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eCREST: a novel online patient simulation resource to aid better diagnosis through developing clinical reasoning
  1. Angelos Kassianos1,
  2. Ruth Plackett1,
  3. Patricia Schartau1,
  4. Christopher Valerio2,
  5. Jenny Hopwood2,
  6. Natasha Kay1,
  7. Sophie Mylan3,
  8. Jessica Sheringham1
  1. 1 Applied Health Research, University College London, London, UK
  2. 2 UCL Medical School, UCL, London, London, UK
  3. 3 Primary Care and Population Health, University College London, London, UK
  1. Correspondence to Dr Jessica Sheringham, Applied Health Research, University College London, London WC1E 6BT, UK; j.sheringham{at}

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In this In Practice report, we describe a novel educational resource using online patient simulations—the electronic Clinical Reasoning Educational Simulation Tool (eCREST). eCREST seeks to improve the quality of diagnoses from common respiratory symptoms seen in primary care by focusing on developing clinical reasoning skills. It has recently been tested with final-year medical students in three UK medical schools. In response to interest, we are exploring the use of eCREST to other medical schools in the UK and internationally and to other professional groups and will conduct further evaluation.


The idea for eCREST arose following research using online patient simulations assessing how physicians make decisions about whether to investigate for cancer. This research found that general practitioners (GPs) made appropriate decisions when they had the relevant information they needed (ie, including common, non-specific symptoms that were not initially volunteered by patients). In cases where they did not have essential information, they were less likely to investigate for possible cancer. In 40% of cases, however, GPs did not elicit this essential information.1 If these patterns are seen in clinical practice, they could lead to delays in diagnosis of cancer.

To reduce diagnostic delays, the Institute of Medicine, among others, recommends the teaching of clinical reasoning should start in medical school, to equip future doctors with the skills necessary to elicit essential information.2 Clinical reasoning can be broadly defined as the thought processes required to apply clinical knowledge to seek information, identify likely diagnoses and reach clinical decisions. Clinical reasoning teaching in medical schools often relies on exposure to real patients, for example during clinical placements.3 There are several logistical and educational reasons to introduce …

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