Exploring Clinical Reasoning Strategies and Test-Taking Behaviors During Clinical Vignette Style Multiple-Choice Examinations: A Mixed Methods Study

BACKGROUND: Clinical vignette multiple-choice questions (MCQs) are widely used in medical education, but clinical reasoning (CR) strategies employed when approaching these questions have not been well described. OBJECTIVES: The aims of the study were (1) to identify CR strategies and test-taking (TT) behaviors of physician trainees while solving clinical vignette MCQs; and (2) to examine the relationships between CR strategies and behaviors, and performance on a high-stakes clinical vignette MCQ examination. METHODS: Thirteen postgraduate year-1 level trainees completed 6 clinical vignette MCQs using a think-aloud protocol. Thematic analysis employing elements of grounded theory was performed on data transcriptions to identify CR strategies and TT behaviors. Participants' CR strategies and TT behaviors were then compared with their US Medical Licensing Examination Step 2 Clinical Knowledge scores. RESULTS: Twelve CR strategies and TT behaviors were identified. Individuals with low performance on Step 2 Clinical Knowledge demonstrated increased premature closure and increased faulty knowledge, and showed comparatively less ruling out of alternatives or admission of knowledge deficits. High performers on Step 2 Clinical Knowledge demonstrated increased ruling out of alternatives and admission of knowledge deficits, and less premature closure, faulty knowledge, or closure prior to reading the alternatives. CONCLUSIONS: Different patterns of CR strategies and TT behaviors may be used by high and low performers during high-stakes clinical vignette MCQ examinations.