The Principles of Medical Education: How to Teach Clinical Reasoning

Dr Neeraj Manikath , claude.ai

Abstract

Clinical reasoning represents the cognitive bridge between theoretical knowledge and patient care excellence. For critical care educators, teaching this complex skill requires structured, evidence-based approaches that accommodate the time-pressured realities of modern medical practice. This review synthesizes contemporary educational frameworks including the One-Minute Preceptor model, SNAPPS methodology, and evidence-based feedback strategies to equip postgraduate educators with practical tools for cultivating clinical reasoning expertise. We explore setting-specific teaching considerations, psychological principles underpinning learner development, and provide actionable "pearls and oysters" gleaned from educational research and clinical teaching experience.

Keywords: Clinical reasoning, medical education, bedside teaching, feedback, clinical preceptorship, cognitive apprenticeship

Introduction

Clinical reasoning—the cognitive process by which clinicians gather data, generate diagnostic hypotheses, and formulate management plans—sits at the heart of medical expertise.¹ In critical care, where patients present with undifferentiated shock, multi-organ dysfunction, and time-sensitive emergencies, the ability to reason rapidly yet accurately becomes literally life-saving. Yet teaching this skill remains one of the most challenging aspects of medical education.²

Traditional models of clinical teaching, characterized by the "see one, do one, teach one" paradigm, have given way to structured, learner-centered approaches grounded in educational theory.³ The cognitive apprenticeship model, which makes expert thinking visible through modeling, coaching, and scaffolding, provides the theoretical foundation for modern bedside teaching.⁴

This review addresses five critical domains of clinical reasoning education, offering intensive care unit (ICU) educators practical frameworks to enhance teaching effectiveness despite the notorious time constraints of clinical practice.

The "One-Minute Preceptor" Model for Efficient Bedside Teaching

Background and Theoretical Framework

The One-Minute Preceptor (OMP) model, developed by Neher et al. in 1992, revolutionized clinical teaching by providing a structured yet time-efficient approach to bedside education.⁵ This microskills model addresses the primary barrier cited by clinical teachers: insufficient time.⁶ The framework comprises five sequential steps, each designed to probe learner thinking, diagnose educational needs, and deliver targeted teaching—all within 5-10 minutes.

The Five Microskills

1. Get a Commitment Rather than immediately providing answers, ask learners to commit to a diagnosis, management plan, or next investigation. Questions include:

"What do you think is going on with this patient?"
"What would you do next?"
"What's at the top of your differential diagnosis?"

This step forces hypothesis generation and reveals the learner's reasoning framework.⁷

2. Probe for Supporting Evidence Ask: "What specific findings led you to that conclusion?" This microskill illuminates whether the learner's reasoning is data-driven or represents pattern recognition without analytical support. In the ICU, this distinguishes between memorized algorithms and genuine understanding of pathophysiology.

3. Teach General Rules Deliver 1-2 concise teaching points applicable beyond the immediate case:

"In undifferentiated shock with normal lactate but elevated ScvO₂, think distributive causes like anaphylaxis or neurogenic shock."
"When vasopressors aren't working, always check your calcium and cortisol."

These generalizable principles build schemas that transfer to future clinical encounters.⁸

4. Reinforce What Was Done Right Provide specific, positive feedback:

"Your systematic approach to the chest X-ray prevented you from missing that small pneumothorax."
"Excellent recognition that the fever pattern suggested drug-induced rather than infectious etiology."

This reinforcement shapes desired behaviors through operant conditioning principles.⁹

5. Correct Mistakes Address errors directly but constructively:

"I noticed you ordered a CT scan before stabilizing the blood pressure. Let's discuss the timing of diagnostics in unstable patients."

Immediate error correction prevents consolidation of incorrect reasoning patterns.¹⁰

Implementation in Critical Care

Pearl #1: The OMP works best for intermediate learners (junior residents) who possess foundational knowledge but lack integrated reasoning skills. For beginners, more scaffolding is needed; for senior residents, Socratic questioning may be more appropriate.

Pearl #2: In the ICU, use the OMP during multidisciplinary rounds at the bedside. The brief, focused nature allows teaching without significantly prolonging rounds that already involve multiple team members.

