Common Biases, Difficulties, and Errors in Clinical Reasoning in Veterinary Medical Encounters with a Case Example

1. Introduction

Similar to other medical professions [1,2], clinical reasoning errors have a major influence on the quality of veterinary medical services [3]. It is a common misconception that being older or more experienced means fewer errors in clinical reasoning, as experience is not synonymous with expertise [2,4]. Becoming an expert means mastering clinical reasoning [5,6,7] but it is not directly proportional to the time spent in practice.

Accurate diagnosis and appropriate management of the encounter are essential to quality veterinary medical services. Diagnostic accuracy heavily relies on the practitioner’s clinical reasoning [8]. Most clinical reasoning errors are not a result of a lack of knowledge of the clinician but rather the effect of the complexity of the clinical work coupled with minor to major faults in cognition or contextualization of the clinical encounter [2,8,9,10,11,12,13]. Errors in the human internal medicine field are high, not as a result of insufficient knowledge but, rather, the defective synthesis of information [12,14,15,16]. Errors in clinical reasoning, and particularly in diagnosis in medical fields, range between 4% and 25% [2,17,18,19,20] whilst errors in adherence to best practices reach up to 45% [2], and some 30% – 70% are preventable [12,18]. These proportions are probably similar in veterinary medical practice [3]. Therefore, learning the clinical reasoning process is essential to any medical field, including veterinary medicine [5,6,21,22,23,24,25]. Clinical reasoning is also a requirement by many accreditation bodies of veterinary medical educators [26,27,28].

Learning and teaching of clinical reasoning should be planned activities. One important task is making learners aware of the potential common biases, difficulties and errors in clinical reasoning [4,11,15,29,30]. This allows for their prevention or the taking of action to moderate the consequences when bias, difficulty, or error in clinical reasoning in a veterinary clinical encounter has occurred (remediation; Figure 1). This is only possible with awareness and recognition of the common clinical veterinary medical biases, difficulties and errors, coupled with a detailed knowledge of the veterinary medical clinical reasoning circle [31,32]. Veterinary medical learners and their clinical instructors who are aware of the common clinical veterinary medical biases, difficulties and errors, should minimize their occurrence, and when they do occur, they should be able to timely implement appropriate remediation strategies.

Biases, difficulties, and/or errors in clinical reasoning can be classified into four major categories, namely cognitive, client ± patient-related, process-related, and system-related factors (Table 1; [19,20]). Many of these factors are similar to, or the same as, the context factors affecting the clinical reasoning in learners [31].

The likelihood of occurrence of biases, difficulties, and errors in clinical reasoning in veterinary medical clinical encounters varies, inextricably influenced by many external and internal factors (Figure 2; [17,32,34,40]). All these factors may result in errors or delays in clinical reasoning decisions, ultimately decreasing the quality of provided veterinary services.

Overall, it was believed that more errors occur when a learner uses an exclusively analytical or intuitive type of reasoning compared to reasoning using the dual type of clinical reasoning [4,29]. This belief is now challenged [6,29]. Difficulties and errors in clinical reasoning may occur due to faulty heuristic recall (intuitive type of clinical reasoning) that has generated the problem, but there is also a failure in the analytical type of clinical reasoning that failed to recognize the problem, and no remediation has occurred [13,29,59]. Yet, in practice, the separation of purely analytical and intuitive, or the use of dual clinical reasoning, is difficult. In reality, any errors in the intuitive type are associated with biases, whilst in analytical types of clinical reasoning errors occur from the limited capacity of the working memory [55], and deficient medical cognition/metacognition [29].

In Figure 3 we extrapolated data from many sources, some being non-peer-reviewed, stating when specific clinical biases/difficulties/errors occur. Significant discrepancies exist between available studies and other sources. We hypothesize that the reason for the existence of these discrepancies is most likely the context [17,34,73]. The difficulties and errors in clinical reasoning are often connected to the learners’ metacognitive competence [19,47,73,74,75] (e.g., general problem-solving skills, reflective practice, and/or self-confidence). This is a research element that can be easily standardized. Yet, as metacognition is affected by internal and external factors, general metacognitive competencies, and clinical reasoning, in particular, should be intertwined with variability in contexts. In many cases, the external factors that affect clinical reasoning can be relatively controlled, particularly in encounter-based discussions. In contrast, internal factors are very difficult to control [34]. Therefore, to decrease the proportion of clinical reasoning difficulties and errors, an important portion of the veterinary medical curricula should address the development of heuristic recall and metacognitive competence in veterinary medical learners.

