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Diagnosis (Berl). 2014 Jan 1;1(1):111-117. doi: 10.1515/dx-2013-0029.

Assessing clinical reasoning: moving from in vitro to in vivo.

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1American Board of Internal, Philadelphia, PA, USA.
2Uniformed Services University of the Health Sciences, Bethesda, MD, USA.


The last century saw dramatic changes in clinical practice and medical education and the concomitant rise in high-stakes, psychometrically-based examinations of medical knowledge. Higher scores on these high-stakes "in-vitro" examinations are modestly associated with better performance in clinical practice and provide a meaningful degree of assurance to the public about physicians' competency in medical knowledge. However, results on such examinations explain only a small fraction of the wide variation currently seen in clinical practice and diagnostic errors remain a serious and vexing problem for patients and the healthcare system despite decades of high-stakes examinations. In this commentary we explore some of the limitations of high-stakes examinations in assessing clinical reasoning and propose utilizing situated cognition theory to guide research and development of innovative modes of "in-vivo" assessments that can be used in longitudinally and continuously in clinical practice.


clinical decision making; clinical reasoning; diagnostic error


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