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UBC Theses and Dissertations

Clinical Reasoning in Dentistry Khatami, Shiva


Background: Clinical reasoning is the core competency of healthcare. It involves cognition and interaction with the environment to understand clinical situations, make diagnostic and therapeutic decisions, and address clinical problems. Defining competency in clinical reasoning is a difficult objective for dental educators because of our limited understanding of this phenomenon which compromises the validity of any curricular model and assessment method that have been used to date. Objectives: To describe the process and strategies of clinical reasoning used by dental clinicians across different levels of expertise to develop a conceptual framework for curricular design and assessment of competency. Methods: Using “think-aloud” method, I interviewed 18 dental students about biopsychosocial issues influencing oral health identified in 6 vignettes; and 8 orthodontic residents plus 11 orthodontists about problems of craniofacial growth and malocclusion presented in 2 vignettes. The interview transcripts were analyzed to explore the process and strategies of clinical reasoning used by the participants. Results: The reasoning process in both groups included: 1) a ritualistic approach to collect information for a treatment plan; 2) forward and backward reasoning to make and test hypotheses from clinical information; 3) pattern recognition and an integrated script of knowledge and experience triggered by related attributes of the script leading to a clinical diagnosis and plan; and 4) decision trees to evaluate treatment options and maximize the probability and utility of outcomes. Seven reasoning strategies (scientific, conditional, collaborative, narrative, ethical, pragmatic and “part-whole”) were used by both groups. However, experienced clinicians were more confident in their appraisal of uncertain situations and dilemmas as they integrated several reasoning strategies in the process; used refined scripts of knowledge and experience in familiar situations; and were able to reflect on the impact on their reasoning of the larger social, cultural and political context. Conclusions: Clinical reasoning in dentistry is a contextual and interactive phenomenon that requires integration of specific reasoning strategies to address the biopsychosocial factors influencing oral health. Expertise in clinical reasoning develops through continuous framing and solving problems to refine networks of knowledge and experience and develop adaptive strategies to address the contextual determinants of oral health.

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