Clinical Thinking and the Role of Simulation in Medical Education

In order to conduct proper medical practice, a graduate of higher educational establishment needs to possess several important skills. These are thorough theoretical knowledge, professional manipulation, good communication skills, the ability to work effectively in a team, and demonstrate appropriate ethical behaviour. At the same time, the process of reflection and decision-making is one of the most important skills of a doctor. The workshop for teachers of higher medical education institutions of Ukraine and the symposium “Clinical thinking and the role of simulation in medical education”, held in November 2023 as part of the Ukraine Digital – Clinical Project, were devoted to the issue of training medical students in the decision-making process in medicine and the prevention of diagnostic errors. The events were held at the Ludwig Maximilian University in Munich (Institut für Didaktik und Ausbildungsforschung der LMU München) with the support of the Deutscher Akademischer Austausch Dienst (DAAD). Our university was represented by the Head of the Department of General Chemistry and the Rector’s Representative for Education Quality Assurance Hryhorii Zahrychuk, Associate Professor of the Department of Paediatrics No. 2 Natalia Haliyash, Associate Professors of the Department of Emergency Medical Care Oksana Sydorenko and Larysa Martyniuk, Associate Professor of the Department of Therapy and Family Medicine Iryna Borovyk, Associate Professor of the Department Propaedeutics of Internal Medicine and Phthisiology Natalia Bilkevysh.

Clinical thinking is a process of reflection and decision-making in medical practice. In other words, it is the doctor’s ability to make decisions based on the available information in order to obtain the most favoгrable result. Teaching students clinical thinking in medical education institutions should be comprehensive, end-to-end, requiring special approaches to the educational process and special training of teachers. At the workshop from the Institute of Medical Didactics of the Ludwig Maximilian University, members of the working group had the opportunity to learn about the modern concept of clinical thinking, to analyze the main cognitive biases that lead to inaccurate judgments, illogical interpretation of information and, as a result, are the cause of diagnostic errors.

Working with practical cases in small groups helped to better understand and master modern educational tools that have proven their effectiveness in the process of teaching students clinical thinking: Case-based method, Ishikawa diagram (“fishbone” diagram), “5 why” discussion technique , strategies for recognizing and avoiding cognitive biases are powerful tools in teaching students about clinical thinking.

The use of the “virtual patients” option on the CASUS platform is one of the ways recommended by the organizers to improve clinical thinking skills. A convenient logical interface and a large number of various real clinical situations of the platform will complement the practical part of students’ classes at clinical departments. After registering using a corporate e-mail, educators and students can work with virtual cases in English and, thanks to teachers from Ukraine, who started working with the resource last year, in Ukrainian. In order to improve clinical thinking skills, the CASUS platform can be used in practical sessions to discuss clinical cases. Also, students can work asynchronously on the platform, solving real clinical situations at a time convenient for them.

The next technique for practicing clinical thinking skills is the Fishbone diagram or Ishikawa diagram. In medicine, this analytical tool was borrowed from business, where it is used to solve complex project tasks. A fishbone diagram provides a visual representation of the various causes that contribute to a particular problem or effect. By identifying root causes rather than focusing solely on symptoms, the Fishbone diagram facilitates effective problem solving and optimal clinical decision-making.

Another tool borrowed for decision-making in medicine from business is the “5 why” discussion technique. It is a simple interactive questioning technique used to discover the cause-and-effect relationships underlying a particular problem. The main purpose of the tool is to identify the root cause of the problem by repeating the question “Why?”. Each question forms the basis for the next question. The number “5” in the name is chosen because in most cases five iterations are enough to solve the problem.

Teachers had the opportunity to verify the effectiveness of all tools in practice, using work in small groups with proposed real clinical situations.

A separate section of the event was devoted to cognitive biases that lead to diagnostic errors. The participants of the training were offered the flipped class method, when before practical work it was necessary to study theoretical materials and pass a test on the topic, and already at the workshop, the educators consolidated the learned material in practice, working out real clinical situations with diagnostic errors. At the same time, the participants decided together which cognitive bias caused the wrong decision and which strategies exist to avoid cognitive distortions in order to prevent errors in clinical decision-making.

Two days of the visit were devoted to the participation of teachers in the symposium “Clinical thinking and the role of simulation in medical education”. The scientific event was organized with the assistance of the German company “Brainlab”, which is a leader in the development of digital medical technologies and gave us the opportunity to learn about the advanced achievements in this field. Brainlab software and hardware are used to generate and improve data quality to enhance the efficiency of critical surgeries, radiosurgery procedures, and operating room functioning. The company also develops modern software for the training and advanced training of doctors. The presentation of virtual games for the gamification of the medical educational process was exciting.

Symposium participants took part in numerous workshops related to pedagogical aspects of simulation technologies, intraprofessional interactions in medicine, communications in palliative care, virtual patients (CASUS platform) and CCD (Clinical Case Discussion), training analytics.

Separate time was allocated for reflection, summarizing and forming the next steps of cooperation.

Based on the results of the visit, the workshop participants plan to hold meetings of peer groups organized at the university, trainings for university teachers on clinical thinking, medical errors and prejudices, the role of simulation technologies, and the introduction of virtual patients on the CASUS platform for the formation of clinical thinking skills in students. It is also planned to cooperate between the universities participating in the program with the aim of harmonizing clinical cases presented in CASUS with the list of syndromes/diseases of the Standard of Higher Education in specialty 222 “Medicine”. A separate direction of further cooperation is the initiation of scientific research in the field of medical education with the support of LMU (Munich) and Charité (Berlin).

We express our deepest appreciation to the organizers of the workshop and symposium for the acquired meaningful knowledge, relevant skills, important communications, warm welcome, excellent logistics, real support and new acquaintances.

We hope for further cooperation for the improvement of medical education and for the Victory of Ukraine.

The information was provided by Iryna Borovyk, Natalia Haliyash, Hryhorii Zahrychuk, Oksana Sydorenko, Larysa Martyniuk, Natalia Bilkevich.