Document Type : Original Article


1 Center for Educational Research in Medical Sciences

2 Endocrinology and Metabolism Research Center (EMRC), Tehran University of Medical Sciences, Tehran,

3 Department of Oncology, Zahedan University of Medical Sciences, Zahedan

4 Department of Internal Medicine, School of Medicine, Babol University of Medical Sciences, Babol, Iran

5 Medical Education Development Center, University of Utrecht Medical Center, Utrecht, Netherlands

6 Medical Education Development Center

7 Medical Education Research Center

8 Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Although some tests for clinical reasoning assessment are now available, the
theories of medical expertise have not played a major role in this filed. In this paper, illness
script theory was chose as a theoretical framework and contemporary clinical reasoning tests
were put together based on this theoretical model. Materials and Methods: This paper is a
qualitative study performed with an action research approach. This style of research is performed in a context where authorities focus on promoting their organizations’ performance
and is carried out in the form of teamwork called participatory research. Results: Results are
presented in four parts as basic concepts, clinical reasoning assessment, test framework,
and scoring. Conclusion: we concluded that no single test could thoroughly assess clinical
reasoning competency, and therefore a battery of clinical reasoning tests is needed. This battery should cover all three parts of clinical reasoning process: script activation, selection and
verification. In addition, not only both analytical and non-analytical reasoning, but also both
diagnostic and management reasoning should evenly take into consideration in this battery.
This paper explains the process of designing and implementing the battery of clinical reasoning in the Olympiad for medical sciences students through an action research.


1. Adibi P, Hadagar A, Hadizadeh F, Haghjoo SH, Monajemi A. Medical
sciecne olympiad: Concepts, discieplines and methods. Isfahan:
Isfahan University of Medical Sciences Publication; 1998.  
2. Hatch JA. Doing Qualitative Research in Educational Settings.
Albany, NY: State University of New York; 2002.
3. Insch GS, Moore JE, Murphy LD. Content analysis in leadership
research: Examples, procedures, and suggestions for future use.
Leadersh Q 1997;8:1-25.
4. Denzin NK, Lincoln YS. Handbook of Qualitative Research. 1st.
Thousand Oaks, CA: Sage Publications; 1994.
5. Higgs J, Jones MA, Loftus S, Chiristensen N. Clinical reasoning in
the health professions. Second ed.
6. Gruppen LD, Frohna AZ. Clinical reasoning. In: Norman GR, Ven Der
Vleuten CP, Newble DI, editors. International handbook of research in
medical education. Great Britain: Kluwer Academic Publishers; 2002.
7. Charlin B, Boshuizen, HP, Custers EJ, Feltovich PJ. Scripts and
clinical reasoning. Med Educ 2007;41:1178-84.
8. Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on
medical expertise: Theory implications. Acad Med 1990;65:611-21.
9. Norman G. Research in clinical reasoning: Past history and current
trends. Med Educ 2005;39:418-27.
10. Monajemi A, Rikers RM. The role of patient management knowledge
in medical expertise development: Extending the contemporary
theory. IJPCE 2011;1:109-14.
11. Custers EJ, Boshuizen HP, Schmidt HG. The influence of medical
expertise, case typicality and illness script component on case
processing and disease probability estimates. Mem Cognit
12. Custers EJ, Boshuizen HP, Schmidt HG. The role of illness scripts
in the development of medical diagnostic expertise: Results from
an interview study. Cognit Instruct 1998;16:367-98.
13. Monajemi A, Rikers RM, Schmidt HG. Clinical case processing: A
diagnostic versus a management focus. Med Educ 2007;41:1166-72.
14. Monajemi A. Clinical Reasoning: Concepts, education and
assessment. Isfahan: Isfahan University of Medical Sciences
Publication; 2011. problems. Acad Med 1997;72:173-9.
15. Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic reasoning
strategies and diagnostic success. Med Educ 2003;37:695-703.
16. Van der Vleuten C, Newble D. How can we test clinical reasoning?
Lancet 1995;345:1032-4.
17. Newble D, Norman G, van der Vleuten C. Assessing clinical
reasoning. In: Higgs J, Jones M, editors. Clinical reasoning in the
health professions. 2nd ed. Oxford: Butterworth-Heinemann; 2000.
18. Brener E, Hamilton LA, Best WR. A new approach to evaluating
problem solving in medical students. J Med Educ1974;49:666-72.
19. Schuwirth L. Is assessment of clinical reasoning still the Holy Grail?
Med Educ 2009;43:298-300.
20. Page G, Bordage G, Allen T. Developing key-feature problems and
examinations to assess clinical decisionmaking skills. Acad Med
21. Grooves M, Scott I, Alexander H. Assessing clinical reasoning:
A method to monitor its development in a PBL curriculum. Med
Teach 2002;24:507-15.
22. Charlin B, Roy L, Brailovsky C, Goulet F, van der Vleuten C. The
script concordance test: A tool to assess the reflective clinician.
Teach Learn Med 2000;12:189-95.
23. Ber R. The CIP (comprehensive integrative puzzle) assessment
method. Med Teach 2003;25:171-6.