Simulación clínica: el puente necesario para la práctica deliberada del razonamiento clínico

Fátima Ayala de Mendoza; Valentina Canese Caballero

doi:10.53732/rccsalud/2026.e81005

Authors

Fátima Ayala de Mendoza Universidad del Norte, Facultad de Postgrado. Asunción, Paraguay https://orcid.org/0009-0006-1745-6591
Valentina Canese Caballero Universidad del Norte, Facultad de Postgrado. Asunción, Paraguay https://orcid.org/0000-0002-1584-7322

DOI:

https://doi.org/10.53732/rccsalud/2026.e81005

Keywords:

clinical reasoning, simulation, metacognition, standardized patients, deliberate practice

Abstract

Clinical Reasoning (CR) is the core competency of medicine, defined as the systematic processing of clinical data under the Dual Process Model to formulate hypotheses and guide decisions. Its explicit teaching is a persistent challenge, with metacognition being essential to mitigate biases. This qualitative Conceptual Narrative Review synthesized evidence (2019–2025) from Scopus, Google Scholar, and SciELO to analyze the contribution of simulation. Clinical Simulation (CS) is validated as the most advantageous strategy, since its deliberate practice with Standardized Patients (SP) guarantees the standardization of data collection and encourages the Construction of Mental Representations. CS is a cognitive catalyst that forces the transition of CR from implicit to explicit, with reflective debriefing being the critical element to activate metacognition. However, high cost barriers and a shortage of teacher training hinder systematization. SC is essential for early CR and bias mitigation, but institutional support and teacher training are required to overcome logistical obstacles and optimize large-scale deliberate practice.

References

Amey L, Donald KJ, Teodorczuk A. Teaching clinical reasoning to medical students. Br J Hosp Med (Lond). 2017;78(7):399–401. https://doi.org/10.12968/hmed.2017.78.7.399

Brown Tyo M, McCurry MK. An integrative review of clinical reasoning teaching strategies and outcome evaluation in nursing education. Nurs Educ Perspect. 2019;40(1):11–17. http://doi.org/10.1097/01.NEP.0000000000000375

Young M, Thomas A, Gordon D, Gruppen L, Lubarsky S, Rencic J, et al. The terminology of clinical reasoning in health professions education: Implications and considerations. Med Teach. 2019;41(11):1277–1284. https://doi.org/10.1080/0142159X.2019.1635686

Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14(Suppl 1):27–35. https://doi.org/10.1007/s10459-009-9182-2

Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022–1028. https://doi.org/10.1097/ACM.0b013e3181ace703

da Bove Rybertt V, Segue Palma F, Arteaga San Martín R, Antileo Pinto C, Carmona Maldonado P. Razonamiento clínico en carreras de la salud: percepción de estudiantes y docentes. Rev méd Chile. 2022;150(11):1526–1533. https://doi.org/10.4067/S0034-98872022001101526

Alcalá Minagorre PJ, Salmerón Fernández MJ, Domingo Garau A, Díaz Pernas P, Nebot Marzal C, Pino Ramírez RM, et al. Estrategias para la mejora de la seguridad diagnóstica y del razonamiento clínico. An Pediatr (Barc). 2025;102(4):1695-4033. https://doi.org/10.1016/j.anpedi.2025.503827

Audétat MC, Dory V, Nendaz M, Vanpee D, Pestiaux D, Junod Perron N, et al. What is so difficult about managing clinical reasoning difficulties? Med Educ. 2012;46(2):216–227. https://doi.org/10.1111/j.1365-2923.2011.04151.x

Guamán J, Rivera Y. Fomentando el pensamiento reflexivo: estrategias para mejorar las habilidades de metacognición. Esprint Investigación. 2024;3(1):28-38. https://doi.org/10.61347/ei.v3i1.63

Aprendizaje del razonamiento clínic-Rivera S, Behrens-Pérez C, Reyes-Aramburu EP, Pérez-Villalobos C, Bastías-Vega N. Apoyos de la simulación al desarrollo del razonamiento clínico en estudiantes de pregrado de medicina. Simulación Clínica. 2020;2(1):19-25. https://doi.org/10.35366/92935

