Learning by Clinical Reasoning: A Cross-Sectional Study of Dental Students

Context: Clinical reasoning is a central skill in optimal medical care. This study aimed to evaluate the perception of clinical reasoning learning training (CRT) sessions among dental students.
Materials and Methods: This was a descriptive cross-sectional study of dental students. The sessions on clinical reasoning were organized by the same teacher-facilitator and ended with an assessment of the learner’s satisfaction with the first Kirkpatrick level by the learners. Thus, a self-administered, anonymous, voluntary questionnaire with 20 closed questions was distributed during the last session. The questionnaire covers socio-demographic data, session organization, scientific interest, educational value, session progress and general assessment using a 4-level Likert scale.
Results: 79 students out of 122 students participated in our study, including 51 women. A total of 93.98% of students appreciated the general concept of clinical reasoning. All the items questioned were fully satisfied by the students, in particular the scientific interest (90.55%), educational contribution (88.37%), organization (86.5%) and conduct of the sessions (89.69%). Finally, 98.3% of the participating students recommended CRT sessions.
Conclusion: Learning through clinical reasoning is an active pedagogy that optimizes both theoretical and clinical performance.

Introduction

Faculties have the responsibilitý of training competent healthcare professionals capable of providing quality care that conforms to the latest scientific recommendations (Ihbibaneet al., 2021; Audétatet al., 2017a).

Competence is built around the acquisition of theoretical knowledge (basic and clinical sciences), relevant skills (clinical, technical, and interpersonal), and clinical reasoning (Charlin, 2003). However, clinical reasoning is considered to be the core competency for all healthcare professionals, as it lies at the heart of daily medical practice (Lorenzo, 2021; Demeesteret al., 2013; Durninget al., 2024).

According to Nendaz, clinical reasoning (CR) corresponds to “the thought processes that enable the clinician to make decisions about the most appropriate actions in a specific context of health problem resolution” (Nendazet al., 2005).

Effective reasoning helps to reduce errors in an increasingly complex, demanding and competitive healthcare environment (Medjberet al., 2022; Bansalet al., 2020). Indeed, several studies indicate that inadequate and difficult clinical reasoning can lead to clinician underperformance and, ultimately to a risk to the quality and safety of patient care (Massartet al., 2020; Ihbibaneet al., 2021; Demeesteret al., 2013; Chamberlandet al., 2001; Higgset al., 2019). In 2015, the Committee on Misdiagnosis in Health Care, under the aegis of the National Academies of Sciences, Engineering and Medicine in the United States of America (NSA), considered that improving the diagnostic process is a professional, moral and public health obligation, and recommended the introduction of teaching methods that promote clinical reasoning throughout the educational continuum (Torreet al., 2019).

Clinical reasoning is currently considered a major skill in the health sciences training reference systems (Lorenzo, 2021). Clinical reasoning cannot be improvised or acquired passively through observation, but needs to be learned (Bansalet al., 2020; Zairiet al., 2017; Sartaniaet al., 2022; Psiuk, 2019).

Thus, clinical reasoning training sessions were first introduced during clerkships in 1990 at the Sherbrooke facultý of medicine and have continued to spread throughout health science faculties (Demeesteret al., 2013; Zairiet al., 2017). CRT is a simple and easily achievable teaching method with a significant pedagogical input. It is based on contextualized teaching and is an alternative to conventional forms of teaching (lectures and directed teaching) (Medjberet al., 2022; Zairiet al., 2017). Its role is not to replace theoretical teaching, but to complement it (Boujoualet al., 2020; Hammiet al., 2020).

The dental curriculum in Morocco lasts six years, divided into a pre-clinical phase (three years) and a clinical phase (three years), comprising courses and clinical internships. Clinical Reasoning Training sessions were organized in the fourth and fifth years of pedodontics. This learning method was first introduced in conservative dentistry for 5th year students in Mohammed VI Faculty of Dentistry.

The aim of this work was to evaluate the perceived interest in these learning sessions by clinical reasoning with 5th year students of the faculty of dentistry in conservative odontology.

Materials and Methods

Study Design and Setting

This is an exhaustive cross-sectional descriptive observational study.

Study Population

All 5th year students of Mohamed VI Faculty of Dentistry were invited to participate in our study.

Inclusion criteria: All 5nd year students at the Faculty of Dentistry who attended the clinical reasoning sessions.

Exclusion criteria: Students from other levels and students in their 5nd year at the Faculty of Dentistry who had not attended the clinical reasoning sessions.

Activity Sequence and Data Collection

Four 60-minute clinical reasoning learning sessions were organized by the same teacher facilitator, who was responsible for leading and guiding the various CRT sessions. An informative session was dedicated to briefing, explaining the concept of clinical reasoning training, and establishing sub-working groups of six to eight students.

During the CRT sessions, a realistic and authentic clinical situation was presented by the teacher facilitator, followed by an interactive discussion within each group to highlight the different stages of clinical reasoning, in particular the development of reasoned diagnostic hypotheses and the collection of justified clinical data (history, endobuccal and exobuccal examination, complementary examinations). Hypotheses were then re-evaluated, followed by the selection of the final diagnosis and development of a treatment plan. At the end of the session, a stage of decontextualization and schematization took place, enabling a synthesis of the approach to the clinical problem and an assessment of the group. Finally, each student had expressed his or her personal feelings and stated the gaps in their knowledge that had disturbed their ability to reason.

