Author s response to reviews

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1 Author s response to reviews Title: Describing complex clinical scenarios at the bed-side: Is a systems science approach useful? Exploring a novel diagrammatic approach to facilitate clinical reasoning Authors: Saroj Jayasinghe (sarojoffice@yahoo.com) Version: 1 Date: 24 Jul 2016 Author s response to reviews: Editor BMC Medical Education Dear Madam / Sir Title: Describing complex clinical scenarios at the bed-side: Is a systems science approach useful? I wish to extend my sincere thanks to the reviewers for their excellent comments which enabled me to improve the paper. I have incorporated almost all their comments. The key element was to add a paragraph on the applicability of learning theories to support the utility of the tool used for a system science approach, namely the Clinical Reasoning Map. Detailed responses are given below, and include the paper on track changes to enable the editors and reviewers to see if I have addressed the issues that were raised. Detailed responses to reviewers comments REPORT BY(REVIEWER #1: KATRI MANNINEN

2 Comment 1: P. 9, line 35: the abbreviation MRCP is used but not explained in the list of abbreviations. Response 1: I have added the following paragraph to enable readers to appreciate the educational status of our group of postgraduates: "An evaluation of effectiveness of CRM as a tool in clinical reasoning was done on 11 postgraduate students, who had completed their internship, worked for more than one year as a medical officer, and passed an entry examination to the postgraduate training programme in medicine (i.e. MD). The entry examination consists of multiple choice questions, single best response, and objective structured clinical examination of clinical skills and could be considered as equivalent to the Membership of the Royal College of Physicians (UK) which now designed to assess clinical knowledge and skills of trainees wishing to enter higher specialist training." Comment 2: I think that it would benefit the article if proposal of using CRM is related to some theoretical concepts of learning. Relating theoretical concepts strengthens the arguments and enhances the understanding of them. Furthermore it can facilitate other health-care professions to use CRM. Concepts that I would suggest are meaningful learning and knowledge construction; how can CRM and the evaluation of users be liked to meaningful learning and what does knowledge construction mean when using CRM. Mayer (2002), Knowles et al. (2012) and Mann et al. (2011) are authors who have written about these concepts, to name some. Response 2: This was a most useful comment and I have added a new paragraph outlining the relationship of CRM to learning theories which includes an additional four references: CRM in relation to learning theories The theoretical basis of CRM broadly fit constructivism, which views human knowledge as been constructed by individuals (or social communities) rather than discovered or is passively absorbed. [14] The interpretation of CCCs using a systems science approach by the clinician is an example of this process where diverse entities are linked to synthesize or construct a holistic picture. The utility of CRM in understanding is explained through meaningful learning and cognitive theory of multimedia learning. [18, 19]. The ability of CRM to link a collection of

3 clinical events adds meaning by relating new information to those already known to the learner (i.e. meaningful learning) and explains why the majority of undergraduates and postgraduates found it to help understand CCCs. Further studies are required to explore the utility of CRM in retaining such meaningful information in the long-term memory. CRM uses a diagrammatic method where words are linked by a set of conventions that add dynamism. This complement lists of differential diagnoses and reflects the principles of multimedia learning, i.e. words and pictures together which helps to produce logical mental constructs, promoting deeper learning than from words alone. [19] CRM is a tool that enables reflection and abstract conceptualization of CCCs. These are components of the experiential learning cycle described Kolb where experience are recognized and transformed through the cycle of concrete experience, reflective observation, abstract conceptualization and active experimentation. [20] Comment 3: About the figure, I suggest to explain the arrows and lines in the figure legend in order to enhance for the reader. The explanation in the article on p 8 is very good, however, it may be difficult to remember the text when reading the figure. Response 3: The legend was improved and now states the following FIGURE LEGEND Figure 1: Clinical Reasoning Map of patient developing CKD. Possible associations ( - ); probable cause ( --> ); more definite causal pathway (-> ); bidirectional arrows to show disorders influencing each other ( <->); uncertain links flagged by a question mark (see text for details). REVIEWER #2 s REPORT Comment 1: On the whole I think the author manages to argue for the need of the new tool but there are things to take in consideration before acceptance for publication. The new tool is already described in an article (Jayasinghe 2011) - is this description exactly the same - if not - are there any improvements or changes made - what is new in this article? - this should be clarified.

4 Response 2: The relationship of CRM to the above reference (i.e. reference 13 in the paper) is made more explicit by the following sentences. The tool was initially proposed in 2009 to promote learning in medical students. [16] Subsequently the term CRM was used to indicate its utility during the process of clinical reasoning and to reflect the web of causation of disease states [13]. The description below is an elaboration of this method. Comment 3: The author concludes by stating three reasons to why the CRM is a useful tool to learn to understand and manage CCSs: The arguments for a systematic science approach (interaction and connectedness) are well underpinned and so are the comparisons with other tools/approaches. The use of the tool in learning and teaching both for undergraduates and postgraduates is the weakest part of the arguments. Underpinning assumptions and theories about learning to understand complex clinical reasoning need to be spelled out and connected to the why the tool might be useful in education. The description of how the CRM was introduced and worked with among postgraduates was very interesting - what theoretical ideas about learning was that learning activity built on? Barrows (1980) and Kahneman (2011) are referred to but that is not enough to reason about learning. The reference to Barrows is very broad and difficult to understand in this context - PBL is an approach supporting the complex nature of learning and here it is mentioned as the utility of CRM has been previously investigated - I can understand the link to basic ideas about learning but it needs to be explained. Response 3: The references to Barrows (1980) and Kahneman (2011) are given in the context of describing clinical reasoning. The comment by the reviewer is further addressed in the new paragraph below, as mentioned in my Comment 2 to Reviewer 1: CRM in relation to learning theories The theoretical basis of CRM broadly fit constructivism, which views human knowledge as been constructed by individuals (or social communities) rather than discovered or is passively absorbed. [14] The interpretation of CCCs using a systems science approach by the clinician is an example of this process where diverse entities are linked to synthesize or construct a holistic picture. The utility of CRM in understanding is explained through meaningful learning and

5 cognitive theory of multimedia learning. [18, 19]. The ability of CRM to link a collection of clinical events adds meaning by relating new information to those already known to the learner (i.e. meaningful learning) and explains why the majority of undergraduates and postgraduates found it to help understand CCCs. Further studies are required to explore the utility of CRM in retaining such meaningful information in the long-term memory. CRM uses a diagrammatic method where words are linked by a set of conventions that add dynamism. This complement lists of differential diagnoses and reflects the principles of multimedia learning, i.e. words and pictures together which helps to produce logical mental constructs, promoting deeper learning than from words alone. [19] CRM is a tool that enables reflection and abstract conceptualization of CCCs. These are components of the experiential learning cycle described Kolb where experience are recognized and transformed through the cycle of concrete experience, reflective observation, abstract conceptualization and active experimentation. [20] Thank you Yours sincerely Saroj Jayasinghe