Oyster Alert: Avoid the "pimp" trap—aggressive questioning that humiliates rather than educates. The OMP's power lies in its supportive structure that reveals thinking without judgment.¹¹

Practical Hack: Create mental "teaching files" of common ICU scenarios (septic shock, ARDS, acute liver failure) with 2-3 generalizable teaching points for each. This preparation allows you to deliver Microskill #3 efficiently without lengthy deliberation.

Evidence Base

Studies demonstrate that faculty trained in OMP techniques spend only marginally more time teaching (mean increase: 1-2 minutes) while learners report significantly enhanced educational value.¹² A randomized trial by Furney et al. showed that preceptors using OMP achieved higher learner satisfaction scores and improved diagnostic accuracy among trainees compared to traditional teaching methods.¹³

SNAPPS: A Learner-Centered Method for Case Presentation

Origins and Educational Philosophy

SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, Select) represents a paradigm shift from passive case presentations to active learning encounters.¹⁴ Developed by Wolpaw and colleagues, SNAPPS transforms the learner from information reporter to active reasoner, making clinical thinking explicit and available for correction.¹⁵

Unlike traditional presentations where learners recite data and await attending pronouncements, SNAPPS requires learners to demonstrate reasoning at each step—mirroring the cognitive processes of expert clinicians.

The SNAPPS Framework

S - Summarize the history and findings The learner provides a focused summary, not an exhaustive recitation. In the ICU: "This is a 67-year-old with COPD, presenting day 3 of ICU admission for hypoxemic respiratory failure, now developing hypotension and altered mental status."

Teaching point: Coach learners to provide context-appropriate detail. ICU sign-out requires different granularity than outpatient presentations.

N - Narrow the differential The learner articulates 2-4 leading diagnoses with justification: "I'm considering septic shock from healthcare-associated pneumonia, cardiogenic shock from new MI, or hemorrhagic shock from a GI bleed."

Pearl #3: This step externalizes the hypothesis generation that expert clinicians perform unconsciously. Making it explicit allows educators to identify reasoning errors (premature closure, availability bias, anchoring).¹⁶

A - Analyze the differential The learner compares and contrasts diagnostic possibilities: "The fever and leukocytosis support sepsis, but the elevated troponin and new Q-waves suggest MI. The CVP is high, arguing against hemorrhage."

This analytic comparison represents sophisticated clinical reasoning—distinguishing from novice pattern recognition.¹⁷

P - Probe the preceptor about uncertainties The learner identifies knowledge gaps and asks specific questions: "I'm uncertain whether to start empiric antifungals given the persistent fevers. What's your threshold in this patient?"

Oyster Alert: Many learners struggle with this step, fearing that asking questions reveals inadequacy. Cultivate a learning culture where curiosity is rewarded. Model this by saying: "That's exactly the question I'd be asking myself."

P - Plan management The learner proposes diagnostic and therapeutic steps: "I'd like to send procalcitonin and β-D-glucan, obtain urgent echo, start norepinephrine, and consult cardiology."

S - Select case-related issues for self-study The learner commits to specific learning: "I'll review the approach to concomitant septic and cardiogenic shock, particularly regarding fluid management."

This step promotes metacognition and self-directed learning—hallmarks of expertise development.¹⁸

Implementation Strategies

For Learners: Provide a wallet card or laminated badge attachment with the SNAPPS mnemonic. Explicitly state expectations: "When presenting cases, use the SNAPPS format—it helps us understand your thinking."

For Educators: After hearing the presentation, probe deeper: "You mentioned sepsis—what specifically made you consider that?" "How did you weigh the possibility of cardiogenic shock?"

Practical Hack: For morning ICU rounds, have overnight residents present using SNAPPS. This not only educates the presenter but provides a teaching template for the entire team observing the interaction.

Pearl #4: SNAPPS excels at revealing cognitive biases. When a learner's differential is anchored on a single diagnosis, the "Narrow" and "Analyze" steps expose this thinking error, allowing targeted teaching on diagnostic reasoning.

Evidence and Outcomes

Wolpaw et al.'s original study demonstrated that learners using SNAPPS showed improved diagnostic accuracy and differential generation compared to traditional presentation formats.¹⁴ Subsequent research confirmed that SNAPPS enhances learner engagement, reduces educator dominance of conversations, and promotes deeper discussion of clinical uncertainty.¹⁹,²⁰

A key advantage in critical care: SNAPPS accommodates the complexity and diagnostic uncertainty inherent in ICU patients, where multiple pathophysiologic processes often coexist.

