Interprofessional clinical reasoning: deciding as a team

At three in the morning, the nurse calls the on-call physician: the patient in bed 12 is different, more drowsy, "not himself." The next morning, the pharmacist notices that a new medication, added to an old one, may explain the drowsiness. The final diagnosis comes from adding the three observations together. None of the three people, alone, would have closed the picture so early.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This guide explains what interprofessional clinical reasoning is, what studies show about deciding as a team, why information spread across professions changes the diagnosis, and how to train this still in undergraduate education.

Key points

• Interprofessional clinical reasoning is the process in which members of different professions negotiate a patient's diagnosis, treatment or prognosis.
• A systematic review found four factors that weigh on performance: how information is distributed, the physician's experience, the exchange of information, and the way each person seeks out what the other knows.
• In a classic study in intensive care, the presence of a pharmacist on the medical round was associated with fewer adverse events preventable by prescription error.
• In a workshop with medical and pharmacy students, almost all said the differential diagnosis changed when they worked the case together.
• Interprofessional education improves attitudes and knowledge about collaboration; the evidence on patient outcomes is still limited.

What interprofessional clinical reasoning is

A working definition

A German systematic review defined collaborative clinical reasoning as the process in which two or more members of the health team negotiate diagnostic, therapeutic or prognostic questions about a patient, reaching a common approach and reducing uncertainty (Kiesewetter et al., 2017). When these members are from different professions, the reasoning is interprofessional.

The word that matters is "negotiate." It is not about the physician deciding and the others carrying it out, nor about each profession handling its own piece in parallel. It is about bringing together different pieces of information and interpretations until reaching a common picture.

Multiprofessional and interprofessional

A multiprofessional team brings together different professions working side by side. An interprofessional team has these professions learn from and decide with one another. The difference shows in the reasoning: in the first, each person records what they saw; in the second, what one saw changes the other's hypothesis.

Where this comes close to other topics on the blog

Peer teaching among students on the same course is in the guide to active learning, and role-play of consultations with debriefing is in the guide to clinical simulation. Here the focus is different: what changes in reasoning when the person beside you has another training.

Each profession sees one part of the patient

Nursing sees the evolution

Whoever spends the shift beside the patient notices small, continuous changes: the way they respond, acceptance of the diet, the night's urine output, the pain that got worse during the bath. These are data the physician, on short visits, rarely collects. In practice, many diagnoses begin with an "he is not well" coming from nursing.

Pharmacy sees the medications as a whole

The clinical pharmacist looks at the entire medication list, the doses, the interactions and the length of use. This brings to the differential diagnosis a question the student often forgets: could this finding be the effect of a medication? The guide to differential diagnosis shows how to keep the list open; the pharmacist is usually the one who adds the medication hypothesis.

The physician puts the pieces together and decides

The physician usually integrates history, examination and additional tests, and is responsible for the final decision. Integrating well, however, depends on receiving well. If information from nursing and pharmacy does not arrive, or arrives without being heard, medical reasoning works with an incomplete patient.

What the studies show about deciding as a team

Four factors that weigh in

The review by Kiesewetter and colleagues included nine studies carried out in hospitals, always with at least one physician on the team (Kiesewetter et al., 2017). The authors identified four factors that influence the performance of collaborative reasoning: the initial distribution of information among the members, the clinical experience of the team's physicians, the exchange of information within the group and the way each person seeks and represents the information held by the others (Kiesewetter et al., 2017). They also point out that empirical evidence on the topic is still scarce (Kiesewetter et al., 2017).

The first factor explains the scene at bed 12. When information starts out spread around, the diagnosis depends on someone putting the parts together. A team that does not exchange information decides as if each person had seen a different patient.

The pharmacist on rounds

In a before and after study in a clinical intensive care unit, a senior pharmacist began accompanying medical rounds and being available for consultation (Leape et al., 1999). The rate of preventable adverse events due to prescribing error fell 66%, from 10.4 to 3.5 per thousand patient-days, while in the coronary unit used as a control it stayed practically the same, from 10.9 to 12.4 (Leape et al., 1999). The pharmacist made 366 recommendations about prescribing, and 362 of them, or 99%, were accepted by the physicians (Leape et al., 1999).