Understandably, knowledge-based difficulties and errors in clinical reasoning decrease with learning and experience (Figure 3), probably because of the improved mental organization of medical cognition in learners. In contrast, skills-based difficulties and errors in clinical reasoning increase with experience (Figure 3), partly because the more experienced practitioners become specialized and their omnicompetence decreases. Rules-based difficulties and errors increase over time, reach a peak, and then decrease (Figure 3). This is most likely a result of the organization of competencies, knowledge, and skills in the learner, initially based on recall, but later based on metacognitive approaches.

2. Example Case

Each veterinary medical encounter should be solved using the eight stages of the clinical reasoning cycle, often moving back and forth between them [31]. In the explanation of clinical reasoning biases, difficulties, and/or errors in veterinary medical education, hereafter, an example of a bovine clinical encounter with a cow with protruding tissues from the tail end will be used (Table 2). Tissues protruding from the hindquarters are relatively common presentations in any species and, therefore, the example case would be suitable for teaching and learning clinical reasoning, and potential biases, difficulties, or errors in clinical reasoning. In this table, italicized text means verbal communication.

3. Remediation of Difficulties and Errors in Clinical Reasoning

Biases, difficulties, or errors in veterinary medical clinical reasoning may occur due to faults in the process by the learner [50] but also due to ineffective supervision [50]. Ineffective supervision may occur due to clinical teaching settings (system-related), ineffective clinical instructors, or a lack of supervision. Prevention and remediation of biases, difficulties and/or errors in clinical reasoning competencies in veterinary medical learners are only possible after being detected/recognized [30,76]. Currently, many clinical teaching settings provide for the late discovery of biases, difficulties, and errors in clinical reasoning, usually associated with some form of assessment [9,10,30,47]. Unfortunately late detection, at assessment, is not always conducive to an opportunity for the learner to acquire methods of prevention or remediation [10]. Early detection of difficulties and errors in clinical reasoning and their remediation are essential to prevent learners from running into major clinical reasoning difficulties [10,18,30,49]. Ineffective supervision by the clinical instructor may be due to a lack of awareness of biases, difficulties, or errors in clinical reasoning but also due to a lack of preparedness in clinical teaching. Lack of supervision may occur due to learner- or instructor-related factors. Learner-related factors may include but are not limited to a lack of enthusiasm or not being interested in feedback. Instructor-related factors may include but are not limited to insufficient time to provide effective feedback, or the lack of awareness in the provision of effective feedback. Indeed, lack of adequate supervision may also occur due to system-related factors including but not limited to the size of the supervised group of learners.

Therefore, biases, difficulties and errors in clinical reasoning should be prevented and remediated early and ‘on-the-go’ (Figure 4; [9,50,52,77]). This can be achieved by using clinical teaching models such as the Five Microskills model of clinical teaching [48,62,78]. The model is associated with immediate feedback, remediation as required and reflection, all being important in the development of clinical reasoning, better mental organization, deeper learning, and prevention and remediation of clinical biases, difficulties and errors [4,62,63]. The use of the clinical teaching models is usually associated with direct and immediate observation/supervision of the learner and is essential for the early detection of biases, difficulties and errors in clinical reasoning [30,63,79]. Indirect supervision can allow only for ad hoc and late remediation [47].

Not every bias, difficulty, and error would result in a major clinical problem. Unfortunately, prediction of the effect of the bias, difficulty, and error on the outcome of the clinical encounter is difficult. Until further developments in the literature are available, we would like to be cautious and recommend that every detected bias, difficulty, and error be remediated using effective feedback, coupled with other strategies listed in Tables 3 and S1 to S8, as applicable. A properly planned and executed remediation strategy should ensure that learners are exposed to further encounters where they practice the prevention of bias, difficulty, or error [10,19]. Remediation should be learner-centered, tailored to address the specific difficulties in the learner [30]. Most of the remediation strategies address the mental organization of medical cognition in learners (Table 3).

Some of the proposed strategies for prevention and remediation of clinical difficulties or errors can be used during the encounter (e.g., Models of clinical teaching, ‘Think aloud’), whilst others can be used after the encounter has finished (e.g., many of the cognitive forcing strategies). Indeed, for hospitalized patients or non-urgent client enquiries, a short delay may be acceptable, and strategies that require learners to undertake research may be completely appropriate. The most important aspect of remediation of clinical difficulties or errors is that there is a need for continuous support for learners with difficulties, and a ‘one-off’ approach is not sufficient [47,63].

