Prototypes and semantic qualifiers: from past to present

GPT-4 assistance for improvement of physician performance on patient care tasks: a randomized controlled trial

While large language models (LLMs) have shown promise in diagnostic reasoning, their impact on management reasoning, which involves balancing treatment decisions and testing strategies while managing risk, is unknown. This prospective, randomized, controlled trial assessed whether LLM assistance improves physician performance on open-ended management reasoning tasks compared to conventional resources. From November 2023 to April 2024, 92 practicing physicians were randomized to use either GPT-4 plus conventional resources or conventional resources alone to answer five expert-developed clinical vignettes in a simulated setting. All cases were based on real, de-identified patient encounters, with information revealed sequentially to mirror the nature of clinical environments. The primary outcome was the difference in total score between groups on expert-developed scoring rubrics. Secondary outcomes included domain-specific scores and time spent per case. Physicians using the LLM scored significantly higher compared to those using conventional resources (mean difference = 6.5%, 95% confidence interval (CI) = 2.7 to 10.2, P < 0.001). LLM users spent more time per case (mean difference = 119.3 s, 95% CI = 17.4 to 221.2, P = 0.02). There was no significant difference between LLM-augmented physicians and LLM alone (-0.9%, 95% CI = -9.0 to 7.2, P = 0.8). LLM assistance can improve physician management reasoning in complex clinical vignettes compared to conventional resources and should be validated in real clinical practice. ClinicalTrials.gov registration: NCT06208423 .

Transformation and articulation of clinical data to understand students' clinical reasoning: a scoping review

BACKGROUND

Despite the importance of effective educational strategies to promote the transformation and articulation of clinical data while teaching and learning clinical reasoning, unanswered questions remain. Understanding how these cognitive operations can be observed and assessed is crucial, particularly considering the rapid growth of artificial intelligence and its integration into health education. A scoping review was conducted to map the literature regarding educational strategies to support transformation and articulation of clinical data, the learning tasks expected of students when exposed to these strategies and methods used to assess individuals' proficiency METHODS: Based on the Joanna Briggs Institute methodology, the authors searched 5 databases (CINAHL, MEDLINE, EMBASE, PsycINFO and Web of Science), ProQuest Dissertations & Theses electronic database and Google Scholar. The data were synthesized narratively using descriptive statistics.

RESULTS

A total of 38 articles were included in the final synthesis. Most studies were conducted in North America and Europe (n = 30, 79%) focused primarily on medical students (n = 35, 92%) and mainly used observational (n = 17, 45%) or methodological (n = 8, 21%) designs. Various educational strategies were identified, the most common were resolution of written or computerized case-based scenarios (n = 13; 52%) and simulated or real patient encounters (n = 6; 24%). The learning tasks comprised, among others, identifying key findings, translating clinical information, synthesizing cases aloud, and writing a summary statement. Furthermore, the review included assessment methods and rubrics with assessment criteria for clinical data transformation and articulation. The narrative synthesis shows positive results when integrating various educational strategies within clinical reasoning curricula compared to a single strategy used episodically.

LIMITATIONS AND CONCLUSIONS

The varying objectives, diversity of educational strategies documented, and heterogeneity of the evaluation tools or rubrics limit our conclusions. However, insights gained will help educators develop effective approaches for teaching clinical reasoning. Additional research is needed to evaluate the impacts of educational strategies aimed at developing skills for the transformation and articulation of clinical data.

CLINICAL TRIAL NUMBER

Not applicable.

"With Great Responsibility Comes Great Uncertainty"

BACKGROUND

Uncertainty is inherent in medicine, and trainees are particularly exposed to the adverse effects of uncertainty. Previous work suggested that junior residents seek to leverage the support of supervisors to regulate the uncertainty encountered in clinical placements. However, a broader conceptual framework addressing uncertainty experience, from the sources of uncertainty to residents' responses, is still needed.

OBJECTIVE

To capture the spectrum of uncertainty experiences in medical residents, providing an integrative framework that considers the influence of specialties and training stages on their experience with clinical uncertainty.

DESIGN

We used Hillen's uncertainty tolerance framework to conduct a thematic template analysis of individual and focus group interviews, identifying themes and subthemes reflecting residents' experience of clinical uncertainty.

PARTICIPANTS

Medical residents from diverse medical specialty training programs, across five French medical schools.

APPROACH

Qualitative study driven by an interpretivist research paradigm.

RESULTS

Twenty residents from all years of medical residency and diverse medical specialties were interviewed during three focus groups and five individual interviews. They described managing treatments, making ethical decisions, and communicating uncertainty, as their major sources of uncertainty. We identified residents' delayed response to uncertainty as a key theme, fostering the development of experiential learnings. Prior clinical experience was a key determinant of uncertainty tolerance in medical residents. Entrusting residents with responsibilities in patient management promoted their perception of self-efficacy, although situations of loneliness resulted in stress and anxiety.

CONCLUSION

Residents face significant uncertainty in managing treatments, ethical decisions, and communication due to limited clinical experience and growing responsibilities. Scaffolding their responsibilities and clearly defining their roles can improve their comfort with uncertainty. To that extent, effective supervision and debriefing are crucial for managing emotional impacts and fostering reflection to learn from their uncertain experiences.

