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Med Teach. 2013 Jun;35(6):472-80. doi: 10.3109/0142159X.2013.774336. Epub 2013 Mar 6.

Effect of stress on clinical reasoning during simulated ambulatory consultations.

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Department of Internal Medicine, Faculty of Medicine, CHU Nantes, Place Alexis Ricordeau, Nantes, France.



The goal of this study was to examine the impact of subjective and physiological stress responses on medical students' diagnostic reasoning and communication skills.


A prospective randomized quantitative study was undertaken, looking at ambulatory consultations in internal medicine. On the first day (baseline day), volunteer year 6 students (n = 41) participated in a simulated ambulatory consultation with standardized patients (SPs). On the second day (study day), one week later, they were randomly assigned to two groups: a low stress (n = 20) and a high stress (n = 21) simulated ambulatory consultation. Stress was measured using validated questionnaires and salivary cortisol. The SPs assessed the students' reasoning and communication. The students completed assessments of their clinical reasoning after the consultations.


Although stress measures were all significantly higher in the high-stress condition (all p < 0.05), no differences were found in diagnostic accuracy and justification scores. However, correlational analyses revealed a negative correlation between multiple-stress measures and the students' ability to generate arguments for differential diagnoses.


Stress was associated with impairments in clinical reasoning, of a nature typically suggestive of premature closure.

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