Martindale J, Shah N, Gusic ME, Wolf SJ. Case-Based Teaching: Does the Addition of High-Fidelity Simulation Make a Difference in Medical Students' Clinical Reasoning Skills? Med Sci Educ. 2020;30(1):307-313. https://doi.org/10.1007/s40670-019-00904-0

Pelaccia T, Jaffrelot M. Simulación para el aprendizaje del razonamiento clínico. En: Palés M, Armas SS, L G L ML, editores. Simulación clínica: Una herramienta para el desarrollo de competencias. Barcelona: Elsevier; 2019. p. 377–389. https://doi.org/10.1016/B978-0-12-815657-5.00026-7

Serna Corredor DS, Martínez Sánchez LM. La simulación en la educación médica, una alternativa para facilitar el aprendizaje. Arch Med (Manizales). 2018;18(2):447-454. https://www.redalyc.org/journal/2738/273857650018/html/

Cleland JA, Abe K, Rethans JJ. The use of simulated patients in medical education: AMEE Guide No 42. Med Teach. 2009;31(6):477–486. https://doi.org/10.1080/01421590903002821

Hernández-Sampieri R, Mendoza C. Metodología de la investigación: las rutas cuantitativa, cualitativa y mixta. Ciudad de México: McGraw-Hill Education; 2018. https://doi.org/10.22201/fesc.20072236e.2019.10.18.6

Amaya Afanador A. Simulación clínica: ¿pretende la educación médica basada en la simulación remplazar la formación tradicional en medicina y otras ciencias de la salud en cuanto a la experiencia actual con los pacientes? Univ Méd. 2008;49(3):399–405.

Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13(Suppl 1):i2–i10. https://doi.org/10.1136/qhc.13.suppl_1.i2

Farrar FC, Suggs L. Potenciando el pensamiento crítico con simuladores computarizados de pacientes. J Coll Teach Learn (TLC). 2010;7(5). https://doi.org/10.19030/tlc.v7i5.114

De Visser H, Watson MO, Salvado O, Passenger JD. Progress in virtual reality simulators for surgical training and certification. Med J Aust. 2011;194(S4):S38–S40. https://doi.org/10.5694/j.1326-5377.2011.tb02942.x

Kononowicz AA, Hege I, Edelbring S, Sobocan M, Huwendiek S, Durning SJ. The need for longitudinal clinical reasoning teaching and assessment: Results of an international survey. Med Teach. 2020;42(4):1–6.

Rudolph JW, Simon R, Raemer DB, Eppich WJ. Debriefing as Formative Assessment: Closing Performance Gaps in Medical Education. Acad Emerg Med. 2008;15(11):1010–1016. https://doi.org/10.1111/j.1553-2712.2008.00248.x

McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010;44(1):50–63. https://doi.org/10.1111/j.1365-2923.2009.03547.x

Muñoz Gualan GG, Elías Sierra R. La simulación clínica en la educación médica moderna: revisión de revisiones. Rev Enferm Vanguard. 2025;19(1):102–116. https://doi.org/10.37135/ee.04.22.08

Segura-Azuara NdlÁ, Valencia Castro JL, López Cabrera MV. Desarrollo del pensamiento crítico mediante la simulación de alta fidelidad con estudiantes de medicina. Investigación en educación médica. 2018;7(28):55–63. https://doi.org/10.22201/facmed.20075057e.2018.28.1749

Tormo Calandín C, Ruiz López JL, Casaña Mohedo J, Casal Angulo C, Adánez Martínez G, García Bermejo P, et al. Aprendizaje de las habilidades psicomotoras en simulación clínica: Metodología docente y resultados preliminares. En: Libro de actas: IX Congreso de Innovación Educativa y Docencia en Red; 13-14 de jul 2023; Valencia. Valencia: Editorial Universitat Politècnica de València; 2023. https://doi.org/10.4995/INRED2024.2024.18515

