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Clinical Process Modeling: An Approach for Enhancing the Assessment of Physicians’ Clinical Reasoning

Cook, Robert J. EdD; Durning, Steven J. MD, PhD

doi: 10.1097/ACM.0000000000002730

To ensure the validity of test interpretation and use, educators must be able to connect the dots between the tasks examinees perform on a test and the decisions educators make based on the results of that test. Toward that end, in this article, the authors introduce an approach called clinical process modeling, which combines clinical reasoning and principled assessment design. The goal of this approach is to better align test item development with the assessment of physicians’ application of knowledge. Clinical process modeling involves creating complex decision trees that can mirror clinical reasoning illness scripts and include the steps and pathways a physician could take to address a specific patient presentation from initial presentation to correct diagnosis and therapy. Once created, these decision trees can be used to inform the assessment development process.

To illustrate this approach, the authors describe how they developed one such clinical process model for a common presentation of low back pain from the field of internal medicine. They explain the steps they took to develop their model and the corresponding test item. They conclude by discussing potential future directions and additional implications for this work, emphasizing how clinical process models can be used to inform other educational processes and clinical practice.

R.J. Cook is senior research scientist, Learning, Assessment, and Navigation Experiences, ACT, Iowa City, Iowa.

S.J. Durning is professor of medicine and pathology and director, Health Professions Education Division, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed herein are those of the authors and not necessarily those of the Department of Defense or other federal agencies.

Previous presentations: An earlier version of this work was presented at the American Educational Research Association Conference in Washington, D.C., in 2016.

Supplemental digital content for this article is available at

Correspondence should be addressed to Robert J. Cook, ACT, 500 ACT Dr., Iowa City, IA 52243; email:

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.