Teaching in the Outpatient vs. Inpatient Setting

Distinct Cognitive Demands

Clinical reasoning varies significantly between outpatient and inpatient environments, requiring educators to adapt teaching approaches accordingly.²¹

Outpatient Context:

Undifferentiated presentations: Patients present with symptoms, not diagnoses
Probabilistic reasoning predominates: Must consider prevalence and pre-test probability
Limited data: Decisions often made with incomplete information
Longitudinal relationships: Chronic disease management and preventive care
Time efficiency crucial: Typical visits 15-20 minutes

Inpatient/ICU Context:

Acute, often life-threatening conditions: Diagnostic urgency with higher stakes
Data-rich environment: Extensive laboratory, imaging, and monitoring data available
Dynamic decision-making: Conditions evolve rapidly; serial reassessment required
Team-based care: Coordination among multiple specialists
Procedural skills integration: Reasoning about invasive procedures and their timing

Tailoring Teaching Strategies

Outpatient Teaching Approaches

Focus on probabilistic reasoning: Emphasize Bayesian thinking and test characteristics.²² Teach learners to ask: "What's the pre-test probability given the patient's demographics and risk factors?"

Example: A 45-year-old with atypical chest pain:

"What's the pre-test probability of ACS in a middle-aged woman with atypical features?"
"How will a negative troponin change your probability estimate?"

Teach pattern recognition for common presentations: Ambulatory care involves frequent exposure to similar complaints. Help learners develop illness scripts for common presentations (URI, UTI, musculoskeletal pain).²³

Pearl #5: Use the "WWYD" (What Would You Do) method: After the learner sees a patient, ask what they would do if you weren't there. This simulates independent practice and identifies knowledge gaps.

Emphasize the "wait and watch" approach: Not every symptom requires immediate action. Teach "safety-netting"—providing specific return precautions and follow-up plans.²⁴

Inpatient/ICU Teaching Approaches

Emphasize systematic evaluation: Teach structured frameworks (ABCDE approach, systematic organ system review) to prevent cognitive shortcuts that miss important findings.

Focus on temporal reasoning: ICU patients evolve rapidly. Teach learners to consider: "How does today's picture differ from yesterday? What trajectory is the patient following?"

Practical Hack: During rounds, explicitly model temporal reasoning: "Yesterday we were worried about ARDS, but today the chest X-ray is improving while the creatinine is rising—this shifts our concern to kidney injury."

Integrate physiology and pathophysiology: The ICU provides unparalleled opportunities to connect pathophysiology to clinical findings.

Example: In septic shock:

"Why is the CVP high despite hypovolemia?" (venous tone changes)
"Why did the lactate rise after we gave norepinephrine?" (splanchnic vasoconstriction)

Pearl #6: Use ventilator graphics, hemodynamic waveforms, and continuous monitoring data as teaching tools. These real-time data visualizations make abstract concepts concrete.

Teach crisis resource management: ICU emergencies require both clinical reasoning and team coordination. Debriefing after codes or rapid responses provides rich teaching material.²⁵

Shared Principles Across Settings

Despite differences, core reasoning principles remain constant:

Hypothesis-driven data gathering: Teach learners to generate hypotheses early and gather data purposefully, not shotgun-fashion.²⁶
Metacognition: Encourage learners to reflect on their thinking: "What led you to consider that diagnosis?" "What might you be missing?"
Consideration of cognitive biases: Name and discuss common biases (anchoring, availability, premature closure) when they arise in real cases.²⁷

Oyster Alert: Avoid the trap of teaching only setting-specific content. The deepest learning occurs when educators help learners extract transferable reasoning principles applicable across contexts.

Giving Effective, Constructive Feedback to Learners

The Feedback Imperative

Feedback represents perhaps the most powerful educational intervention, yet it's frequently done poorly or omitted entirely.²⁸ In medical education, feedback serves multiple functions: correcting errors, reinforcing effective practices, guiding skill development, and promoting professional identity formation.²⁹

Effective feedback in critical care must balance the high-stakes nature of ICU practice with learners' developmental needs and emotional well-being.

Principles of Effective Feedback

1. Timeliness and Specificity

Feedback loses impact when delayed. Provide it immediately or shortly after the observed behavior.³⁰

Poor feedback: "Overall, you're doing well on the rotation."

Effective feedback: "During today's code, you recognized PEA quickly and immediately initiated high-quality CPR. However, you seemed hesitant to call for epinephrine. Let's discuss the timing of medications in cardiac arrest."