Large Language Model Influence on Management Reasoning: A Randomized Controlled Trial

Importance

Large language model (LLM) artificial intelligence (AI) systems have shown promise in diagnostic reasoning, but their utility in management reasoning with no clear right answers is unknown.

Objective

To determine whether LLM assistance improves physician performance on open-ended management reasoning tasks compared to conventional resources.

Design

Prospective, randomized controlled trial conducted from 30 November 2023 to 21 April 2024.

Setting

Multi-institutional study from Stanford University, Beth Israel Deaconess Medical Center, and the University of Virginia involving physicians from across the United States.

Participants

92 practicing attending physicians and residents with training in internal medicine, family medicine, or emergency medicine.

Intervention

Five expert-developed clinical case vignettes were presented with multiple open-ended management questions and scoring rubrics created through a Delphi process. Physicians were randomized to use either GPT-4 via ChatGPT Plus in addition to conventional resources (e.g., UpToDate, Google), or conventional resources alone.

Main Outcomes and Measures

The primary outcome was difference in total score between groups on expert-developed scoring rubrics. Secondary outcomes included domain-specific scores and time spent per case.

Results

Physicians using the LLM scored higher compared to those using conventional resources (mean difference 6.5 %, 95% CI 2.7-10.2, p<0.001). Significant improvements were seen in management decisions (6.1%, 95% CI 2.5-9.7, p=0.001), diagnostic decisions (12.1%, 95% CI 3.1-21.0, p=0.009), and case-specific (6.2%, 95% CI 2.4-9.9, p=0.002) domains. GPT-4 users spent more time per case (mean difference 119.3 seconds, 95% CI 17.4-221.2, p=0.02). There was no significant difference between GPT-4-augmented physicians and GPT-4 alone (-0.9%, 95% CI -9.0 to 7.2, p=0.8).

Conclusions and Relevance

LLM assistance improved physician management reasoning compared to conventional resources, with particular gains in contextual and patient-specific decision-making. These findings indicate that LLMs can augment management decision-making in complex cases.

Trial registration

ClinicalTrials.gov Identifier: NCT06208423; https://classic.clinicaltrials.gov/ct2/show/NCT06208423.

Clinical reasoning-the essentials for teaching medical students, trainees and non-medical healthcare professionals

Clinical reasoning is fundamental for effective clinical practice. Traditional consultation models for teaching clinical reasoning or conventional approaches for teaching students how to make a diagnosis or management plan that rely on learning through observation only, are increasingly recognised as insufficient. There are also many challenges to supporting learners in developing clinical reasoning over time as well as across different clinical presentations and contexts. These challenges are compounded by the differences in how experts and novices make sense of clinical information, and the different cognitive processes each use when processing and communicating this information using precise medical language. Diagnostic errors may be due to cognitive biases but also, in a majority of cases, due to a lack of clinical knowledge. Therefore, effective educational strategies to develop clinical reasoning include identifying learners' knowledge gaps, using worked examples to prevent cognitive overload, promoting the use of key features and practising the construction of accurate problem representations. Deliberate reflection on diagnostic justification is also recommended, and overall, contributes to a growing number of evidence-based and theory-driven educational interventions for reducing diagnostic errors and improving patient care.

Transformation and Articulation of Clinical Data to Understand Students' and Health Professionals' Clinical Reasoning: Protocol for a Scoping Review

BACKGROUND

There are still unanswered questions regarding effective educational strategies to promote the transformation and articulation of clinical data while teaching and learning clinical reasoning. Additionally, understanding how this process can be analyzed and assessed is crucial, particularly considering the rapid growth of natural language processing in artificial intelligence.

OBJECTIVE

The aim of this study is to map educational strategies to promote the transformation and articulation of clinical data among students and health care professionals and to explore the methods used to assess these individuals' transformation and articulation of clinical data.

METHODS

This scoping review follows the Joanna Briggs Institute framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist for the analysis. A literature search was performed in November 2022 using 5 databases: CINAHL (EBSCOhost), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and Web of Science (Clarivate). The protocol was registered on the Open Science Framework in November 2023. The scoping review will follow the 9-step framework proposed by Peters and colleagues of the Joanna Briggs Institute. A data extraction form has been developed using key themes from the research questions.

RESULTS

After removing duplicates, the initial search yielded 6656 results, and study selection is underway. The extracted data will be qualitatively analyzed and presented in a diagrammatic or tabular form alongside a narrative summary. The review will be completed by February 2024.

CONCLUSIONS

By synthesizing the evidence on semantic transformation and articulation of clinical data during clinical reasoning education, this review aims to contribute to the refinement of educational strategies and assessment methods used in academic and continuing education programs. The insights gained from this review will help educators develop more effective semantic approaches for teaching or learning clinical reasoning, as opposed to fragmented, purely symptom-based or probabilistic approaches. Besides, the results may suggest some ways to address challenges related to the assessment of clinical reasoning and ensure that the assessment tasks accurately reflect learners' developing competencies and educational progress.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50797.