Many strategies for the detection and remediation of clinical difficulties or errors rely on established norms. However, with the change in the learners’ generation, it is more likely that case/problem discussions and standardized clients ± patients will need some more modern approaches. Therefore, despite the variety of approaches to teaching, other modalities should be explored and become available, particularly those using information technology approaches (e.g., high-fidelity simulations) [19,99,100,101]. It should be noted that even the best technology-based systems often provide lists with many extraneous diagnoses/management approaches and that the final decision still lies with the learner [19].

4. Bias in Clinical Reasoning in Veterinary Clinical Encounters and Their Remediation

Over 100 biases are described in the psychology literature, although many are rare in medical clinical practice, at least 38 have been discussed [29]. The common biases in the clinical reasoning of medical learners, including veterinary medical learners, and proposed strategies to remediate them are presented in Table 4. Summarized, biases in clinical reasoning may occur due to deficient medical cognition, inadequate collection of data, inappropriate data analysis or processing, faulty metacognition, and/or high influence of context [9,14,18,30,51,57,65,102,103].

5. Stage-by-Stage Difficulties And Errors in Veterinary Medical Clinical Reasoning

The field of detection, prevention, and remediation of biases/deficiencies/errors in clinical reasoning is relatively immature, particularly in veterinary medical education, and often is speculative. Unfortunately, there is a complete lack of framework for the detection, prevention, and remediation of clinical reasoning difficulties and errors in veterinary medical education, but there is some framework available in human medical education [9,10,47,49,52]. Currently, identification, prevention, and remediation of difficulties and errors in clinical reasoning of veterinary medical learners is highly dependent on the capacity and willingness of clinical instructors to assist the learner in a non-structured manner. Therefore, the lack of a specific framework results in many clinical instructors being reluctant or having reservations about being involved in the remediation strategies [55,98]. We propose a framework that will provide a standardized approach to the detection, prevention, and remediation of difficulties and errors in clinical reasoning for veterinary medical learners (Tables S1 to S8). In the development of our framework, we have drawn on the frameworks presented by Audétat and others (2013 and 2017) [9,10,52], Carr and others (2022 and 2023)[66,74], and Weinstein and others (2017) [49]. They assisted us in defining the biases, deficiencies, and errors in clinical reasoning, and the proposing of effective prevention/remediation strategies. Whenever possible, we added examples applicable to veterinary medical education using the case of the cow with a prolapsed uterus, complicated by hypocalcemia and hypomagnesemia (Tables S1 to S8). In our opinion, the proposed framework is easily adjustable to any type of veterinary clinical encounter. The framework is described for each stage of the veterinary medical clinical reasoning circle [31] separately. This is for didactic reasons. In practice, veterinary medical learners may be working on a few stages of the clinical reasoning circle concurrently. Therefore, at any single point, difficulties and errors in veterinary medical clinical reasoning may be spread across various stages of the veterinary medical clinical reasoning circle (Figure 5 [9,10,14,15,18,19,31,41,42,43,44,45,46,47,48,49]).

Awareness of common biases, deficiencies, and errors, in addition to their prevention and remediation strategies, is required by both learners and clinical instructors [10,11,14,15,19,30,39,40,48,49,52,58,66,78,104]. There is no guarantee that awareness will decrease the proportion of clinical errors but should, at least, result in improved attention to detail [19,30]. The occurrence of biases, difficulties, and errors in clinical reasoning may be related to the level of development of the veterinary learner. In this paper, we differentiate learners' development using the (O)RIME model [54].

One difficulty in clinical reasoning that is not even mentioned in Tables S1 to S8, but has shown relative efficacy in all prevention and remediation approaches, is the recognition of self-limitation/s, self-reflection, and seeking assistance (e.g., clinical instructor, decision-making support systems, second opinion, and teamwork) [19]. Indeed, this has to be considered with a concurrent cost-benefit analysis and the likelihood of the increase in false-positive outcomes [19]. Facilitation of self-reflection is stimulated with effective feedback [30,74,105], regularly mentioned in Tables S1 to S8.