Pearl #7: The "Feedback on the Fly" technique: Deliver brief, specific feedback in the moment during clinical activities. Reserve longer feedback sessions for complex issues or formal evaluations.

2. Focus on Behaviors, Not Traits

Feedback should address observable actions, not personality characteristics or assumed intentions.³¹

Avoid: "You're disorganized and scattered."

Prefer: "I noticed you moved between tasks without completing them during this morning's procedures. Let's discuss strategies for prioritizing and completing tasks systematically."

3. The Feedback Sandwich: Proceed with Caution

The traditional "positive-negative-positive" sandwich has fallen out of favor because it dilutes important corrective feedback and can seem insincere.³² However, authentic recognition of strengths alongside areas for improvement remains valuable.

Better approach: Use the Pendleton model:³³

Learner identifies what went well
Teacher reinforces and adds additional strengths observed
Learner identifies areas for improvement
Teacher adds additional growth areas
Collaborative action plan

This sequence promotes self-assessment and learner engagement in the feedback process.

4. Make Feedback Dialogic, Not Monologic

Feedback should be conversational, not a one-way pronouncement. The R2C2 model (Relationship, Reaction, Content, Coaching) provides a framework:³⁴

Relationship: Establish rapport and psychological safety
Reaction: Explore learner's initial emotional response to feedback
Content: Discuss specific feedback with examples
Coaching: Collaborate on action plans

Practical Hack: Start with "I'd like to discuss..." rather than "I need to give you feedback." The latter triggers defensiveness; the former invites dialogue.

5. Address Cognitive and Affective Dimensions

In critical care, feedback often addresses both knowledge/skill deficits (cognitive) and emotional responses to high-stakes situations (affective).

Example: A resident who hesitated during an airway emergency: "You correctly identified that the patient needed intubation, which shows good clinical judgment. However, I noticed you seemed uncertain about proceeding. Can you tell me what was going through your mind? Were you worried about something specific?"

This approach addresses the cognitive aspect (recognizing need for intubation) while exploring the affective barrier (anxiety, fear of complications).

Feedback Models for Clinical Teaching

The "Ask-Tell-Ask" Model

Particularly useful for corrective feedback:³⁵

Ask: "How do you think that procedure went?"
Tell: "I noticed the central line insertion took longer than expected because..."
Ask: "What could you do differently next time?"

This model activates learner self-assessment and reduces defensiveness.

The SAID Framework

Effective for urgent or serious feedback:³⁶

Situation: Describe the specific context
Action: State what the learner did
Impact: Explain consequences
Desired behavior: Clarify expectations

Example: "During this morning's family meeting (Situation), you told the family their mother was 'basically dead' (Action). This language was distressing to them and undermined their trust (Impact). In future conversations, I'd like you to use clear but compassionate language and explicitly acknowledge their emotions (Desired)."

Creating a Feedback Culture

Individual feedback techniques matter less than the overall learning environment. Psychological safety—the belief that one can speak up, ask questions, and make mistakes without punishment—is fundamental to feedback receptivity.³⁷

Pearl #8: Model receiving feedback yourself. When a nurse or junior team member makes a suggestion, respond with: "That's a great catch—I should have considered that. Thank you." This normalizes feedback as a tool for everyone's growth, not just learners.

Pearl #9: Implement "feedback Fridays" or regular structured feedback sessions. Predictability reduces anxiety and normalizes the feedback process.

Oyster Alert: Beware the "MedEd speak" trap—using educational jargon that distances rather than connects. Saying "You demonstrated inadequate synthesis of data" is less effective than "You seemed to focus on the chest X-ray findings and didn't integrate the elevated BNP, which suggested cardiac rather than pulmonary etiology."

Feedback for Professionalism and Attitudes

Critical care requires not just technical competence but professional behaviors: reliability, communication, teamwork, emotional regulation.³⁸ Feedback on these domains is essential but challenging.

Framework for professionalism feedback:

Describe observed behavior: "I noticed you seemed frustrated when pharmacy questioned your antibiotic choice."
Explore context: "Can you help me understand what happened?"
Discuss impact: "When we respond defensively to questions, it can discourage the collaborative atmosphere we need in the ICU."
Set expectations: "I expect all team members, including physicians, to respond to questions with curiosity rather than defensiveness."
Support development: "Let's role-play how to respond when your decisions are questioned."