Reasoning on Rounds: a Framework for Teaching Diagnostic Reasoning in the Inpatient Setting

Internal medicine trainees learn a variety of clinical skills from resident clinical teachers in the inpatient setting. While diagnostic reasoning (DR) is increasingly emphasized as a core competency, trainees may not feel entirely comfortable teaching it. In this perspective article, we provide a framework for teaching DR during inpatient rounds, which includes focusing on the one-liner, structuring a reasoning-focused A&P, and performing a day of discharge reflection.

Semantic competence and prototypical verbalizations are associated with higher OSCE and global medical degree scores: a multi-theory pilot study on year 6 medical student verbalizations

OBJECTIVES

The organization of medical knowledge is reflected in language and can be studied from the viewpoints of semantics and prototype theory. The purpose of this study is to analyze student verbalizations during an Objective Structured Clinical Examination (OSCE) and correlate them with test scores and final medical degree (MD) scores. We hypothesize that students whose verbalizations are semantically richer and closer to the disease prototype will show better academic performance.

METHODS

We conducted a single-center study during a year 6 (Y6) high-stakes OSCE where one probing intervention was included at the end of the exam to capture students' reasoning about one of the clinical cases. Verbalizations were transcribed and coded. An assessment panel categorized verbalizations regarding their semantic value (Weak, Good, Strong). Semantic categories and prototypical elements were compared with OSCE, case-based exam and global MD scores.

RESULTS

Students with Semantic 'Strong' verbalizations displayed higher OSCE, case-based exam and MD scores, while the use of prototypical elements was associated with higher OSCE and MD scores.

CONCLUSIONS

Semantic competence and verbalizations matching the disease prototype may identify students with better organization of medical knowledge. This work provides empirical groundwork for future research on language analysis to support assessment decisions.

Clinical reasoning pattern used in oral health problem solving - A case study in Indonesian undergraduate dental students

BACKGROUND

Health professionals are known to use various combinations of knowledge and skills, such as critical thinking, clinical reasoning, clinical judgment, problem-solving, and decision-making, in conducting clinical practice. Clinical reasoning development is influenced by knowledge and experience, the more knowledge and experience, the more sophisticated clinical reasoning will be. However, clinical reasoning research in dentistry shows varying results .

AIMS

This study aims to observe the clinical reasoning pattern of undergraduate dental students when solving oral health problems, and their accordance with their knowledge acquisition.

MATERIAL AND METHODS

This qualitative study employed the think-aloud method and the result was assessed through verbal protocol analyses. Five respondents from final year dental undergraduate students were agreed to participate. A unique hypothetical clinical scenario was used as a trigger. The audio data were transcribed, interpreted, and categorized as a clinical reasoning pattern; and the concept maps created were assessed by a Structure of Learning Outcomes (SOLO) taxonomy as knowledge acquisition.

RESULTS

Observations on clinical reasoning patterns and the level of knowledge acquisition in five undergraduate dental students showed varying results. They applied clinical reasoning patterns according to their knowledge acquisition during didactical phase. Learners with inadequate knowledge relied on guessing, meanwhile learners with adequate knowledge applied more sophisticated reasoning pattern when solving problems.

CONCLUSIONS

Various problem-solving strategies were encountered in this study, which corresponded to the level of knowledge acquisition. Dental institutions must set minimum standards regarding the acquisition of conceptual knowledge accompanied by improvement of clinical reasoning skills, as well as refinement of knowledge and procedural skills.

An examination of student nurse practitioners' diagnostic reasoning skills

AIM

To examine the diagnostic reasoning skills of two nurse practitioner student cohorts.

INTRODUCTION

Nurse practitioners continue to play a pivotal role in health care provision. Diagnostic reasoning is a core skill of advanced practice. A comparative diagnostic reasoning study between two student cohorts was undertaken between 2018 and 2019.

METHODS

A validated diagnostic reasoning scale was completed by nurse practitioner students in the United Kingdom and the United States of America at the beginning and end of their clinical placements. The study utilized descriptive quantitative statistics from the data submitted by 22 survey respondents from an online survey.

RESULTS

Analysis of the diagnostic reasoning skills suggested there was a difference in the structural memory scores when compared with the beginning of their clinical placements and the final semester of their clinical placements.

CONCLUSION

Diagnostic reasoning skills are a core skill of advanced practice. As students progress through their training, these skills improve. Despite the statistical difference in diagnostic reasoning scores, caution should be made in determining any larger implications due to the small number of participants in this study. Further study is needed in this area.

Semantic competency as a marker of clinical reasoning performance

Background: This study sought to explore the relationship between semantic competence (or dyscompetence) displayed during “think-alouds” performed by resident and attending physicians and clinical reasoning performance. Methods: Internal medicine resident physicians and practicing internists participated in think-alouds performed after watching videos of typical presentations of common diseases in internal medicine. The think-alouds were evaluated for the presence of semantic competence and dyscompetence and these results were correlated with clinical reasoning performance.  Results: We found that the length of think-aloud was negatively correlated with clinical reasoning performance. Beyond this finding, however, we did not find any other significant correlations between semantic competence or dyscompetence and clinical reasoning performance. Conclusions: While this study did not produce the previously hypothesized findings of correlation between semantic competence and clinical reasoning performance, we discuss the possible implications and areas of future study regarding the relationship between semantic competency and clinical reasoning performance.

