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TACTIC: An innovative method of teaching clinical reasoning to senior medical students that enhances all steps of clinical reasoning skills.

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.

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 2 showed a perfect Item Content Validity index for all steps and excellent overall agreement as measured Scale-Content Validity Index/Ave.

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.

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.

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).