The study measures prescribing, not diagnosis, and has a before and after design, which limits the conclusion. Even so, it shows a point that applies to reasoning: the other profession present at the moment of the decision changes the decision.

What the trials say about collaboration

A Cochrane review gathered nine randomized trials, with 6,540 participants, on interventions to improve interprofessional collaboration in practice, such as joint rounds, meetings and checklists (Reeves et al., 2017). The authors found signs of small improvement in adherence to recommended practices and in the use of resources, but with low or very low certainty, and concluded that the evidence is insufficient for firm conclusions (Reeves et al., 2017).

For those who study the topic, the honest reading is this: collaboration makes sense because of the way information is distributed, and there are encouraging studies, but the effect on patient outcomes is still being measured.

Interprofessional education: what is known

Studying with, from and about other professions

Interprofessional education is when students from two or more professions learn with each other, from each other and about each other, in order to collaborate better in care (Ni et al., 2024). The idea is to train collaboration before the habits of each profession set in.

The BEME review

A review in the BEME series gathered 46 high-quality studies on interprofessional education (Reeves et al., 2016). Using a modified version of the Kirkpatrick model to classify the outcomes, the authors concluded that students respond well, that attitudes and perceptions of one profession about another improve and that participants report more knowledge and collaborative skill (Reeves et al., 2016). The evidence on behavior change, institutional practice and patient benefit is more limited, although growing (Reeves et al., 2016).

Medicine and nursing

A systematic review on interprofessional education between medicine and nursing included 15 studies with 1,185 participants, among professionals and students (Shuyi et al., 2024). All the types of outcome assessed improved after the interventions, and simulation with multiple scenarios, standardized communication tools and debriefing sessions appeared among the elements associated with better results (Shuyi et al., 2024). The authors call for caution, because the certainty of the evidence was classified as very low (Shuyi et al., 2024).

Pharmacy

In pharmacy, a review included seven randomized trials and seven cohort studies that compared students in interprofessional activities with students in traditional classes (Ni et al., 2024). Eight studies showed a positive effect on interprofessional competence, but the effect on technical knowledge of one's own profession varied between studies (Ni et al., 2024).

A diagnosis made with four hands

A two-hour online workshop brought together 154 second-year medical students and third-year pharmacy students in small groups (Lang et al., 2024). Each profession received different and complementary information about the same case, which was revealed in two stages, and the groups had to talk to put together the differential diagnosis (Lang et al., 2024).

Almost all the students, 99%, said that data collection and the differential diagnosis changed because they had worked together (Lang et al., 2024). The pharmacy students reported that the medical students broadened the differential (71%) and added information (72%), and the medical students reported that the pharmacy students helped justify (54%) and clarify (22%) the hypotheses, often linking the mechanism of the medicines to the findings (Lang et al., 2024). The design measures perception, not accuracy, but it shows how dividing the information forces conversation.

Simulated visit with several professions

In Germany, 29 final-year medical, nursing and physiotherapy students took part in a simulated visit with standardized patients (Nikendei et al., 2016). In the focus groups, the participants praised the preparation and the learning climate, and pointed out as a difficulty the gap between the trained visit and the everyday visit, in which collaboration tends to be weaker (Nikendei et al., 2016).

How to train during graduation

Ask what the other profession saw

On the rotation, before presenting a patient, ask nursing how the night went and ask pharmacy whether there is anything in the prescription that draws attention. Bring those answers into the presentation. The guide on clinical reasoning in the internship shows how to structure that presentation to the preceptor.

Include the medicine in the list of hypotheses

In every differential diagnosis, set aside a line for "medicine effect". If you do not know how to assess it, ask the pharmacist. The habit trains exactly what the medical students valued in the workshop by Lang and colleagues (Lang et al., 2024).

Write to be read by other professions

A clear progress note, with the main hypothesis and what you expect to happen, lets nursing know what to watch. The guide on reasoning in the medical record shows how to make the reasoning visible in the text.