Representation, interaction and interpretation. Making sense of the context in clinical reasoning

BACKGROUND

All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised.

AIMS

Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning.

DISCUSSION

We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning.

CONCLUSION

The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.

Unravelling the polyphony in clinical reasoning research in medical education

RATIONALE

Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion.

AIMS AND OBJECTIVES

We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses.

METHODS

A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review.

RESULTS

A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described.

CONCLUSIONS

Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.

Psychometric validation of the reconstructed version of the assessment of reasoning tool

BACKGROUND

Assessing learners' competence in diagnostic reasoning is challenging and unstandardized in medical education. We developed a theory-informed, behaviorally anchored rubric, the Assessment of Reasoning Tool (ART), with content and response process validity. This study gathered evidence to support the internal structure and the interpretation of measurements derived from this tool.

METHODS

We derived a reconstructed version of ART (ART-R) as a 15-item, 5-point Likert scale using the ART domains and descriptors. A psychometric evaluation was performed. We created 18 video variations of learner oral presentations, portraying different performance levels of the ART-R.

RESULTS

152 faculty viewed two videos and rated the learner globally and then using the ART-R. The confirmatory factor analysis showed a favorable comparative fit index = 0.99, root mean square error of approximation = 0.097, and standardized root mean square residual = 0.026. The five domains, hypothesis-directed information gathering, problem representation, prioritized differential diagnosis, diagnostic evaluation, and awareness of cognitive tendencies/emotional factors, had high internal consistency. The total score for each domain had a positive association with the global assessment of diagnostic reasoning.

CONCLUSIONS

Our findings provide validity evidence for the ART-R as an assessment tool with five theoretical domains, internal consistency, and association with global assessment.

Grounding judgement in context: A conceptual learning model of clinical reasoning

CONTEXT

Contemporary research on clinical reasoning focuses on cognitive problem-solving processes. However, the decisive role that clinical context plays in clinical reasoning is often overlooked. We explored how novice learners make sense of the patient encounter in the clinical situation. In particular, we examined medical students' own judgements concerning diagnostic and management decisions and how the clinical context impacts on this. We aimed to produce a conceptual model of how students learn clinical reasoning in the clinical environment.

METHOD

We used grounded theory methodology to develop a conceptual learning model. A total of 23 medical students in their third academic year were recruited. Qualitative data were gathered from semi-structured interviews, participant observations and field interviews, during clinical clerkships.

RESULTS

Learners participating in the clinical environment experienced tensions, called 'Disjunctions.' These disjunctions emerged in the context of the student-patient encounter and in particular in situations where an element from the interaction with the patient was perceived as being inconsistent with existing frames of reference. We categorised the sources of disjunctions into four subcategories: (a) observing the manifestations of clinical signs in reality; (b) fitting the symptoms to a diagnosis; (c) considering management decisions, and (d) communicating a medical decision to the patient. Disjunctions involved an affective component and were associated with feelings of uncertainty. These tensions provoked reactions from the learners, leading them to reassess and modify held assumptions in order to accommodate the encountered inconsistent elements. This facilitated changes in judgement. When making a judgement, participants learned to take into consideration situational elements.

CONCLUSIONS

Students experience disjunctions in the clinical environment as they encounter situations that challenge their frames of reference. These disjunctions carry significant learning potential. This study can contribute to knowledge concerning the role of the patient encounter in advancing clinical reasoning by transforming problematic habits of the mind.

Clinical reasoning: exploring its characteristics and enhancing its learning

Clinical reasoning is an extensive and intricate field, dealing with the process of thinking and decision making in practice. Its study can be quite challenging because it is context and task dependent. Educational frameworks such as the conscious competence model and the dual process reasoning model have been developed to help its understanding. To enhance the learning of clinical reasoning, there are significant areas that can be targeted through learning processes. These include knowledge adequacy; ability to gather appropriate patient data; use of proper reasoning strategies to address specific clinical questions; and the ability to reflect and evaluate on decisions taken, together with the role of the wider practice community and the activity of professional socialisation. This article explores the characteristics of clinical reasoning and delves deeper into the various strategies that prove useful for learning.

Use of Inductive, Problem-Based Clinical Reasoning Enhances Diagnostic Accuracy in Final-Year Veterinary Students

Despite tremendous progression in the medical field, levels of diagnostic error remain unacceptably high. Cognitive failures in clinical reasoning are believed to be the major contributor to diagnostic error. There is evidence in the literature that teaching problem-based, inductive reasoning has the potential to improve clinical reasoning skills. In this study, 47 final-year veterinary medicine students at the Royal Veterinary College (RVC) were presented with a complex small animal medicine case. The participants were divided into two groups, one of which received a prioritized problem list in addition to the history, physical exam, and diagnostic test results provided to both groups. The students' written approaches to the case were then analyzed and assigned a diagnostic accuracy score (DAS) and an inductive reasoning score (IRS). The IRS was based on a series of predetermined characteristics consistent with the inductive reasoning framework taught at the RVC. No significant difference was found between the DAS scores of each group, indicating that the provision of a prioritized problem list did not impact diagnostic accuracy. However, a significant positive correlation between the IRS and DAS was illustrated for both groups of students, suggesting increased use of inductive reasoning is associated with increased diagnostic accuracy. These results contribute to a body of research proposing that inductive, problem-based reasoning teaching delivered in an additive model, can enhance the clinical reasoning skills of students and reduce diagnostic error.