The CRT session ended with an evaluation of the satisfaction at the first Kirkpatrick level by the learners who had participated in the clinical reasoning training sessions.

A voluntary, anonymous, self-administered paper questionnaire, based on a literature review, was distributed in the last session. The questionnaire was written in French and pre-tested with the department’s interns to ensure comprehension of the items and the time required, which was estimated at less than 10 minutes. It consisted of 20 closed questions on the socio-demographic data of the respondents and on the organization of the session, the scientific interest, the pedagogical value, the conduct of the session, and the general appreciation of the CRT using a 4-level Likert scale: 1 = not satisfied; 2 = not very satisfied; 3 = satisfied; 4 = very satisfied. In order to measure overall satisfaction based on the main elements, we considered that responses 3 and 4 corresponded to good satisfaction and responses 1 and 2 to low satisfaction.

Statistical Analysis

Descriptive statistical analysis of the data was carried out using SPSS version 25 software.

Ethical Consideration

Ethical considerations were respected during this survey. In accordance with the 1964 Declaration of Helsinki, participation was entirely voluntary, with no direct or indirect compensation, and data collection was entirely anonymous. All respondents gave their informed consent after being informed of the nature and purpose of the survey. Data confidentiality was ensured, and access to data was granted only to the principal investigator. The study was approved by the ethics committee under number CE /UM6SS /30/24.

Results

The number of students participating in the CRT sessions was 79 out of a total of 122 students enrolled in 5th year, including 51 women and 28 men. Students absent from the CRT sessions were excluded from the study. All students who attended the CRT sessions participated in the satisfaction study so we collected 79 completed questionnaires, that is, a student response rate of 100%. The average age of the students was 21 +− 0.74. For all the students, this was their first experience of CRT in conservative dentistry, and they greatly appreciated the general concept of CRT, giving it an overall satisfaction rating of 93.98%. The students were fully satisfied with all the items surveyed, in particular, the scientific interest, educational contribution, and organization and running of the sessions. Finally, 98.3% of the participating students recommended arc sessions, the results are detailed in Fig. 1 and Table I.

Fig. 1. Average student satisfaction with CRT sessions.

Table I. Evaluation of Satisfaction (in Percentage) of CRT Sessions According to the Likert

	1	2	3	4
Organization :
The duration of the session is adapted	5.1	10.1	29.1	55.7
The general atmosphere was conducive to learning	1.3	12.7	26.6	59.5
Structured and well-organized session	1.3	3.8	27.8	67.1
Progress of the session:
Clear communication of session objectives	0	3.8	24.1	72.2
Clarity of instructions	1.3	2.5	26.6	69.6
Interesting clinical cases	0	3.8	27.8	68.4
Session generated low workload	1.3	7.6	34.2	57
Easy communications and exchanges	0	6.3	31.6	62
Speaking possible	0	6.3	29.1	64.6
Good working atmosphere	0	10.1	26.6	63.3
Interest in CRT sessions:
Application of previous theoretical knowledge	1.3	2.5	31.6	64.6
Acquisition of new clinical knowledge	0	3.8	27.8	68.4
Good memorization of information received after ARC	0	0	38	62
Contribution of CRT sessions:
CRT allowed me to improve the history	1.3	5.1	45.6	48.1
CRT allowed me to improve the synthesis of diagnostic hypothesis and to choose complementary examinations	1.3	1.3	39.2	58.2
CRT allowed me to improve the diagnosis	0	1.3	39.2	59.5
CRT allowed me to improve the implementation of a treatment plan	0	1.3	36.7	62
Overall evaluation of CRT sessions:
The quality of teaching is good	1.3	2.5	22.8	73.4
The CRT session is interesting	0	0	19	81
I recommend CRT for other courses	0	1.3	19	79.7

Discussion

We currently live in a hyper-connected society dominated by screens and overwhelmed by the immediacy and instantaneous sharing of events, but where paradoxically concentration and attention are steadily declining, especially among the rising generation of students. To adapt to this universal trend, active teaching techniques have emerged to place students at the center of learning (Khemisset al., 2022). According to Romainville, active pedagogy involves students in their learning process, makes them cognitively active, places them in guided autonomy, and helps them innovate, collaborate and solve problems that simulate their future professional practice (Sartaniaet al., 2022; Puaud, 2018; Frellsenet al., 2008). An active student is more successful in his or her studies than a passive student because memorization is better (Salthun-Lassalle, 2021). The advantages of this collaborative pedagogy are multiple and clearly established. It enhances learning through higher-order thinking, notably self-reflection, analysis, argumentation and critical thinking, which promotes in-depth learning. It develops cross-disciplinary skills (know-how and interpersonal skills) and increases learner’s motivation, interest, and commitment. Through interaction and group work, it promotes group cohesion, a sense of belonging and cooperation (Sartaniaet al., 2022; Puaud, 2018; Frellsenet al., 2008).