One deficiency/error in clinical reasoning is included in Tables S1 to S8, namely ‘Deficient medical cognition’. This may be a real cognitive deficiency, yet metacognitive deficits cannot be ruled out. In this type of deficiency/error in clinical reasoning, the learner approaches the encounter stereotypically, resulting in a very long process leading to client dissatisfaction. Additionally, data are typically presented non-organized, and not interpreted. Finally, this deficiency/error may occur due to over-reliance on artificial intelligence [100,101]. This deficiency/error, in a safe environment, should be a ‘normal’ occurrence for an Observer level of learner development. It may also occur at a Reporter level in clinical settings. The effect of medical cognitive deficiency can be significantly reduced using a flip classroom approach [44,94,106] and building upon prior knowledge, both being referred to as experiential learning [107,108,109,110].

The deficiency/error of stereotyping is also included in Tables S1 to S8. In this type of deficiency/error in clinical reasoning, the learner approaches the encounter in a rigid, stereotypical way (so-called ‘cookbook recipe approach’), without being tailored to the client, context, particular encounter, or patient. Early levels of learners (Observer, Reporter), inexperienced practitioners, and occasionally more advanced learner levels (≥ Interpreter) with a deficient clinical medical cognition may lack tailoring capacity. Typically, learners mechanically follow a set of rules rather than adjusting as required based on hypothesis and/or circumstances. However, the depth of medical knowledge is not dependent only on the learner's capacity but also on the available time, awareness of the clinical relevance through the process, and the learner’s motivation to acquire a specific piece of medical knowledge (reviewed by [6]). The awareness of the clinical relevance and guiding the process related to cognitive knowledge, are areas in which clinical instructors can have a significant influence on clinical reasoning in learners.

‘Repeated practice with a variety of simulations, followed by a variety of encounters’ are also included in Tables S1 to S8. Repeated effective practice is essential for proper development and maturation of clinical reasoning skills [46] with effective practice meaning one that stimulated deep learning and metacognition. Purposefully prepared, a variety of case discussions/presented clinical encounters, provides multiple opportunities for learners to develop and master their essential affective, cognitive, and psychomotor competencies and skills [46]. These discussions/encounters must have time blocked for debriefing, allowing for reflection, as essential parts of deep learning and metacognition [62]. Additionally, during these encounters, coaching may be provided by the clinical instructors, or learners may coach themselves doing teamwork [46].

5.1. Stage 1 – Consider Client ± Patient Situation

The most common problem at this stage is the inadequate use of veterinary medical communication with the client and the inability to detect the client’s primary complaint (Table S1; [9,10,46,52,67]). Veterinary medical communication related to veterinary clinical encounters has been discussed elsewhere [66,111].

5.2. Stage 2 – Collect Data

The most common problem at this stage is the inadequate early generation of hypotheses preventing a hypothesis-driven approach to the collection of data (Table S2; [9,10,18,43,46,48,52]). The inadequate early generation of the hypothesis may result from deficient medical cognition (e.g., early level in learner development). Yet, it may also occur due to inadequate integration and synthesis of knowledge (e.g., early level of learner development or learners of higher levels capable of knowledge recall during exams but lacking appropriate mental organization of knowledge in clinical circumstances).

5.3. Stage 3 – Analyze the Data

The most common problems at this stage are an inadequate list of hypotheses or inadequate refinement of tested hypotheses, including prioritizing the list of hypotheses (Table S3; [9,10,18,30,43,46,48,52]). Both major problems at this stage may happen due to deficient medical cognition, including misinterpretation (e.g., early learner level or advanced learner level with non-organized mental representation), poor use of metacognition (e.g., unable to integrate and synthesize information), over-reliance on artificial intelligence [100], and various biases (e.g., anchoring). Additionally, the recognition failure of key features results in an inadequate list of hypotheses. The same may occur with an inability to properly refine the tested hypotheses. The recognition failure of key features is typically more common in early learner development levels (Observer to Interpreter) but may occur in Managers, even Educators, when faced with uncommon or complicated cases.