The Tyranny of Content: "Content Coverage" as a Barrier to Evidence-Based Teaching Approaches and Ways to Overcome It

Instructors have inherited a model for conscientious instruction that suggests they must cover all the material outlined in their syllabus, and yet this model frequently diverts time away from allowing students to engage meaningfully with the content during class. We outline the historical forces that may have conditioned this teacher-centered model as well as the disciplinary pressures that inadvertently reward it. As a way to guide course revision and move to a learner-centered teaching approach, we propose three evidence-based strategies that instructors can adopt: 1) identify the core concepts and competencies for your course; 2) create an organizing framework for the core concepts and competencies; and 3) teach students how to learn in your discipline. We further outline examples of actions that instructors can incorporate to implement each of these strategies. We propose that moving from a content-coverage approach to these learner-centered strategies will help students better learn and retain information and apply it to new situations.

Sex Differences in Symptom Phenotypes Among Patients With Acute Myocardial Infarction

BACKGROUND

The diagnosis of acute myocardial infarction (AMI) is missed more frequently in young women than men, which may be related to the cognitive psychology of the diagnostic process. Physicians start the diagnostic process by intuitively recognizing familiar symptom phenotypes, but little is known about how symptoms combine in individuals as unique symptom phenotypes. We examined how symptoms of AMI combine as unique symptom phenotypes in individual patients to compare the distribution of symptom phenotypes in women versus men.

METHODS AND RESULTS

The VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) was a multicenter, observational cohort study of 3501 young adults hospitalized with AMI. Data were collected on presenting symptoms with standardized interviews and from medical record abstraction. The number and distribution of unique symptom phenotypes were compared between women and men. Because of the 2:1 female-to-male enrollment ratio, women and men were compared with permutation testing and repeated subsampling. There were 426 interview-symptom phenotypes in women and 280 in men. The observed difference between women and men of 146 phenotypes was significant, even allowing for the greater enrollment of women (permutation P=0.004, median difference 110 under the null hypothesis of no association between sex and phenotype). The repeated subsample analysis also showed significantly more interview-symptom phenotypes in women than men (206.8±7.3 versus 188.6±6.0, P<0.001). Women were more broadly distributed among symptom phenotype subgroups than men (P<0.001). Similar findings were observed in the analysis of symptoms abstracted from the medical record.

CONCLUSIONS

Women exhibited substantially more variation in unique symptom phenotypes than men, regardless of whether the symptoms were derived from structured interviews or abstracted from the medical record. These findings may provide an explanation for the higher missed diagnosis rate in young women with AMI and may have important implications for teaching and improving clinicians' ability to recognize the diagnosis of AMI in women.

Communication at Transitions of Care

Communication errors during transitions of care are a leading source of adverse events for hospitalized patients. This article provides an overview of the role of communication errors in adverse events, describes the complexities of communication for hospitalized patients, and provides evidence regarding the positive effects of applying high-reliability principles to transitions of care and culture of safety. Elements of effective handoffs and a detailed approach for successful implementation of a handoff program are provided. The role of handoff communication in medical education at all levels, as well as for the interprofessional team, is discussed.

Identifying the narrative used by educators in articulating judgement of performance

INTRODUCTION

Modern assessment in medical education is increasingly reliant on human judgement, as it is clear that quantitative scales have limitations in fully assessing registrars' development of competence and providing them with meaningful feedback to assist learning. For this, possession of an expert vocabulary is essential.

AIM

This study aims to explore how medical education experts voice their subjective judgements about learners and to what extent they are using clear, information-rich terminology (high-level semantic qualifiers); and to gain a better understanding of the experts' language used in these subjective judgements.

METHODS

Six experienced medical educators from urban and rural environments were purposefully selected. Each educator reviewed a registrar clinical case analysis in a think out loud manner. The transcribed data were analyzed, codes were identified and ordered into themes. Analysis continued until saturation was reached.

RESULTS

Five themes with subthemes emerged. The main themes were: (1) Demonstration of expertise; (2) Personal credibility; (3) Professional credibility; (4) Using a predefined structure and (5) Relevance.

DISCUSSION

Analogous to what experienced clinicians do in clinical reasoning, experienced medical educators verbalize their judgements using high-level semantic qualifiers. In this study, we were able to unpack these. Although there may be individual variability in the exact words used, clear themes emerged. These findings can be used to develop a helpful shared narrative for educators in observation-based assessment. The provision of a rich, detailed narrative will also assist in providing clarity to registrar feedback with areas of weakness clearly articulated to improve learning and remediation.

The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners

Background

Excellence in clinical reasoning is one of the most important outcomes of medical education programs, but assessing learners’ reasoning to inform corrective feedback is challenging and unstandardized.

