Development of clinical reasoning in an undergraduate medical program at a Brazilian university

ABSTRACT CONTEXT AND OBJECTIVE The cognitive processes relating to the development of clinical reasoning are only partially understood, which explains the difficulties in teaching this skill in medical courses. This study aimed to understand how clinical reasoning develops among undergraduate medical students. DESIGN AND SETTING Quantitative and qualitative exploratory descriptive study conducted at the medical school of Universidade Federal de Goiás. METHODS The focus group technique was used among 40 students who participated in five focus groups, with eight students from each year, from the first to fifth year of the medical school program. The material was subjected to content analysis in categories, and was subsequently quantified and subjected to descriptive statistical analysis and chi-square test for inferential statistics. RESULTS The content of the students' statements was divided into two categories: clinical reasoning - in the preclinical phase, clinical reasoning was based on knowledge of basic medical science and in the clinical phase, there was a change to pattern recognition; knowledge of basic medical science - 80.6% of the students recognized its use, but they stated that they only used it in difficult cases. CONCLUSION In the preclinical phase, in a medical school with a traditional curriculum, clinical reasoning depends on the knowledge acquired from basic medical science, while in the clinical phase, it becomes based on pattern recognition.

**背景与研究目的**
与临床推理能力发展相关的认知过程目前仅得到部分阐明，这也解释了医学课程中该技能教学所面临的诸多困境。本研究旨在探究医学本科生的临床推理能力是如何形成与发展的。

**研究设计与实施地点**
本研究为定量与定性相结合的探索性描述性研究，开展于戈亚斯联邦大学（Universidade Federal de Goiás）医学院。

**研究方法**
本研究采用焦点小组（focus group）技术，共纳入40名学生，分为5组开展焦点小组访谈，每年级各8名学生，覆盖医学院一至五年级的培养方案。对收集到的访谈资料进行分类内容分析，随后进行量化处理，开展描述性统计分析，并采用卡方检验进行推断统计分析。

**研究结果**
学生的发言内容被划分为两大类别：
1. 临床推理：临床前期阶段的临床推理基于基础医学科学知识；而在临床实践阶段，临床推理模式转变为以模式识别（pattern recognition）为核心。
2. 基础医学科学知识：80.6%的学生认可其应用价值，但表示仅在疑难病例中会使用该类知识。

**研究结论**
在采用传统课程体系的医学院校中，临床前期阶段的临床推理能力依赖于学生所掌握的基础医学科学知识，而进入临床阶段后，临床推理则转向以模式识别为核心依据。