Keywords
Clinical reasoning, critical thinking, learning instructions; diagnostic reasoning; health professions education; Instructional design; Team-based learning strategies; Content validity; Educational innovation; Case-based learning.
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Al-Jefout M, Zareba K, Maki S et al. Team-Based Analysis for Critical Thinking in Clinical Cases (TACTIC): Development of a new innovative method for teaching clinical reasoning [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1447 (https://doi.org/10.12688/f1000research.173531.1)
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Method Article
Team-Based Analysis for Critical Thinking in Clinical Cases (TACTIC): Development of a new innovative method for teaching clinical reasoning
[version 1; peer review: awaiting peer review]
PUBLISHED 24 Dec 2025
OPEN PEER REVIEW
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Abstract
Corresponding authors:
Shamsa Al Awar, Mohi Eldin Mazoub
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2025 Al-Jefout M et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Al-Jefout M, Zareba K, Maki S et al. Team-Based Analysis for Critical Thinking in Clinical Cases (TACTIC): Development of a new innovative method for teaching clinical reasoning [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1447 (https://doi.org/10.12688/f1000research.173531.1)
First published: 24 Dec 2025, 14:1447 (https://doi.org/10.12688/f1000research.173531.1)
Latest published: 24 Dec 2025, 14:1447 (https://doi.org/10.12688/f1000research.173531.1)
Practice points
1. TACTIC: An innovative method of teaching clinical reasoning to senior medical students that enhances all steps of clinical reasoning skills.
2. TACTIC is a highly interactive, cognitively rich, and authentic framework.
3. Trains medical students in both analytical and non-analytical reasoning.
4. It maintains feasibility and objectivity through step-by-step structured design.
5. TACTIC allows for simultaneous coverage of multiple real-life clinical problems in a single session.
Background
A major goal of undergraduate medical education is to equip students with the ability to apply medical knowledge in real clinical contexts through effective clinical reasoning. Learning past three decades, problem-based learning (PBL) and, more recently, team-based learning (TBL) have emerged as powerful methods to foster knowledge acquisition, active learning, and collaboration among students. These approaches have demonstrated positive effects on knowledge retention, learner engagement, and teamwork (Schmidt 1983, Burgess, van Diggele et al. 2020, Michaelsen, Parmelee et al. 2023).
However, clinical reasoning presents a unique instructional challenge. Unlike factual knowledge, clinical reasoning involves a dynamic process of collecting and synthesizing information, formulating and revising hypotheses, weighing probabilities, and making contextually appropriate decisions under uncertainty (Bowen 2006, Norman, Monteiro et al. 2017). It is not a single skill but a complex integration of biomedical knowledge, clinical experience, cognitive heuristics, and metacognitive strategies.
Traditional instructional formats, including lectures and even PBL/TBL, often fail to provide learners with structured opportunities to practice iterative diagnostic thinking, which is essential for making safe and competent clinical decisions. Approaches such as case-based discussions, think-aloud strategies, and concept mapping address discrete components of reasoning but often lack structure, scalability, or sustained learner engagement (Charlin, Tardif et al. 2000, Kassirer 2010, Henning, Ram et al. 2013).
This fragmentation creates a pedagogical gap: students may accumulate knowledge and communication skills yet struggle to apply systematic reasoning in authentic clinical scenarios. There is a need for instructional methods that integrate hypothesis generation, iterative refinement, peer collaboration, and real-world reasoning, while remaining feasible for faculty to implement.
To address this gap, we developed Team-Based Analysis for Critical Thinking in Clinical Cases (TACTIC), a structured, interactive, and scalable method designed to cultivate clinical reasoning in authentic contexts. This article will cover the development and description of the method and the steps we have taken to reach a consensus on these five points.
Methods
Settings and context
The setting is the College of Medicine and Health Sciences, United Arab Emirates University. TACTIC applied to year five medical students during their obstetrics and gynecology rotations.
Team-Based Analysis for Critical Thinking in Clinical Cases (TACTIC) is a structured, team-based instructional strategy designed to enhance diagnostic reasoning in undergraduate medical education through collaborative engagement with authentic clinical problems. The approach emphasizes iterative hypothesis generation, peer discussion, and guided feedback, mirroring the real-world diagnostic process. TACTIC sessions are typically conducted in small groups of four to five students and last approximately two hours. The classroom is organized to facilitate interaction, with round tables, writable surfaces, and digital displays to support shared note-taking. Each session follows a standardized sequence of five steps, combining individual preparation, team reasoning, and guided reflection:
Design. Three-round expert consensus using a modified Delphi with a concluding nominal-group meeting to specify and finalize the TACTIC steps, definitions, and prompts.
Panel. Ten faculty experts from the College of Medicine, United Arab Emirates University, two method leads, and eight implementers with ≥2 years’ experience using TACTIC in teaching.