Methods

The Society to Improve Diagnosis in Medicine formed a multi-specialty team of medical educators to develop the Assessment of Reasoning Tool (ART). This paper describes the tool development process. The tool was designed to facilitate clinical teachers’ assessment of learners’ oral presentation for competence in clinical reasoning and facilitate formative feedback. Reasoning frameworks (e.g. script theory), contemporary practice goals (e.g. high-value care [HVC]) and proposed error reduction strategies (e.g. metacognition) were used to guide the development of the tool.

Results

The ART is a behaviorally anchored, three-point scale assessing five domains of reasoning: (1) hypothesis-directed data gathering, (2) articulation of a problem representation, (3) formulation of a prioritized differential diagnosis, (4) diagnostic testing aligned with HVC principles and (5) metacognition. Instructional videos were created for faculty development for each domain, guided by principles of multimedia learning.

Conclusions

The ART is a theory-informed assessment tool that allows teachers to assess clinical reasoning and structure feedback conversations.

Uncovering the relation between clinical reasoning and diagnostic accuracy - An analysis of learner's clinical reasoning processes in virtual patients

BACKGROUND

Clinical reasoning is an important topic in healthcare training, assessment, and research. Virtual patients (VPs) are a safe environment to teach, assess and perform research on clinical reasoning and diagnostic accuracy. Our aim was to explore the details of the clinical reasoning process and diagnostic accuracy of undergraduate medical students when working with VPs using a concept mapping tool.

METHODS

Over seven months we provided access to 67 German and 30 English VPs combined with a concept mapping tool to visualize and measure the clinical reasoning process of identifying problems, differential diagnoses, recommended tests and treatment options, and composing a summary statement about a VP. A final diagnosis had to be submitted by the learners in order to conclude the VP scenario. Learners were allowed multiple attempts or could request the correct diagnosis from the system.

RESULTS

We analyzed 1,393 completed concept maps from 317 learners. We found significant differences between maps with a correct final diagnosis on one or multiple attempts and maps in which learners gave up and requested the solution from the system. These maps had lower scores, fewer summary statements, and fewer problems, differential diagnoses, tests, and treatments.

CONCLUSIONS

The different use patterns and scores between learners who had the correct final diagnosis on one or multiple attempts and those who gave up, indicate that diagnostic accuracy in the form of a correct final diagnosis on the first attempt has to be reconsidered as a sole indicator for clinical reasoning competency. For the training, assessment, and research of clinical reasoning we suggest focusing more on the details of the process to reach a correct diagnosis, rather than whether it was made in the first attempt.

How case representations of medical students change during case processing - Results of a qualitative study

Objective: Representations are mental summaries of a clinical case and help in understanding a clinical problem. However, it is still largely unknown which clinical information medical students include in their case representations. In this study, therefore, the structure and quality of students' case representations were examined to better understand the diagnostic process and its relationship to diagnostic accuracy. What information do medical students include in their representations and is there an association between this information and the diagnostic accuracy? Method: 43 medical students in the fourth and fifth clinical year worked on four clinical cases. During the diagnostic process, they were asked three times per case to write a case representation. 516 representations were qualitatively evaluated using a content-based coding scheme. An analysis was made of the nature and composition of the clinical information. In addition, the association between the general representation structure and the correct case solution was examined. Results: At the beginning, students include most of the clinical information in their representation (66%), but as the case progresses, they begin to select the information offered (2nd representation 42%, 3rd representation 38%). The length of the representation (number of words) does not correlate with the correct case solution (r=-0.08-0.31). The representations do not depend on the case difficulty but have a significant individual component: the representations written by a student are formally very similar in all four cases (r=0.60-0.86). Conclusion: Medical students can select the relevant clinical information and include it in their case representations. Lack of representation does not seem to be a reason for misdiagnosis; Students' deficits in diagnosis are more likely due to knowledge gaps.

Diagnosing and Remediating Clinical Reasoning Difficulties: A Faculty Development Workshop

INTRODUCTION

Clinical reasoning is a complex cognitive process that involves multiple steps. Diagnosing and remediating clinical reasoning difficulties requires faculty to have an understanding of the cognitive theory behind clinical reasoning, familiarity with terminology, and a framework to identify different domains of struggle in their learners. Published resources on faculty development to diagnose and remediate clinical reasoning difficulties are limited. We created and implemented a workshop to assist faculty in developing these skills based on the five-domain framework described by Audétat, Laurin, and Sanche. This workshop provides all the materials needed to replicate this training with faculty at other institutions.

METHODS

The workshop consists of a didactic component and case-based active learning in small groups. Each case focuses on different domains of clinical reasoning difficulties and targets different learner levels (preclinical medical students through residents). The workshop was given in multiple venues in 2016 and 2017.

RESULTS

Participants reported the session was valuable (4.71/5.0), the facilitators were effective (4.5/5.0), and the objectives were met (4.28/5.0). They highlighted the strengths of the interactive format, the framework to diagnose and remediate clinical reasoning difficulties, and the excellent take-home resources. They suggested more time for the workshop, revision of cases to better highlight difficulties, and refinement of instructions to approach the cases. These suggestions were incorporated into the current iteration of the workshop.

