Enhancing Clinical Reasoning in Physician Assistant Education: Reflections From Implementing the Differential Diagnosis, Investigations, and Clinical Examination Assessment

INTRODUCTION: Developing critical thinking and clinical reasoning, particularly in differential diagnosis, remains a significant challenge for PA students and is often overlooked by traditional curricula. To directly address this educational gap, our program implemented the Differential Diagnosis, Investigations, and Clinical Exam (DICE) assessment tool, designed to immerse students in authentic clinical encounters and reinforce real-time decision-making skills through structured faculty feedback. METHODS: Students from the 2025 and 2026 cohorts participated in DICE assessments in Patient Assessment and Counseling III labs. DICE involved case-based, real-time stations where students rotated as both provider and simulated patient, performing focused physical examinations, formulating and justifying differential diagnoses, selecting diagnostic tests, developing treatment plans, and receiving immediate faculty feedback. Student perceptions of preparedness and confidence were quantified via surveys and benchmarking tools. RESULTS: Following DICE implementation, both cohorts demonstrated high confidence and robust preparedness in core domains of clinical reasoning (average Likert scores ≥4.0), with notable strengths in differential diagnosis formulation and critical thinking. Most compelling, first-time physician assistant national certifying examination pass rates improved dramatically from 53% (2023, pre-DICE) and 82% (2024, pre-DICE) to 100% for the 2025 graduating cohort. DISCUSSION: The DICE assessment proved effective in bridging the gap between didactic instruction and clinical application, supporting the growth of PA students into confident practitioners. While variations in performance emerged between cohorts, ongoing data collection and analysis are guiding curricular improvements. The DICE model demonstrates that explicit, structured clinical reasoning education is not a luxury, but a necessity in promoting safer care, professional confidence, and excellent patient outcomes.