Round 1 Drafting . Two leads synthesized three years of implementation experience to produce V.1 (step list, brief definitions, tutor prompts).
Round 2 Rating & revision . The 8 implementers independently rated each step’s importance on a 5-point scale (1 = least, 5 = utmost importance) and suggested edits/re-ordering. We computed median (IQR), mean (SD), % ≥ 4 A priori: accept if median ≥ 4, IQR ≤ 1, revise otherwise; drop/merge if median ≤ 3.
Round 3 Consensus meeting . Panelists reviewed anonymized Round-2 results, discussed contested items, and re-rated live. Final acceptance required ≥80% ratings ≥4 and median ≥ 4; step order followed majority preference.
Analysis. Ratings were exported to CSV and summarized in R/Python; we report item medians (IQR), means (SD), % ≥ 4, I-CVI , and S-CVI/Ave across steps. Qualitative suggestions were coded (wording, content, sequence) and used to refine v.1
Ethics. The data collection tool we utilized did not collect any personal data or identifiable information, was anonymous and voluntary, and only evaluated the development and description of the TACTIC educational tool. According to the United Arab Emirates University Research Guidelines, this was an exemption from an ethical review.
Results
In round 1, the two researchers initially listed the steps shown in column 1 of Table 1 and shared them with participants. The results of round 2 were disclosed in Table 1, which showed a high level of agreement among the participants as evidenced by the high median and mean values and low SD and IQR.
Table 1. Summary statistics for each step of tactic.
Table 2 showed a perfect Item Content Validity index for all steps and excellent overall agreement as measured Scale-Content Validity Index/Ave.
Table 2. CVI and S-CVI/Ave.
| Metric | Value | Interpretation |
|---|---|---|
| I-CVI (all steps) | 1.00 | All 8 raters gave every step ≥ 4 (excellent) |
| S-CVI/Ave | 1.00 | Overall perfect agreement |
In the nominal group process, an agreement was reached on the final wording as well as the timing for each step.
The results of the agreed steps are shown below.
Description of the steps
1. Group Formation and Briefing (10 minutes):
Students are assigned to teams, select a leader, and choose a team name. The tutor introduces the clinical scenario from his own clinical practice (e.g., “Team 1: A 25-year-old woman with infertility), outlines session goals, and clarifies ground rules for participation and timing.
2. Initial Hypothesis Generation (15 minutes):
Teams collaboratively develop an initial list of differential diagnoses (DD1) and formulate key history questions. The tutor acts as a simulated patient, responding to each team’s inquiries to provide relevant information. Based on new data, teams revise their differentials (DD2) and justify their reasoning.
3. Iterative Clinical Reasoning (30 minutes):
The process is repeated as teams receive examination findings and investigation results, prompting additional refinements (DD3 and DD4). This iterative cycle encourages flexible reasoning and progressive hypothesis revision. Teams are expected to articulate the reasoning behind each diagnostic shift, emphasizing pattern recognition, pathophysiological logic, by bridging and integrating basic with clinical sciences and critical thinking.
4. Synthesis and Presentation (30 minutes):
Each team synthesizes its case into a concise presentation that includes key clinical data, differential diagnoses, diagnostic reasoning steps, relevant pathophysiology, and management plans using EBM and international guidelines, prognosis, and patient counseling. Teams also construct a concept map linking clinical findings to underlying mechanisms and proposed interventions. This step consolidates analytical reasoning into a structured narrative.
5. Discussion and Feedback (20 minutes):
Teams present to the class, engage in peer questioning, and receive structured feedback from peers and the tutor. The feedback focuses on diagnostic logic, reasoning transparency, and communication clarity. All materials are shared digitally to support collective learning and reference.
Tutor preparation and role
Tutors receive a facilitator guide outlining session flow, key prompts, anticipated student responses, and potential reasoning pitfalls. They are briefed to balance guidance with learner autonomy, probing with open-ended questions rather than providing direct answers. The tutor also serves as a simulated patient, using prepared real clinical case scripts to ensure realism and consistency. Faculty implementing TACTIC for the first time are encouraged to observe an experienced facilitator before leading their own session.
Student preparation
Before each session, students receive a list of learning objectives, pre-reading materials, and relevant clinical guidelines. This self-directed preparation ensures that class time is used primarily for reasoning rather than factual recall. Students are encouraged to bring concise reference notes and diagnostic frameworks (e.g., symptom-based differentials) to support active discussion.
Assessment and feedback mechanisms
TACTIC emphasizes formative assessment through structured peer and tutor feedback. Each team’s final presentation is evaluated using a rubric that assesses reasoning structure, use of evidence, clarity of explanation, and teamwork dynamics. Students also complete brief reflection sheets summarizing key diagnostic learning points and identifying personal areas for improvement. These reflections are later discussed during debriefing sessions to reinforce metacognitive awareness.