DISCUSSION

We successfully implemented a workshop for diagnosing and remediating clinical reasoning difficulties in multiple venues. The sessions were diverse in terms of faculty participants and learner groups addressed.

The effect of multimedia replacing text in resident clinical decision-making assessment

Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η _p²  = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η _p²  = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in CDMS, particularly in less experienced clinicians.

Transforming Medical Assessment: Integrating Uncertainty Into the Evaluation of Clinical Reasoning in Medical Education

In an age where practicing physicians have access to an overwhelming volume of clinical information and are faced with increasingly complex medical decisions, the ability to execute sound clinical reasoning is essential to optimal patient care. The authors propose two concepts that are philosophically paramount to the future assessment of clinical reasoning in medicine: assessment in the context of "uncertainty" (when, despite all of the information that is available, there is still significant doubt as to the best diagnosis, investigation, or treatment), and acknowledging that it is entirely possible (and reasonable) to have more than "one correct answer." The purpose of this article is to highlight key elements related to these two core concepts and discuss genuine barriers that currently exist on the pathway to creating such assessments. These include acknowledging situations of uncertainty, creating clear frameworks that define progressive levels of clinical reasoning skills, providing validity evidence to increase the defensibility of such assessments, considering the comparative feasibility with other forms of assessment, and developing strategies to evaluate the impact of these assessment methods on future learning and practice. The authors recommend that concerted efforts be directed toward these key areas to help advance the field of clinical reasoning assessment, improve the clinical care decisions made by current and future physicians, and have positive outcomes for patients. It is anticipated that these and subsequent efforts will aid in reaching the goal of making future assessment in medical education more representative of current-day clinical reasoning and decision making.

How Expert Clinicians Intuitively Recognize a Medical Diagnosis

Research has shown that expert clinicians make a medical diagnosis through a process of hypothesis generation and verification. Experts begin the diagnostic process by generating a list of diagnostic hypotheses using intuitive, nonanalytic reasoning. Analytic reasoning then allows the clinician to test and verify or reject each hypothesis, leading to a diagnostic conclusion. In this article, we focus on the initial step of hypothesis generation and review how expert clinicians use experiential knowledge to intuitively recognize a medical diagnosis.

Teaching and Assessing Clinical Reasoning Skills

Clinical reasoning is a core competency expected to be acquired by all clinicians. It is the ability to integrate and apply different types of knowledge, weigh evidence critically and reflect upon the process used to arrive at a diagnosis. Problems with clinical reasoning often occur because of inadequate knowledge, flaws in data gathering and improper approach to information processing. Some of the educational strategies which can be used to encourage acquisition of clinical reasoning skills are: exposure to a wide variety of clinical cases, activation of previous knowledge, development of illness scripts, sharing expert strategies to arrive at a diagnosis, forcing students to prioritize differential diagnoses; and encouraging reflection, metacognition, deliberate practice and availability of formative feedback. Assessment of clinical reasoning abilities should be done throughout the training course in diverse settings. Use of scenario based multiple choice questions, key feature test and script concordance test are some ways of theoretically assessing clinical reasoning ability. In the clinical setting, these skills can be tested in most forms of workplace based assessment. We recommend that clinical reasoning must be taught at all levels of medical training as it improves clinician performance and reduces cognitive errors.

Does medical students' diagnostic performance improve by observing examples of self-explanation provided by peers or experts?

Educational strategies that promote the development of clinical reasoning in students remain scarce. Generating self-explanations (SE) engages students in active learning and has shown to be an effective technique to improve clinical reasoning in clerks. Example-based learning has been shown to support the development of accurate knowledge representations. The purpose of this study was to investigate the effect of combining student's SE and observation of peer's or expert's SE examples on diagnostic performance. Fifty-three third-year medical students were assigned to a peer SE example, an expert SE example or control (no example) group. All participants solved a set of the same four clinical cases (training cases), 1-after SE, 2-after listening to a peer or expert SE example or after a control task, and 3-1 week later. They solved a new set of four different cases (transfer cases) also 1 week later. For training cases, students improved significantly their diagnostic performance overtime but the main effect of group was not significant suggesting that students' SE mainly drives the observed effect. On transfer cases, there was no difference between the three groups (p > .05). Educational implications are discussed and further studies on different types of examples and additional strategies to help students actively process examples are proposed.

