Abdul Rahman, Nur Faraheen Binti; (2023) Clinical Reasoning Teaching and Learning in Undergraduate Primary Care Medical Education. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

My PhD thesis explores the nature and praxis of clinical reasoning teaching and learning in a primary care setting and examines the roles of participants, namely the medical students, clinical teachers and patients involved. The work comprises two significant strands. The first is a systematic narrative review exploring clinical reasoning training in workplace-based undergraduate primary care settings through meta- synthesis mapped against ten steps of transformative learning. Data from twenty-nine studies were analysed and produced knowledge about a variety of clinical reasoning teaching and learning activities, typically embedded within clinical placements but also explicitly taught using specific tools. Theories of learning and systems of care underlie teaching and learning implementations. Fortifiers, connoisseurs, mediators and monitors represent clinical teachers’ roles. Patients were involved in a two-dimensional matrix of service-focused and teaching-focused from passive to active engagement. The nature of assignments, context, and community of encounters explain barriers and facilitators for clinical reasoning teaching and learning. Elements of transformative learning are notable. A gap in this review is the lack of approaches and processes that elucidate clinical reasoning teaching and learning in primary care settings, begging for in-depth exploratory study. My empirical work was accomplished through a COVID-19 mitigated ethnography, with 51 participants in a Family Medicine clinical placement of a Bachelor of Medicine and Surgery programme at a public university in Malaysia. Field notes and audio transcriptions from interviews were analysed using reflexive thematic analysis through the activity theory lens. Four key events construed students' learning trajectories in this clinical placement. Students enter, traverse, expand and egress physical and metaphorical spaces as they learn clinical reasoning in the clinic. This thesis weaves participant stories with my interpretations. It forges activity systems of negotiating, navigating, engaging and transforming clinical reasoning mediated by artefacts, including waiting rooms, the hierarchy of useful knowledge, debriefing sessions, and patients' involvement in student- patient consultations. Apart from contributing insights on factors shaping clinical reasoning teaching and learning in primary care settings, this thesis also proposes a complex and uncertainty-supportive, system-based, practical and participatory approach for future instructional designs and implementations.

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