Resources and logistics
The TACTIC model requires modest logistical resources but careful coordination. Optimal implementation includes:
- Classrooms that accommodate multiple simultaneous team discussions;
- Projected case materials or digital platforms (e.g., Google Slides or Padlet) for shared input;
- Well-developed clinical case banks with tiered information (history, exam, investigations);
- Facilitators familiar with clinical reasoning frameworks such as dual-process theory or illness scripts.
Discussion and lessons learned
In this study, we utilized a modified Delphi technique followed by a nominal group process to achieve expert consensus on the steps and delivery of the TACTIC method. Both approaches are widely recognized for facilitating structured consensus among experts in education and healthcare (Hasson et al. 2000, Humphrey-Murto et al. 2017). Our process achieved an exceptionally high level of agreement, with an overall I-CVI approaching 1.00. This strong consensus reflects the high engagement of participants and the iterative discussions that ensured clarity, feasibility, and standardized delivery of the TACTIC framework. Establishing unified steps is expected to enhance fidelity of implementation and ultimately achieve TACTIC’s primary goal—enhancing clinical reasoning skills.
Although originally designed for face-to-face sessions, TACTIC can be adapted for hybrid or online learning. Digital breakout rooms, collaborative whiteboards, and interactive polling tools can support distributed reasoning, while “simulated patient” interactions can be conducted via videoconferencing or AI-based conversational interfaces. These approaches are consistent with research showing that virtual and simulation-based learning can maintain engagement and reasoning quality comparable to in-person teaching (Liaw et al., 2021). Future iterations will explore integrating automated feedback and adaptive case branching to support scalable, resource-efficient deployment across institutions.
Lessons learned
Enhanced student engagement and participation
TACTIC’s structured, stepwise reasoning format encouraged active participation from all team members, including those who are less vocal in traditional lecture or problem-based learning settings. Structured collaborative reasoning promotes equitable participation, reduces cognitive overload, and enhances diagnostic accuracy (Schmidt and Mamede 2015, Dolmans, Loyens et al. 2016). The TACTIC format created a psychologically safe environment that promoted questioning, critical thinking, and deeper reflection.
Broadened exposure to diverse clinical problems
TACTIC allowed concurrent exploration of multiple clinical scenarios in a single session. Each team worked on a different case, and through peer presentations and discussion, students were exposed to a wide spectrum of reasoning approaches. Peer-to-peer learning has been shown to strengthen knowledge integration and transfer of diagnostic reasoning skills (Cheng, Grant et al. 2015).
Promotion of collaborative and reflective learning
The team-based format fostered mutual learning and reflection. Students benefited from observing how peers generated, tested, and justified hypotheses—behaviors central to adaptive expertise (Mylopoulos and Regehr 2009). Peer questioning and open dialogue enhanced collaborative reasoning, self-assessment, and metacognitive awareness (Tanner 2012).
Development of both non-analytical and analytical reasoning
TACTIC supports dual-process reasoning: learners initially employ intuitive (System 1) thinking based on pattern recognition, followed by analytical (System 2) reasoning that applies a hypothetico-deductive approach to refine and validate hypotheses. This balance mirrors cognitive models of clinical reasoning and helps mitigate diagnostic error (Norman 2005, Croskerry 2009).
Positive learner perceptions and satisfaction
Preliminary feedback indicated high satisfaction with TACTIC sessions. Students valued the authenticity of cases, the iterative reasoning process, and opportunities for structured decision-making in a psychologically safe, low-stakes environment. Experiential approaches such as these consistently improve diagnostic reasoning and learner motivation (Bowen 2006, Kassirer 2010, Fontaine, Cossette et al. 2019).
Limitations
Despite its strengths, TACTIC is a resource-intensive approach. Implementation requires trained facilitators who can act as both tutors and simulated patients, well-constructed cases, and adequate facilities to support small-group activities. Preparing multiple parallel cases can be time-consuming, particularly for faculty new to the approach. Effective facilitation also requires balancing guidance with learner autonomy. Faculty-development initiatives and standardized facilitator guides are necessary to ensure consistent delivery and sustain educational quality (Steinert, Cruess et al. 2007).
Next steps
• Conduct systematic evaluations of TACTIC’s impact on clinical reasoning outcomes using validated assessment tools (Bowen 2006).
• Develop structured facilitator guides and standardized feedback rubrics to enhance consistency and reduce tutor workload.
• Explore digital and hybrid adaptations (e.g., AI-supported simulated patients, virtual breakout rooms) to improve scalability and sustainability.
• Integrate TACTIC into undergraduate and clerkship curricula to complement existing clinical-teaching methods.
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how to cite this article
Al-Jefout M, Zareba K, Maki S et al. Team-Based Analysis for Critical Thinking in Clinical Cases (TACTIC): Development of a new innovative method for teaching clinical reasoning [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1447 (https://doi.org/10.12688/f1000research.173531.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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