Among the active pedagogies applied in the health sciences, our work focuses on learning through clinical reasoning. Clinical reasoning is at the heart of the acquisation of clinical skills. According to Pelaccia, it is a complex, multifactorial cognitive process that requires a structured organization of knowledge and its rapid, relevant mobilization in an authentic context (Lorenzo, 2021; Medjberet al., 2022; Zairiet al., 2017; Cogan et al., 2022). This process synthesizes the information obtained from a specific clinical situation and uses it to perform a diagnostic analysis and an appropriate decision for patient management, integrating previous knowledge and experience (Charlinet al., 2003; Coganet al., 2020; Perezet al., 2023; Mohd Tambeh & Yaman, 2023). This mental activity results in the production of new information from the acquired knowledge, thus enriching clinical experience and developing reflective thinking (Lorenzo, 2021; Higgset al., 2019). Clinical reasoning was based on 3 models. The non-analytical model, which is based on characteristic signs (pattern recognition) or similarities with previously encountered cases, for an immediate spontaneous and unconscious identification of the clinical problem, and the hypothetico-deductive analytical model, which is a voluntary and conscious process taking place in several stages based on the generation and verification of hypotheses, the interpretation of clinical data, and complementary examinations, leading to the establishment of a diagnosis and the choice of a treatment plan adapted to the patient and his context. Finally, in the mixed model, the two processes interact with each other (Ihbibaneet al., 2021; Medjberet al., 2022; Higgset al., 2019).

Clinical knowledge is associative in nature, linking the signs and symptoms of a disease, examinations, and treatments; therefore, there is a difference in clinical reasoning between a novice and an experienced clinician (Lorenzo, 2021; Higgset al., 2019; Coganet al., 2020; Jainet al., 2019).

According to Tardif, when a student links new information with his or her network of prior knowledge, he or she reorganizes his or her knowledge, resulting in learning. Analytical processes are gradually built up in working memory, whereas non-analytical processes are linked to the long-term recall of available instances or prototypes (Audetat et al., 2017). The highest stage of medical competence is thus characterized by the existence of an enormous repertoire of concrete cases (Boujoualet al., 2020).

Sessions are organized in all health science courses to improve students’ ability to transfer declarative knowledge to problems, to facilitate the learning of medical information, and to improve techniques for clinical examination of patients, synthesis of diagnostic hypotheses, and development of appropriate therapeutics (Medjberet al., 2022; Bansalet al., 2020; Zairiet al., 2017; Sartaniaet al., 2022; Audétatet al., 2017b; Salari & Amini, 2025).

The Kirkpatrick model is a popular and frequently used evaluation method owing to its simplicity and relevance. It classifies the effectiveness of the teaching intervention into four levels according to the degree of behavioral change in learners. According to Kirkpatrick, training is effective if it provokes a positive reaction from the learner and a high level of satisfaction (>80%). During our work, all the evaluated items received full satisfaction from the students, notably organization, pedagogical contribution, progress, scientific interest, and overall evaluation. These results are in complete agreement with published studies (Zairiet al., 2017; Boujoualet al., 2020; Hammiet al., 2020; Khemisset al., 2022; Touilet al., 2021). This high level of learner satisfaction can be explained on the one hand by the students’ interactions with each other during this group activity, but also by the learners’ feedback from the facilitating teacher, who must possess clinical expertise and pedagogical skills (Chamberlandet al., 2001; Psiuk, 2019; Coganet al., 2020; Schlenzig, 2021).

Moreover, the choice of concise but information-rich real-life clinical cases makes CRT an authentic and credible learning experience and increases interest and active participation in the sessions.

Clinical reasoning training, like all active methods, has certain drawbacks: it is time-consuming and requires a reduction in the amount of assimilated information. They require both rigor in the design and organization of activities, and flexibility to adapt to learners’ reactions (Puaud, 2018; Audetatet al., 2017c; Coganet al., 2020).

A limitation of our study is that we only evaluated the first level of Kirkpatrick’s model. The other levels can be examined at a later date, when CRT is integrated into student training over several years, to assess real changes in student behavior and attitudes, the transfer and integration of learning, and the impact on patient care. Furthermore, the use of self-reported questionnaires could expose the study to the risk of self-report bias and social desirability bias in the data which we tried to reduce by respecting the anonymity of the data and using a Likert scale.

This was the first CRT experience in conservative dentistry, and students’ evaluations were highly positive. The satisfaction results obtained were very encouraging, reflecting the students’ full support for this active teaching method and encouraging us to develop CRT sessions further.

Conclusion

Clinical reasoning training is an active learning pedagogy that enables the development of high-level cognitive skills, ensuring a correlation between theoretical and clinical performance and the acquisition of skills needed in the professional world. However, even if the development of CRT sessions is a complex process that requires investment in time and trained teaching staff, the high satisfaction scores of our students encourage us to introduce it into other teaching modules in dentistry.

Acknowledgment

We thank the students of the 5th year of dental medicine at Mohammed VI University of Health Sciences for their participation in this scientific work.

Conflict of Interest

Declaration of Interest: The authors have no link of interest in relation to this article.