Hornos E, Pleguezuelos E, Bala L, Collares CF, Freeman A, van der Vleuten C, et al. Reliability, validity and acceptability of an online clinical reasoning simulator for medical students: An international pilot. Med Teach. 2024;46(9):1220–1227. https://doi.org/10.1080/0142159X.2024.2308082

Brentnall J, Thackray D, Judd B. Evaluating the clinical reasoning of student health professionals in placement and simulation settings: A systematic review. Int J Environ Res Public Health. 2022;19(2):936. https://doi.org/10.3390/ijerph19020936

Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10-28. https://doi.org/10.1080/01421590500046924

Cant RP, Cooper SJ. Use of simulation-based learning in undergraduate nurse education: An umbrella systematic review. Nurse Educ Today. 2017;49:63-71. http://doi.org/10.1016/j.nedt.2016.11.015

Bernita Zamora MM, Sevillano Paredes EP, Zambrano Torres DM, Montaño Quiñonez ML, Velez Zambrano AM. El enfoque socio-constructivista y su relación con los estilos de aprendizaje en la educación secundaria en Ecuador. Arandu UTIC. 2025;12(3):1019–1032.

McGraw RC, O'Connor HM. Standardized patients in the early acquisition of clinical skills. Med Educ. 1999;33(8):572–578. https://doi.org/10.1046/j.1365-2923.1999.00381.x

Ayala de Mendoza F, López Esquivel N. Pacientes estandarizados: clave para el aprendizaje clínico. Rev cient cienc salud. 2025;7:01–07. https://doi.org/10.53732/rccsalud/2025.e7301

Fida M, Kassab SE. Do medical students' scores using different assessment instruments predict their scores in clinical reasoning using a computer-based simulation? Adv Med Educ Pract. 2015;6:135–141. https://doi.org/10.2147/AMEP.S77459

Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011;306(9):978–988. https://doi.org/10.1001/jama.2011.1234

Giraldo Echeverri LM, Gómez AM, Buitrago Bach R, Luna IF, Royeth Pérez L, Rodríguez Padilla LM. Percepción de estudiantes de medicina sobre la simulación presencial y virtual durante la pandemia: estudio transversal analítico. Iatreia. 2024;37(3). https://doi.org/10.17533/udea.iatreia.245

Rodríguez-Díez MC, Beunza JJ, López-Del Burgo C, Hyder O, Civeira-Murillo MP, Díez N. Aprendizaje de la historia clínica con pacientes simulados en el grado de Medicina. Educ Méd. 2012;15(1):47-52. http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1575-18132012000100010&lng=es&tlng=es

Makransky G, Bonde MT, Wulff JS, Wandall J, Hood M, Creed PA, et al. Simulation based virtual learning environment in medical genetics counseling: an example of bridging the gap between theory and practice in medical education. BMC Med Educ. 2016;16:98. https://doi.org/10.1186/s12909-016-0620-6

Plackett R, Kassianos AP, Kambouri M, Kay N, Mylan S, Hopwood J, et al. Online patient simulation training to improve clinical reasoning: a feasibility randomised controlled trial. BMC Med Educ. 2020;20(1):245. https://doi.org/10.1186/s12909-020-02168-4

Genes S, González M, Navarro R, Osorio F, Ocampos S. Contribución de la Didáctica y Evaluación para la Construcción del Razonamiento Clínico en Estudiantes de Medicina. An Fac Cienc Méd (Asunción). 2025;58(2):25–32. https://doi.org/10.18004/anales/2025.058.02.25

Elendu C, Amaechi DC, Okatta AU, Amaechi EC, Elendu TC, Ezeh CP, et al. The impact of simulation-based training in medical education: A review. Medicine (Baltimore). 2024;103(27):e38813. https://doi.org/10.1097/MD.0000000000038813

Rognoni Amrein G, Benet Bertran P, Castro Salomó A, Gomar Sancho C, Villalonga Vadell R, Zorrilla Riveiro J. La simulación clínica en la educación médica: Ventajas e inconvenientes del aprendizaje al lado del paciente y en entorno simulado. Med Clin Pract. 2024;7(4):100459. https://doi.org/10.1016/j.mcpsp.2024.100459