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Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance

Daniel, Michelle MD, MHPE; Rencic, Joseph MD; Durning, Steven J. MD, PhD; Holmboe, Eric MD; Santen, Sally A. MD, PhD; Lang, Valerie MD, MHPE; Ratcliffe, Temple MD; Gordon, David MD; Heist, Brian MD, MSc; Lubarsky, Stuart MD, MHPE; Estrada, Carlos A. MD, MS; Ballard, Tiffany MD; Artino, Anthony R. Jr PhD; Sergio Da Silva, Ana PhD; Cleary, Timothy PhD; Stojan, Jennifer MD, MHPE; Gruppen, Larry D. PhD

doi: 10.1097/ACM.0000000000002618

Purpose An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore the existing menu of CR assessments.

Method Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were sorted by assessment methods and reviewed by pairs of authors. Extracted data were used to construct descriptive appendixes, summarizing each method, including common stimuli, response formats, scoring, typical uses, validity considerations, feasibility issues, advantages, and disadvantages.

Results A total of 377 articles were included in the final synthesis. The articles broadly fell into three categories: non-workplace-based assessments (e.g., multiple-choice questions, extended matching questions, key feature examinations, script concordance tests); assessments in simulated clinical environments (objective structured clinical examinations and technology-enhanced simulation); and workplace-based assessments (e.g., direct observations, global assessments, oral case presentations, written notes). Validity considerations, feasibility issues, advantages, and disadvantages differed by method.

Conclusions There are numerous assessment methods that align with different components of the complex construct of CR. Ensuring competency requires the development of programs of assessment that address all components of CR. Such programs are ideally constructed of complementary assessment methods to account for each method’s validity and feasibility issues, advantages, and disadvantages.

M. Daniel is assistant dean for curriculum and associate professor of emergency medicine and learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan; ORCID:

J. Rencic is associate program director of the internal medicine residency program and associate professor of medicine, Tufts University School of Medicine, Boston, Massachusetts; ORCID:

S.J. Durning is director of graduate programs in health professions education and professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

E. Holmboe is senior vice president of milestone development and evaluation, Accreditation Council for Graduate Medical Education, and adjunct professor of medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois; ORCID:

S.A. Santen is senior associate dean and professor of emergency medicine, Virginia Commonwealth University, Richmond, Virginia; ORCID:

V. Lang is associate professor of medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York; ORCID:

T. Ratcliffe is associate professor of medicine, University of Texas Long School of Medicine at San Antonio, San Antonio, Texas.

D. Gordon is medical undergraduate education director, associate residency program director of emergency medicine, and associate professor of surgery, Duke University School of Medicine, Durham, North Carolina.

B. Heist is clerkship codirector and assistant professor of medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

S. Lubarsky is assistant professor of neurology, McGill University, and faculty of medicine and core member, McGill Center for Medical Education, Montreal, Quebec, Canada; ORCID:

C.A. Estrada is staff physician, Birmingham Veterans Affairs Medical Center, and director, Division of General Internal Medicine, and professor of medicine, University of Alabama, Birmingham, Alabama; ORCID:

T. Ballard is plastic surgeon, Ann Arbor Plastic Surgery, Ann Arbor, Michigan.

A.R. Artino Jr is deputy director for graduate programs in health professions education and professor of medicine, preventive medicine, and biometrics pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID:

A. Sergio Da Silva is senior lecturer in medical education and director of the masters in medical education program, Swansea University Medical School, Swansea, United Kingdom; ORCID:

T. Cleary is chair, Applied Psychology Department, CUNY Graduate School and University Center, New York, New York, and associate professor of applied and professional psychology, Rutgers University, New Brunswick, New Jersey.

J. Stojan is associate professor of internal medicine and pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.

L.D. Gruppen is director of the master of health professions education program and professor of learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan; ORCID:

Funding/Support: None reported.

Other disclosures: E. Holmboe works for the Accreditation Council for Graduate Medical Education and receives royalties for a textbook on assessment from Elsevier.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of their universities, the U.S. Navy, the Department of Defense, or the United States Government.

Previous presentations: A portion of this work was accepted for presentation as a workshop entitled Clinical Reasoning Assessment Tools: So Many Methods How to Choose at the Association of American Medical Colleges 2018 Annual Meeting; Austin, Texas; November 6, 2018.

Supplemental digital content for this article is available at,,, and

Correspondence should be addressed to Michelle Daniel, University of Michigan Medical School, 6123 Taubman Health Sciences Library, 1135 Catherine St., SPC 5726, Ann Arbor, MI 48109; telephone: (734) 763-6770; e-mail:; Twitter: @Emergdoc1975.

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.