5.4. Stage 4 – Identify Problem/s ± Issue/s

The most common problem at this stage is the inadequately summarized problem representation (Table S4; [9,10,18,41,43,48,52]). This may be related to the context (e.g., client unable to communicate effectively), the encounter/patient itself (e.g., signs and syndromes not clear), or inadequate mental representation (e.g., lack of available mental representation) and over-reliance on artificial intelligence [100]. Indeed, some difficulties/errors at this stage, and particularly inadequate problem representation, maybe a function of the learner’s development (both experience and knowledge). It should be expected for learners at Interpreter and above levels to provide an adequate problem representation. Due to a lack of semantic qualifiers or deficient/rudimentary medical cognition and insufficient practice, learners at the Observer and Reporter level are often unable to integrate the collected data into a simple summary, or even less to look at the problem globally. Similarly, learners at the early levels of Observer and Reporter, and occasionally higher levels, often approach each encounter using a ‘cookbook recipe’ (stereotyping). Undeniably, inadequate problem representation may occur in learners of higher levels (e.g., Interpreter or higher) capable of knowledge recall during exams (i.e., rote learning) but the mental organization of knowledge is not suitable for clinically relevant recall (e.g., during case-solving discussion or clinical encounter). These learners apparently have a suitable level of medical cognition/knowledge, but the clinical application is deficient. Finally, inadequate problem representation may occur at any level of learner due to biases (e.g., premature closure) and context (e.g., a high-stake encounter).

5.5. Stage 5 – Establish Mutually Agreed Goals

Mutually agreed goals for the encounter may need a proposal for further investigation (data collection) or a management plan. The most common problems at this stage are inadequate communication and inappropriate goals for the encounter/management plan (Table S5; [9,10,18,30,42,52,67]). Theoretically, inadequate communication should be a problem seen in early learner development levels (Observer and Reporter) but in practice, the problem may be seen in Reporters, even Managers, rarely Educators. This slippage of inadequate communication in learners into advanced levels of development may occur with insufficient direct supervision. Learners may be capable of communicating using medical jargon but unable to translate the conversation into lay language. Additionally, indirect supervision makes the instructor completely oblivious to the body language and attitude of the learner whilst communicating with the client. Furthermore, inadequate communication, particularly during the data collection stage, may fail to consider the client’s perspective during the discussion of the goals for the encounter.

Similarly, to connect a diagnosis with the best further investigations and/or management approach/es, at early learner development levels (Observer and Reporter) there is a lack of sufficient clinical mental organization. The problem can be detected also in learners of higher levels (e.g., Interpreter or higher) when their mental organization of medical knowledge is not suitable for clinically relevant recall.

Mutually agreed goals should be tailored to the client’s needs. This is an area with a complete dearth of literature relating to clinical reasoning in veterinary medical education. Setting goals for the companion animal client is very similar to other medical fields and medical educational literature is closely related. Yet, performance and production animal veterinary medical education have additional complexities, namely product quality, production performance, and the risk to trade. The inappropriate goals for the encounter may result from deficient knowledge of the context. One common problem the authors have seen is a lack of knowledge of industry recommendations and standards (e.g., lack of awareness of milk quality requirements when dealing with a dairy cow). If omni-competence is the aim for graduates, as the gap in industry knowledge has increased with the increase in metropolitan enrolments, this gap must be addressed in the veterinary medical curricula.

5.6. Stage 6 – Take Action

The most common problems at this stage include inadequate elaboration of the management approach and stereotyping (Table S6; [9,10,48,52]). Inadequate elaboration of the management approach may occur due to deficient medical knowledge, insufficient knowledge of the decision-making process or insufficient clinical mental organization, including a management approach that is not based on SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) principles and, finally, a lack of self-confidence. These factors may result in delaying the decision for a management approach to be instituted that is common in earlier levels of learner development (Observer, Reporter, ± Interpreter) but, particularly when there is a lack of self-confidence, may occur even in later stages of development of the learner. The lack of a SMART approach to taking action may result in a lack of success of the intervention. This is often a problem related to stereotyping. Specificity, measurability and relevance of the management approach are particularly important for the success of the intervention. Without tailoring to the encounter, the outcome is unlikely to be successful. It is expected that learners at the Manager and Educator levels should always tailor their approach in their response to the encounter.

5.7. Stage 7 – Evaluate the Outcome/s

The most common problems at this stage include inadequate follow-up of the encounter and inappropriate or poor evaluation of the outcome (Table S7; [9,10,52]). Inadequate follow-up is usually due to underdeveloped workplace organization skills that may be common in the early stages of learners’ development (Observer, Reporter, ± Interpreter). Learners at this stage may lack awareness that a follow-up is essential for every veterinary clinical encounter. Poor evaluation of the outcome of the encounter may occur in the early stages of learners’ development (Observer, Reporter, Interpreter) as they may lack a holistic and longitudinal perspective of the encounter. At these stages of development, learners may also look for binomial outcomes only, not accepting a level of uncertainty. Finally, learners at the early development levels may also not be able to select the best outcome that has to be evaluated. However, except for complicated and infrequent encounters, it is expected that learners at the Manager and Educator levels should be able to evaluate the outcome/s appropriately.