Evidence Base

Multiple studies confirm that specific, timely, actionable feedback improves clinical performance.²⁹,³⁹ Research by Ende et al. established that feedback should be based on direct observation, delivered promptly, and focus on specific behaviors.⁴⁰ More recent work emphasizes the importance of feedback as dialogue rather than transmission, with learner engagement predicting uptake and behavior change.³⁴

Fostering a Growth Mindset and Resilience in Trainees

The Psychological Foundation of Learning

Clinical competence develops not just through knowledge acquisition but through psychological attributes that enable learning from experience. Carol Dweck's growth mindset theory—the belief that abilities develop through effort rather than being fixed traits—has profound implications for medical education.⁴¹

In critical care, where stakes are high and errors visible, learners with fixed mindsets may avoid challenging cases, hide uncertainties, and become paralyzed by fear of failure. Conversely, growth-minded learners embrace challenges as learning opportunities.⁴²

Principles of Growth Mindset Cultivation

1. Praise Effort and Strategy, Not Intelligence

Fixed mindset praise: "You're a natural at procedures."

Growth mindset praise: "Your systematic approach to that difficult central line—identifying landmarks, using ultrasound, adjusting your technique when you met resistance—that's what led to success."

The second version attributes success to controllable factors (strategy, effort) rather than innate ability, encouraging continued skill development.⁴³

2. Reframe Failure as Information

In the ICU, clinical "failures" are inevitable—patients deteriorate despite excellent care, procedures occasionally fail, diagnoses are initially missed. How educators respond to these moments profoundly shapes learner mindsets.

Fixed mindset response: "You should have caught that earlier."

Growth mindset response: "This patient's presentation was subtle. Let's analyze what clues were present and how we might recognize similar cases earlier. What have you learned that will help you next time?"

Pearl #10: After difficult cases, conduct structured debriefings focused on learning, not blame. Use the Plus/Delta framework: What went well? What would we change next time?⁴⁴

3. Normalize Struggle

Explicitly state that struggle is expected and valuable: "This patient is diagnostically challenging. I'm finding it difficult to integrate all these findings, so I know you are too. Let's work through it together."

Such statements destigmatize difficulty and model the iterative nature of clinical reasoning.⁴⁵

4. Teach Metacognitive Skills

Growth mindset thrives when learners monitor and regulate their own learning. Teach explicit metacognitive strategies:

Self-explanation: "After seeing a patient, explain out loud why you chose your differential diagnoses."
Prediction: "Before reading the CT report, predict what you expect to find based on clinical data."
Reflection: "After rounds, identify one thing you understood well and one thing you need to study."

These practices promote self-regulated learning—the hallmark of expertise development.⁴⁶

Building Resilience in High-Stress Environments

Resilience—the capacity to adapt and thrive despite adversity—is essential for sustainable critical care practice.⁴⁷ Educators can foster resilience through specific practices.

1. Acknowledge the Emotional Reality

Pretending that critical care isn't emotionally demanding does learners a disservice. Normalize emotional responses:

"Losing a patient is hard, even when we did everything right. It's okay to feel sad or frustrated. How are you processing this?"

Pearl #11: Model healthy emotional expression yourself. Saying "This case is really affecting me" gives permission for learners to acknowledge their own feelings.

2. Teach Cognitive Reframing

Help learners reinterpret stressful situations:

Unhelpful cognition: "I'm a terrible doctor—I can't manage these sick patients."

Reframe: "I'm a learner managing complex patients with attending supervision. I'm developing skills that will take years to master."

Cognitive reframing doesn't deny reality but provides perspective that enables continued effort despite setbacks.⁴⁸

3. Promote Deliberate Recovery

Resilience isn't about toughing it out; it requires active recovery. Teach and model:

Tactical breathing during acute stress (4-second inhale, 4-second hold, 4-second exhale)⁴⁹
Structured handoffs that allow mental separation from clinical responsibility
Debriefing after traumatic events

Practical Hack: After codes or deaths, take 5 minutes for team huddle: "That was intense. How is everyone doing? What do we need right now?" This brief investment prevents emotional accumulation.

4. Foster Connection and Belonging

Isolation amplifies stress. Create opportunities for connection:

Team meals or debriefs
Peer support groups for residents
Mentorship relationships

Pearl #12: The "Rounds Appreciation" practice—end rounds by having each team member acknowledge one thing a colleague did well. This builds social support and collective efficacy.