Build cases with divided information

If your student league or medical school organizes discussions, divide the case information among students from different courses, as in the workshop described above. Nobody has the whole picture, and conversation becomes necessary. The guide on case-based learning offers other ways to run the discussion.

Watch out for hierarchy

When the other profession disagrees, the tendency is to defend the hypothesis you already have. The guide on heuristics shows how the first impression resists new data. Treat disagreement as a data point, not as an attack.

The case of the day in a mixed class on NEXO

On NEXO, the case arrives in up to six clues, and each guess receives its proximity in ICD-10 across five levels. The cases are fictional with a real clinical presentation, which lets medical, nursing and pharmacy students play the same case of the day and then compare at which clue each one changed their hypothesis.

The group ranking helps organize that class. The conversation after the case is where interprofessional reasoning shows up: what clue three meant for each profession and which medicine-related hypothesis came in or stayed out. How the modes are released is on the NEXO Economy page, and the guide what NEXO is explains the game.

If you coordinate a course, a student league or a residency and want to bring different professions together around the same case, see NEXO Closer. Researchers who study collaborative reasoning can propose studies through NEXO Researcher. Physicians who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What is interprofessional clinical reasoning?

It is the process in which professionals from different areas negotiate together the diagnosis, treatment or prognosis of a patient (Kiesewetter et al., 2017).

What is the difference between a multiprofessional and an interprofessional team?

In a multiprofessional team, the professions work side by side. In an interprofessional one, they learn and decide with one another, and what one sees changes the other's hypothesis.

Does interprofessional education work?

It improves attitudes and knowledge about collaboration; the evidence on behavior and patient benefit is still limited (Reeves et al., 2016).

Does the pharmacist help with diagnosis?

In a workshop with students, medical students reported that pharmacy students helped justify and clarify the differential diagnosis (Lang et al., 2024).

How can a medical student train this?

Ask nursing and pharmacy before presenting the patient, keep one hypothesis for a medication effect, and take part in case discussions with other courses.

How can NEXO fit into an interprofessional activity?

Students from different courses play the same case of the day, with up to six clues, and then compare at which clue each one changed their hypothesis.

Interprofessional reasoning checklist

1. Ask nursing how the course went.
2. Ask pharmacy about the whole prescription.
3. Keep one hypothesis for a medication effect.
4. Put the information together before closing the picture.
5. Write the course so other professions can read it.
6. Treat disagreement as data.
7. Train with cases of information split between courses.

Want to train with your class? Play the case of the day on NEXO.

References

1. Kiesewetter J, Fischer F, Fischer MR. Collaborative Clinical Reasoning-A Systematic Review of Empirical Studies. J Contin Educ Health Prof. 2017. https://pubmed.ncbi.nlm.nih.gov/28562501/
2. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999. https://pubmed.ncbi.nlm.nih.gov/10422996/
3. Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017. https://pubmed.ncbi.nlm.nih.gov/28639262/
4. Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, McFadyen A, Rivera J, Kitto S. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016. https://pubmed.ncbi.nlm.nih.gov/27146438/
5. Shuyi AT, Zikki LYT, Mei Qi A, Koh Siew Lin S. Effectiveness of interprofessional education for medical and nursing professionals and students on interprofessional educational outcomes: A systematic review. Nurse Educ Pract. 2024. https://pubmed.ncbi.nlm.nih.gov/38101092/
6. Ni J, Liu Q, Li X, Chen M. Outcomes of interprofessional education for pharmacy students: a systematic review. BMC Med Educ. 2024. https://pubmed.ncbi.nlm.nih.gov/39563306/
7. Lang VJ, Symoniak MR, Williams SP. Interprofessional Coproduction of Diagnosis with Medical and Pharmacy Students: An Interactive Case-Based Workshop. MedEdPORTAL. 2024. https://pubmed.ncbi.nlm.nih.gov/39318830/
8. Nikendei C, Huhn D, Pittius G, Trost Y, Bugaj TJ, Koechel A, Schultz JH. Students' Perceptions on an Interprofessional Ward Round Training - A Qualitative Pilot Study. GMS J Med Educ. 2016. https://pubmed.ncbi.nlm.nih.gov/27280125/