Supervision of clinical reasoning

Supervision strategies to promote the development of clinical reasoning in daily practice

A previous Teaching Moment published in Canadian Family Physician emphasized the importance of direct observation in supervision.3 Although regular clinical supervision keeps our expectations of the time that we actually have to work with residents individually both modest and realistic, the clinical context clearly offers incredible teaching potential. Practical experience plays a determining role in the development of skills, especially if it is accompanied by reflection, during and after, to foster understanding and make room for any necessary adjustments.4

From this perspective, the supervision strategies presented in Table 1 are easy to put into practice, even if you did not observe the consultation, and they do not have to be time-consuming. These strategies will stimulate the development of clinical reasoning skills on a daily basis, calling on both the resident and the supervisor to articulate their thought processes.5,6

Identifying and describing common difficulties encountered in clinical reasoning

The supervisor’s duties and responsibilities point to 2 specific roles: that of a clinician who is responsible for the medical care of patients and that of a teacher who is responsible for helping residents to develop their clinical skills.7 In a pedagogic reasoning process that is very similar to the medical reasoning process, the supervisor starts to look for clues that will enable him or her to develop hypotheses on the quality of the resident’s reasoning process, so that the supervisor can identify the resident’s learning needs. The supervisor can then make a pedagogic diagnosis and choose a specific form of supervision that takes his or her conclusions into account. In this way, supervision becomes a reflective, targeted, dynamic process.8

A tool for supervisors that facilitates the collection of clues and the beginning of an intervention with the resident

From our experience of supervision and our discussions with our colleagues who are teachers, we have noted that:

• Physicians who also teach tend to doubt their perceptions of the difficulties encountered by residents. Because of this, there is a risk that opportunities for remedial work will be lost during the residency, which is already short and condensed.

• In general, physicians who are teachers feel inadequate and routinely report that they lack simple and effective tools for quickly identifying and objectifying the various stages of the medical reasoning process.

In order to observe the resident’s process and understand it, the supervisor must keep in mind the key steps of the medical reasoning process, as summarized in Box 1.

We have developed a tool* to assist clinician teachers in evaluating the clinical reasoning processes of their residents. This tool targets various times in the supervision process, such as the consultation (direct supervision), the presentation of the case by the resident (case discussion), and manifestations of clinical reasoning best observed at these times. This tool can also be used by the supervisor to document the strengths and weaknesses in the resident’s clinical reasoning, to share his or her observations with the resident, to determine what is standing in the way of effective clinical reasoning, and to pursue clinical reasoning in daily practice using the strategies proposed in Table 1.9 This tool is available at CFPlus.*