Article Text

Download PDFPDF
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}

Statistics from

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 …

View Full Text


  • P and RP contributed equally.

  • Contributors APK led the codevelopment of eCREST, managing site and content development. RP conducted evidence reviews to inform development design and content, and contributed to all elements of the development process. PS, NK, SM and JH devised the online patient simulated cases. SB and CV advised on the initial design of eCREST and how to maximise its value to medical students, commented on versions of eCREST during its development and facilitated recruitment of students at UCL. JS had the initial idea for the study, secured funding for it as the PI and oversaw aspects of the study. RP and JS produced the initial draft of the manuscript. All authors commented on drafts of the manuscript and agreed the decision to submit for publication.

  • Funding This report presents independent research commissioned andfunded by the National Institute for Health Research (NIHR) Policy ResearchProgramme, conducted through the Policy Research Unit in Cancer Awareness,Screening and early Diagnosis, PR-PRU-1217-21601. JS is supported by theNational NIHR Collaboration for Leadership in Applied Health Research and Care NorthThames at Barts Health NHS Trust. The views expressed are those of the authorsand not necessarily those of the NIHR, the Department of Health and Social Careor its arm’s length bodies, or other Government Departments. RP was funded by The Health Foundation Improvement Science PhD Studentship.

  • Competing interests None declared.

  • Ethics approval University ethics approval for the feasibility RCT was obtained from all participating medical schools: UCL Research Ethics Committee, ref: 9605/001 31st October 2016; Institute of Health Sciences Education review committee at Barts and The London medical school, ref: IHSEPRC-41 31st January 2017; the Faculty of Medicine and Health Sciences Research Ethics Committee at Norwich medical school University of East Anglia, ref: 2016/2017 – 99 21st October 2017.

  • Provenance and peer review Not commissioned; internally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.