5.8. Stage 8 – Reflect on Process and New Learning

The reflection associated with every encounter is an essential step in developing deep learning/metacognition in veterinary medical learners. The development and maturation of clinical reasoning competence are only possible when learners engage in effective reflective clinical practice [46,112]. The most common problems at this stage include inadequate self-awareness and self-efficacy by the learner (Table S8; [1,19,46,47,48,64]).

As reflection is a metacognitive skill in clinical encounters, it is affected by similar factors as in clinical reasoning, teaching, and learning effective reflective practice should consider the teaching environment. For effective reflective practice, early learners (Observers, Reporters, ± Interpreters) should be in traditional academic settings, whilst more advanced learner levels (Manager and Educator ± Interpreter) can be in clinical settings.

6. Conclusions

Veterinary medical clinical biases, difficulties or errors in clinical reasoning occur more commonly than believed. Veterinary medical learners should receive specific training in clinical reasoning. An important part of the training should be raising awareness of the common veterinary medical clinical biases, difficulties or errors. In this paper, we propose a framework for the detection and remediation of the common difficulties and errors in clinical reasoning, using a case example of a cow with a prolapsed uterus, complicated by hypocalcemia and hypomagnesemia. We hope the proposed framework can be easily adjusted to any other veterinary clinical encounter and included in the clinical teaching of veterinary medical learners as it is.

