAW) was used by each TBLgroup to facilitate in-class group exercises that werespecific to the following article types: cohort study;case–control study; diagnostic testing; randomisedcontrolled trial, and meta-analysis. Learners workedthrough exercises in TBL groups for 30 minutesusing the CAW to introduce specific aspects of studytypes. The course instructor used the remainder ofthe time to reinforce specific content (calculation ofodds ratios, risk ratios and numbers needed to treat;randomisation; blinding, etc.) according to sessionobjectives. This format was followed for five of eightsessions.

The remaining three sessions involved searchingthe literature to address a focused clinical question.Medical librarians presented strategies for formingclinical questions using the PICO (Patient problem,Intervention, Comparison, Outcome) framework andfor searching online databases. Each TBL group thenselected a clinical question from a pre-formulated listcreated by the course director. Groups were tasked touse strategies demonstrated by the librarians toidentify the article that best addressed the selectedclinical question. In the last session, the TBL groupscritically appraised the journal articles they hadidentified as an in-class final, leveraging the skillslearned earlier in the course.Evaluation of results and impact Of all respondents,81.3% agreed that the CAW was a useful self-directed tool for appraising journal articles. Learnersreported a 17.5% (95% confidence interval [CI] 9.6–25.3%) increase in perceived ability to search theliterature.

Throughout this EBM course, the practice ofturning to the literature in situations of clinicaluncertainty was emphasised and modelled. Thelearners practised the same behaviour and 70% oflearners agreed or strongly agreed that these EBMskills would be helpful in the future (using a Likertscale of 1–5, where 1 = strongly disagree and5 = strongly agree; mean score: 3.86, 95% CI3.65–4.06).

Our next step, in partnership with the internalmedicine clerkship, is to eschew standard studenttopic presentations and adopt a focused clinicalquestion approach. Thus, an examination of whetherone imaging modality (ultrasound) is superior toanother (computed tomography) in acute pancreati-tis will replace a 5-minute review on pancreatitis. Weplan to disseminate this approach to all otherclerkships so that the desired behaviours of literature-searching and critical appraisal introduced in the

EBM course are reinforced throughout Years 3 and 4,providing the foundation for solid lifelong learningbehaviour’s.

Correspondence: Dr Chayan Chakraborti, Department of Medicine,Faculty of General Internal Medicine, Tulane UniversitySchool of Medicine, New Orleans, Louisiana 70112, USA.Tel: 00 1 504 988 7518; Fax: 00 1 504 988 8252;E-mail: cchakra@gmail.com

doi: 10.1111/j.1365-2923.2011.03972.x

Teaching about child abuse with a mock trial

Richard van Wylick & Lindsay Davidson

Context and setting The diagnosis and managementof child abuse is a recognised component ofundergraduate medical training. The role of thedoctor in the legal proceedings that may resultfrom the diagnosis of child abuse is less consistentlytaught in medical school. We describe a novelapproach used to introduce medical students to themedical and legal aspects of child abuse in thecontext of a first-year course focusing onmusculoskeletal disease and trauma.Why the idea was necessary In 2008, the Inquiry intoPediatric Forensic Pathology in Ontario (the‘Goudge Inquiry’) examined the interface betweenmedical expert witnesses and the courts in criminalcourt cases. One recommendation of the Inquirysays, in part: ‘All individuals and institutions thatprovide or oversee the education of medical studentsin Ontario should focus on the critical importanceof the criminal justice system in medico-legaleducation.’1 We therefore set up a mock trial tohighlight the role and limitations of the expertmedical witness, the controversies that exist indiagnosing child abuse and the need for expertwitnesses to be objective.What was done Members of each pre-establishedsmall group of students were given different rolesas, respectively, prosecuting lawyer, defence lawyer,expert witness and judge. Using a web-basedplatform, students were provided with informationabout the case ahead of time; this information wasgiven in different depths depending on thestudents’ respective roles. All students wereprovided with an article describing the role of thedoctor as expert witness. The prosecution anddefence players questioned the expert witness onthe details of the case, attempting to raisecontroversies and facts leading to the diagnosis ofchild abuse. At the end of the session, the judge