5. Identify and Address Burnout Early

Burnout—characterized by exhaustion, cynicism, and reduced professional efficacy—afflicts up to 50% of critical care providers.⁵⁰ Educators must remain vigilant for signs in trainees:

Detachment from patients
Cynical comments about care
Declining performance
Social withdrawal

When identified, intervene:

Normalize: "What you're describing sounds like burnout, which is common in our field."
Validate: "It makes sense given the demands you're facing."
Resource: "Let's discuss what support you need—time off, counseling, schedule changes."
Follow-up: "I'm checking in because I care about your wellbeing."

Oyster Alert: Don't confuse resilience training with accepting toxic work environments. If systemic factors (excessive hours, inadequate support, harassment) contribute to distress, resilience interventions alone are insufficient—system change is required.⁵¹

The Role of Self-Compassion

Kristin Neff's research on self-compassion—treating oneself with kindness during difficulty rather than harsh self-judgment—shows profound benefits for wellbeing and learning.⁵² Medical culture often promotes perfectionism and self-criticism, but these traits predict burnout and impaired learning.⁵³

Teach self-compassion explicitly:

"You made an error, and that's human. What would you say to a colleague who made the same mistake? Now, can you say something similar to yourself?"

**The Three Components of Self-Compassion:**⁵²

Self-kindness vs. self-judgment: Treating oneself gently vs. harshly criticizing
Common humanity vs. isolation: Recognizing that struggle is universal vs. believing "only I fail"
Mindfulness vs. over-identification: Balanced awareness vs. being consumed by difficult emotions

Evidence suggests self-compassionate physicians demonstrate greater emotional wellbeing, career satisfaction, and patient-centered care.⁵⁴

Creating a Growth-Oriented Learning Environment

Individual interventions matter, but the learning environment is paramount. West et al. identified key features of supportive educational climates:⁵⁵

Psychological safety to ask questions and acknowledge uncertainty
Emphasis on learning over evaluation
Faculty who model vulnerability and continuous learning
Systems that support rather than undermine wellbeing

Practical Hack: The "Learning Priority" statement—begin rotations by explicitly stating: "On this service, learning is the priority. I'd rather you ask every question and make supervised mistakes than hide uncertainty. There are no stupid questions here."

Evidence and Outcomes

Research confirms that growth mindset interventions improve academic performance, reduce attrition, and enhance wellbeing.⁴¹,⁵⁶ In medical education specifically, growth mindset correlates with greater engagement, help-seeking behavior, and recovery from failures.⁵⁷

Resilience training programs have shown promise in reducing burnout and improving professional satisfaction among medical trainees and practicing physicians.⁵⁸,⁵⁹

Integration and Practical Implementation

Creating a Comprehensive Teaching Practice

The frameworks presented—OMP, SNAPPS, setting-specific adaptations, effective feedback, and growth mindset cultivation—are not isolated techniques but integrated components of effective clinical teaching.

A Typical ICU Teaching Scenario:

Morning: During rounds, use SNAPPS for case presentations, allowing residents to articulate reasoning. Apply OMP microskills at the bedside to probe thinking and deliver focused teaching points.

Afternoon: Provide immediate feedback after a procedure using Ask-Tell-Ask. When the resident expresses frustration about difficulty intubating a patient, reframe it as a growth opportunity and discuss learning from challenging airways.

End of Day: Brief team debrief—acknowledge the emotional weight of the day, appreciate specific contributions, and identify learning goals for tomorrow.

Overcoming Barriers to Implementation

Time Constraints: The perennial challenge. Solutions:

Recognize that structured teaching (OMP, SNAPPS) may initially feel time-consuming but ultimately becomes more efficient than unstructured discussion⁶
Use "micro-moments"—brief teaching during transitions, not just dedicated teaching rounds
Prioritize high-yield teaching moments (patient deteriorations, diagnostic dilemmas, procedures)

Resistance from Learners: Some residents prefer traditional didactic teaching. Address by:

Explaining the rationale: "I'm asking you to present your thinking because that's how you'll practice independently"
Starting gradually: "Let's try SNAPPS for one patient this week"
Soliciting feedback: "How is this approach working for you?"