7. Glossary

Term	Meaning
Analytical type of clinical reasoning	Based on more deliberate, explicit, purposeful, rational and slow, and focuses on hypotheses generation and deductive reasoning that is closer to the cognitive processes associated with problem-solving. Common synonyms Deductive, Deliberate, Rational, Rule-governed or System / Type 2 clinical reasoning.
Bias (in clinical reasoning)	The preconceived notions and subconscious prejudices that veterinary medical professionals may hold towards clients or patients based on various attributes (e.g., client: age, disability, ethnicity, gender, gender orientation, race, or socioeconomic status; patient: age, breed, production type, reproductive status, sex, and species) and context (e.g., hygiene, production system, and season).
Case-based discussion	A clinical teaching tool that consists of a structured approach to learners’ clinical reasoning around written case records and/or structured interviews with a simulated client and patient.
Checklists (medical)	An algorithmic listing of actions to assist the learner in consistently carrying out each action, recording the completion, and minimizing errors.
Clinical competency	The ability to select and carry out relevant clinical tasks pertaining to the clinical encounter. These aim at resolving the health or productivity problem/s for the client, industry and/or patient, in an economical, effective, efficient and humane manner, followed by self-reflection on the performance indicating the occurrence of deep learning.
Clinical encounter	Any physical or virtual contact with a veterinary patient and client (e.g., owner, employee) with the primary responsibility to carry out clinical assessment or activity.
Clinical instructor	In addition to the regular veterinary practitioner’s duties, should also fulfil the roles of assessor, facilitator, mentor, preceptor, role model, supervisor, and teacher of veterinary learners in a clinical teaching environment. It may include any of the following: Apprentice/intern in the upper years, Resident, Veterinary educator/teacher, or Veterinary practitioner.
Clinical reasoning	The cognitive process interjected with unconscious operations during which a learner or practitioner collects information (clinical and context), process it, comes to an understanding of the problem presented during a clinical encounter, and prepares a management plan, followed by evaluation of the outcome and self-reflection. Common synonyms: Clinical / Diagnostic / Medical: Acumen / Cognition / Critical thinking / Decision-making / Information processing / Judgment / Problem solving / Rationale / Reasoning.
Clinical teaching	A form of interpersonal communication between a clinical instructor and a learner that involves a physical or virtual clinical encounter.
Cognition	A mental activity or a process for acquiring knowledge and understanding.
Cognitive forcing strategy	A group of interventions that use mechanisms to disrupt the heuristic processing of information. It is part of the metacognitive approach.
Context	A complex interaction of factors (including, but not limited to, affective/physical state, client, encounter, environment, finances, patient, and social environment) having an effect on the clinical reasoning competence of the learner.
Critical thinking	A self-directed, self-disciplined, self-monitored, and self-corrective objective, unbiased analysis and evaluation of information from a variety of sources to form a judgement.
Debrief	A formal and structured analysis of the action carried out to obtain useful intelligence or information that could be applied in future.
Decision-making	The process of making choices by identifying a decision, gathering information, and assessing alternative hypotheses.
Decision-tree	A non-parametric supervised learning algorithm, a hierarchical model that uses a tree-like model of solutions and their possible consequences, including chance event outcomes, resource costs, and utility.
Deep learning	Learner aims to master essential academic content; think critically and solve complex problems; work collaboratively and communicate effectively; have an academic mindset; and be empowered through self-directed learning.
Deliberate reflection	A systematic review of the grounds of the initial hypothesis and considering alternatives.
Dual type of clinical reasoning	Clinical reasoning that utilizes concurrently the analytical and intuitive types. Common synonyms: Dual- / Mixed– process clinical reasoning / theory.
Educator in (O)RIME	A learner representative of the advanced part of the clinical curriculum, should be capable of doing all competencies prescribed for the other levels coupled with a critique of the encounter, including important omissions and further research questions, and present the case in a way that can educate others. Learners at this level are truly self-directed. It is a reality that some learners do not reach the level of educator by the time they graduate from veterinary school and may need 2 – 3 years post-graduation or residency to reach this level.
Effective feedback	A purposeful conversation between the clinical instructor and the veterinary medical learner with the aim to stimulate further development of clinical competencies and deep earning.
Error (medical)	An act of omission or commission in the planning or execution of clinical reasoning or a deviation from the standard with the potential to contribute to an unintended outcome.
Five Microskills model	An instructor-centered model of clinical teaching: 1) Get a commitment; 2) Probe for supporting evidence; 3) Teach general rules; 4) Reinforce what was done well; and 5) Correct mistakes. An additional stage is the ‘Debrief’.
Flipped classroom	An instructional strategy, a type of blended learning, with the aim to increase learners’ engagement and learning by having them learn at home basic concepts normally covered during class activity and work on applications and building upon these concepts, usually using live problem-solving, during class time. Common synonyms: Backwards/Inverse/Reverse classroom.
Guided reflection	A framework to facilitate and assess reflective veterinary medical practice that is usually assisted by the clinical instructor or mentor.
Heuristic	The general methods used in problem-solving not following a prescribed methodology, involving discovery, learning or problem-solving, mainly using experiential and trial-and-error bases.
Hypothesis-driven data collection	A combination of data collection and clinical reasoning resulting in the early generation of hypotheses and resultant data collection, used to rank competing differentials/management approaches, resulting in limited but focused data collection. Common synonym: Serial-cue approach.
Illness script	An organized mental summary of the knowledge of a disorder. Common synonyms: Medical scripts, Schema.
Interpreter in (O)RIME	A learner capable of organizing gathered information logically, preparing a prioritized list of differential diagnoses without prodding, and able to support their arguments for inclusion/exclusion of particular diagnoses/tests. The interpreter may or may not be able to propose a management plan for the clinical encounter.