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ruled on whether the case had been proven.Students provided feedback on the session using ananonymous web-based survey.Evaluation of results and impact Feedback receivedsuggests that students recognised that this casecontributed to their learning of the medical expertrole in the context of child abuse. The larger goal ofincreasing the students’ level of knowledge abouttheir future potential role in the criminal justicesystem remains a challenge. Many students foundthe task of assuming a non-medical role contrivedand this may have lessened the impact of thiseducational activity. Future implementations ofthis session may benefit from a more detailedintroduction to the activity with particular emphasison the non-medical expert roles embedded in thetrial, such as those of communicator, professional andadvocate. In addition, specific contextualisation ofthe role-play grounded in the Goudge Inquiryrecommendations could be re-framed as acollaborative effort with the teachers involved inrelated courses.

REFERENCE

1 Goudge ST. Inquiry into Pediatric Forensic Pathology inOntario. Toronto, ON: Queen’s Printer for Ontario2008;Vol 3:301.

Correspondence: Dr Richard van Wylick, Department of Paediatrics,Hotel Dieu Hospital, Queen’s University, 166 Brock Street,Kingston, Ontario K7L 5G2, Canada. Tel: 00 1 613 544 3310;Fax: 00 1 613 544 3559; E-mail: richard.vanwylick@queensu.ca

doi: 10.1111/j.1365-2923.2011.03956.x

Fostering clinical reasoning in medical students

Michele Groves

Context and setting Diagnosis based on soundclinical reasoning lies at the heart of medicalpractice; consequently, medical schools focus ondeveloping students’ clinical reasoning in more orless explicit ways. The principal emphasis in theearly undergraduate years is on learning andintegrating basic and clinical sciences in order tounderstand disease processes and principles oftreatment and management; at best, clinicalreasoning is acquired as a serendipitous side-effectrather than being learned as an essential skill in itsown right. Frequently, it is not until the final yearsof medical school, when students spend the

majority of their time in direct contact withpatients, that they begin to recognise theimportance of clinical reasoning in the diagnosticprocess. Even then, diagnostic skill is oftenacquired more by a process of osmosis thanactively within a broadly applicable framework.

This project aimed to develop an online resource toembed the cognitive processes involved in clinicalreasoning and to complement the experientiallearning occurring in the later years of training. Anessential criterion was to provide immediate qualita-tive feedback on performance.Why the idea was necessary Even medicalprogrammes that explicitly teach clinical reasoningare more likely to focus on developing patternrecognition through the provision of ready-madealgorithms and other schema aimed at diagnosingcommonly encountered presentations, than on thecognitive process of clinical reasoning. Even inproblem-based learning curricula that emphasiseproblem-solving skills, little attention is given toproviding students with the basic principles neededto tackle difficult, rare or atypical diagnosticproblems.What was done The clinical reasoning problem(CRP) is a paper-based clinical scenario designed toprovide students with an analysis of their clinicalreasoning process. Used in sets of 10, CRPs havedemonstrated validity and reliability in assessing threesteps in the clinical reasoning process, namely:hypothesis generation, and clinical data identificationand interpretation.1 However, although it ispracticable in research contexts with relatively smallsubject numbers, the paper-based format has someweaknesses, in particular, a labour-intensive markingscheme and limited capacity to provide qualitativefeedback, which makes the CRP unsuitable as a large-scale learning resource.

To remedy these deficiencies, we converted theCRPs into an interactive web-based application(eCRPs) that provides feedback to studentsimmediately on the completion of each set ofproblems. The feedback compares the respondent’sperformance in diagnostic hypothesis generation andclinical data identification and interpretation withthat of an expert reference group of generalpractitioners. The eCRPs have been subsequentlytrialled with senior medical students.Evaluation of results and impact Evaluation dataindicated that students found the eCRPs challengingand useful in providing a yardstick by which theycould assess their performance. eCRPs wereconsidered ‘a good way, personally, to analyse my ownthinking process’ and ‘[to] make you think abouthow one would come to a diagnosis’. Other

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