Lack of Faculty Training: Many critical care attendings never received formal training in teaching. Solutions:

Implement faculty development programs focused on these frameworks⁶⁰
Create teaching communities of practice where educators support each other
Use this article as a faculty development resource for discussion

Measuring Teaching Effectiveness

Evaluate teaching using multiple modalities:

Learner feedback: Regular surveys on teaching quality
Direct observation: Peer observation of teaching with structured feedback
Learner outcomes: Performance on evaluations, clinical reasoning assessments
Self-reflection: Regular personal assessment of teaching practices

Pearl #13: The "Teaching Portfolio" approach—maintain a collection of teaching reflections, learner feedback, and teaching innovations. This promotes continuous improvement in teaching practice.

Conclusion

Teaching clinical reasoning in critical care represents a complex educational challenge that requires more than content expertise—it demands pedagogical skill, psychological insight, and authentic commitment to learner development. The frameworks presented in this review—the One-Minute Preceptor for efficient teaching, SNAPPS for learner-centered presentations, setting-specific adaptations, evidence-based feedback practices, and growth mindset cultivation—provide practical, evidence-based tools for educators.

The intensive care unit, despite its frenetic pace and high acuity, offers unparalleled opportunities for clinical reasoning education. Every unstable patient, every diagnostic dilemma, every procedure represents potential teaching material. By applying structured approaches, making reasoning explicit, providing effective feedback, and fostering psychological attributes that enable learning, critical care educators can transform daily clinical work into powerful educational experiences.

The ultimate goal transcends individual teaching encounters: we aim to develop clinicians who reason systematically, embrace uncertainty with curiosity, learn continuously from experience, and approach patient care with both scientific rigor and humanistic compassion. In critical care, where reasoning errors have immediate consequences, this educational mission is not merely academic—it is a moral imperative.

As educators, we must remember that every interaction with a learner shapes not just their knowledge but their professional identity. By teaching with intentionality, empathy, and excellence, we honor our responsibility to the next generation of critical care physicians and, ultimately, to the patients they will serve.

Key Takeaways: Pearls and Oysters

Pearls (Clinical Teaching Wisdom)

The OMP works best for intermediate learners; adjust scaffolding based on trainee level
Use OMP during multidisciplinary rounds for efficient team-based teaching
SNAPPS reveals cognitive biases; use the "Narrow" and "Analyze" steps to diagnose reasoning errors
SNAPPS excels in ICU settings where diagnostic complexity and uncertainty are high
Use the "WWYD" method in outpatient teaching to simulate independent practice
Leverage ICU monitoring (ventilator graphics, hemodynamics) as teaching tools
"Feedback on the Fly"—deliver brief, specific feedback in real-time during clinical activities
Model receiving feedback yourself to normalize it as a universal growth tool
Implement regular structured feedback sessions (e.g., "Feedback Fridays")
After difficult cases, use Plus/Delta debriefing: What went well? What would we change?
Model healthy emotional expression to normalize feelings in high-stress environments
End rounds with "Rounds Appreciation"—acknowledge team members' contributions
Maintain a "Teaching Portfolio" to promote continuous improvement in educational practice

Oysters (Pitfalls to Avoid)

Avoid the "pimp" trap: Aggressive questioning humiliates rather than educates
Beware "MedEd speak": Educational jargon distances; use clear, concrete language
Don't confuse resilience with accepting toxicity: Systemic problems require systemic solutions, not just individual coping
Avoid teaching only setting-specific content: Extract transferable reasoning principles applicable across contexts
Avoid the feedback sandwich: It dilutes important messages; use authentic, specific feedback instead

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Author's Note

This review represents a synthesis of educational theory, empirical research, and practical wisdom gained from years of bedside teaching in critical care environments. While the frameworks presented are evidence-based, their implementation requires adaptation to local context, institutional culture, and individual teaching style. Educators are encouraged to experiment with these approaches, gather feedback from learners, and continuously refine their teaching practice.

The future of clinical reasoning education lies in personalized, technology-enhanced approaches that adapt to individual learner needs while preserving the irreplaceable human connection at the heart of medical apprenticeship. As we navigate this evolving landscape, the principles outlined here—making thinking visible, providing effective feedback, and fostering psychological attributes that enable learning—will remain foundational to excellent clinical teaching.

Correspondence: This article is intended for educational purposes. Questions and feedback may be directed through standard academic channels.

Conflict of Interest: None declared.

Funding: No external funding supported the preparation of this manuscript.

Friday, October 24, 2025