Intuitive type of clinical reasoning	Based more on cognitive short-cuts (e.g., heuristics) than real intuitive (gestalt effect) processes. Therefore, even the intuitive type of clinical reasoning is not equal to the real meaning of intuitive (‘judgment made quickly and without apparent effort’). Common synonyms: Experiential, ‘Gut feeling’, Inductive, Non-analytical, Tacit, or System / Type 1 clinical reasoning.
Manager in (O)RIME	A learner representative of the mid- to late-part of the clinical curriculum should be capable of summarizing the gathered information in a logical way using veterinary medical language, preparing a prioritized list of differential diagnoses, supporting their arguments and proposing an appropriate management plan. At the manager level, the learner should consider the client’s circumstances, needs and preferences.
Mental organization (of knowledge)	All types of concepts and schemes for organizing medical information that promotes retrieval in a clinically relevant manner.
Mental representation	A cognitive or metacognitive processing of medical information processing in which medical information is received, recorded, but also modified by a complex process of associating new and previously known elements.
Metacognition	Critical awareness of one’s thought processes and learning, and an understanding of the patterns of thinking and learning (‘thinking about thinking’).
Mind mapping	A diagram used to visually put medical information into a hierarchy linked to and arranged around a central concept/hypothesis.
Observer in (ORIME)	A learner representative of the very early part of the curriculum, lacks skills to conduct a comprehensive health interview and/or present the clinical encounter at rounds or to peers or instructors. Learners at the observer level lack competencies that would contribute to the management of the case and patient care.
(O)RIME	Programmatic framework of assessment of competency of veterinary medical learners: (Observer) - Reporter – Interpreter – Manager – Educator.
Problem-solving	A complex set of attitudinal, behavioral and cognitive components, often used in a multiple-step process to arrive at the solution (i.e., collection, interpretation and integration of information).
Reflection	The metacognitive process that may occur before, during or after an encounter that aims to develop a deeper understanding of the encounter and self ± the team to inform the ongoing and/or future actions, behaviors, and encounters.
Reflection-for-action	A process of self-evaluation of the action to happen, including planning for action and doing the action, anticipating the unexpected, and planning and executing adjustments from before, during and after the encounter.
Reflection-in-action	A process of self-evaluation of the action as it happens resulting in ongoing adjustments during the encounter.
Reflection-on-action	A process of self-evaluation of the action after it has been completed, planning for adjustment in future encounters.
Reflective practice	A metacognitive, learner-centered strategy that assists learners in making sense of the learned material and engaging in deep learning.
Reporter in (O)RIME	A learner representative of the late part of the pre-clinical and early part of the clinical curriculum, should be capable of gathering reliable clinical information, preparing basic clinical notes, differentiating normal from abnormal, and presenting their findings to peers and/or instructors.
Role model	A person who learners look to as a good example and whose behavior they try to copy.
Safe (learning) environment	An environment in which a learner feels safe, relaxed, and willing to take risks in pursuing a goal; enhances self-esteem and encourages exploration.
Scaffolding	A teaching strategy in which the process is broken into manageable units and learners grasp the concepts and master new skills with a decreased input by the instructor.
Self-analysis	Part of the reflective practice characterized by reflective self-assessment of the performance versus goals for the encounter.
Self-awareness	Part of the reflective practice characterized by acceptance of constructive criticism and/or recognition of self-limitations.
Self-confidence	Part of the reflective practice characterized by the ability to speak in an awkward situation.
Self-directed learning	A method in which learners take charge of their own learning process by identifying learning needs, goals, and strategies and evaluating learning performances and outcomes. Learner-centered approach to learning.
Self-efficacy	Part of the reflective practice characterized by spending time to self-reflect and avoid/change/enhance actions in the on-going and/or future encounters.
Self-esteem	Part of the reflective practice characterized by believing in the self.
Self-evaluation / monitoring	Part of the reflective practice characterized by rechecking every decision to be or already made with the aim to adjust it.
Self-regulation	Part of the reflective practice characterized by controlling the behavior and expressions of the affective state.
Semantic qualifiers	Abstractions expressed using medical rather than lay terminology. Generally, they exist as divergent pairs that aid in comparing or contrasting the hypotheses. Examples of semantic qualifiers include acute or chronic, being affected by XX or previously healthy, bilateral or unilateral, constant or exacerbated by XX, continuous or intermittent, copious or scant, dull or sharp, frequent or rare, generalized or localized, left or right, mild or severe, etc.
Simulation	A model of a set of problems or clinical encounters that can be used to teach learners how to do something or deal with an encounter.
SNAPPS	A learner-centered model of clinical teaching: 1. Summarize briefly the history and findings; 2. Narrow the differential to two or three relevant possibilities; 3. Analyze the differential by comparing and contrasting the possibilities; 4. Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches; 5. Plan management for the patient's medical issues; and 6. Select a case-related issue for self-directed learning.
Stimulated recall	A cognitive-forcing strategy used to prompt learners' retrospection by employing diverse stimuli and interview strategies.
Team-based learning	A method in which solving of an authentic clinical case using clinical reasoning skills. Particularly useful in developing basic science concepts through a peer-learning approach (learning occurs within a team but also between teams when activity is carried out concurrently with more than one team) and activation of prior knowledge. Learner-centered approach to learning.
Work-based learning	An educational method that immerses the learners in the workplace. Common synonyms: Experiential learning; Exposure to practice.
Working memory	One of the executive functions of the brain associated with the retention of a small amount of information in a readily accessible form necessary for comprehension, learning, and reasoning