Novel Examination for Evaluating Medical Student Clinical Reasoning: Reliability and Association With Patients Seen

Background: Medical students learn clinical reasoning, in part, through patient care. Although the numbers of patients seen is associated with knowledge examination scores, studies have not demonstrated an association between patient problems and an assessment of clinical reasoning. Aim: To examine the reliability of a clinical reasoning examination and investigate whether there was association between internal medicine core clerkship students' performance on this examination and the number of patients they saw with matching problems during their internal medicine clerkship. Methods: Students on the core internal medicine clerkship at the Uniformed Services University students log 11 core patient problems based on the Clerkship Directors in Internal Medicine curriculum. On a final clerkship examination (Multistep), students watch a scripted video encounter between physician and patient actors that assesses three sequential steps in clinical reasoning: Step One focuses on history and physical examination; Step Two, students write a problem list after viewing additional clinical findings; Step Three, students complete a prioritized differential diagnosis and treatment plan. Each Multistep examination has three different cases. For graduating classes 2010–2012 (n = 497), we matched the number of patients seen with the problem most represented by the Multistep cases (epigastric pain, generalized edema, monoarticular arthritis, angina, syncope, pleuritic chest pain). We report two-way Pearson correlations between the number of patients students reported with similar problems and the student's percent score on: Step One, Step Two, Step Three, and Overall Test. Results: Multistep reliability: Step 1, 0.6 to 0.8; Step 2, 0.41 to 0.65; Step 3, 0.53 to 0.78; Overall examination (3 cases): 0.74 to 0.83. For three problems, the number of patients seen had small to modest correlations with the Multistep Examination of Analytic Ability total score (r = 0.27 for pleuritic pain, p &lt; 0.05, n = 81 patients; r = 0.14 for epigastric pain, p &lt; 0.05, n = 324 patients; r = 0.19 for generalized edema, p &lt; 0.05, n = 118 patients). Discussion or Conclusion: Although a reliable assessment, student performance on a clinical reasoning examination was weakly associated with the numbers of patients seen with similar problems. This may be as a result of transfer of knowledge between clinical and examination settings, the complexity of clinical reasoning, or the limits of reliability with patient logs and the Multistep.

Sequencing learning experiences to engage different level learners in the workplace: An interview study with excellent clinical teachers

PURPOSE

Learning in the clinical workplace can appear to rely on opportunistic teaching. The cognitive apprenticeship model describes assigning tasks based on learner rather than just workplace needs. This study aimed to determine how excellent clinical teachers select clinical learning experiences to support the workplace participation and development of different level learners.

METHODS

Using a constructivist grounded theory approach, we conducted semi-structured interviews with medical school faculty identified as excellent clinical teachers teaching multiple levels of learners. We explored their approach to teach different level learners and their perceived role in promoting learner development. We performed thematic analysis of the interview transcripts using open and axial coding.

RESULTS

We interviewed 19 clinical teachers and identified three themes related to their teaching approach: sequencing of learning experiences, selection of learning activities and teacher responsibilities. All teachers used sequencing as a teaching strategy by varying content, complexity and expectations by learner level. The teachers initially selected learning activities based on learner level and adjusted for individual competencies over time. They identified teacher responsibilities for learner education and patient safety, and used sequencing to promote both.

CONCLUSIONS

Excellent clinical teachers described strategies for matching available learning opportunities to learners' developmental levels to safely engage learners and improve learning in the clinical workplace.

Educational strategies for improving clinical reasoning

Clinical reasoning serves as a crucial skill for all physicians regardless of their area of expertise. Helping trainees develop effective and appropriate clinical reasoning abilities is a central aim of medical education. Teaching clinical reasoning however can be a very difficult challenge for practicing physicians. Better understanding of the different cognitive processes involved in physician clinical reasoning provides a foundation from which to guide learner development of effective reasoning skills, while pairing assessment of learner reasoning abilities with understanding of different improvement strategies offers the opportunity to maximize educational efforts for learners. Clinical reasoning errors often can occur as a result of one of four problems in trainees as well as practicing physicians; inadequate knowledge, faulty data gathering, faulty data processing, or faulty metacognition. Educators are encouraged to consider at which point a given learner's reasoning is breaking down. Experimentation with different strategies for improving clinical reasoning can help address learner struggles in each of these domains. In this chapter, various strategies for improving reasoning related to knowledge acquisition, data gathering, data processing, and clinician metacognition will be discussed. Understanding and gaining experience using the different educational strategies will provide practicing physicians with a toolbox of techniques for helping learners improve their reasoning abilities.

How is clinical reasoning developed, maintained, and objectively assessed? Views from expert internists and internal medicine interns

INTRODUCTION

There is limited understanding of how clinical reasoning is developed, maintained, and objectively assessed. Using the theoretical lens of deliberate practice, we explored physicians' views on clinical reasoning. We compared responses from internists (faculty) and internal medicine interns, to identify potential qualitative and/or quantitative differences in how clinical reasoning is developed and maintained.

METHODS

Participants' free-text comments regarding how clinical reasoning is developed, maintained, and objectively assessed were analyzed. Three investigators coded responses using a constant-comparative, grounded theory approach. We also compared the frequencies of each theme between the 2 groups.

RESULTS

Twenty-two faculty and 17 interns participated in this study. Faculty and intern themes for how clinical reasoning is developed, maintained, and objectively assessed were similar, but quantitative and qualitative differences emerged. Interrater reliability of themes was high (overall kappa: 0.92; range: 0.88-0.98). Only experts (faculty) mentioned the value of teaching for development and maintenance of clinical reasoning. Interns focused on knowledge acquisition activities and use of online resources. Experts and intern participants both struggled with how to best measure clinical reasoning; direct observation was rarely mentioned as a strategy.

DISCUSSION

Consistent with our theoretical expectations, we found quantitative and qualitative differences in participants' responses, which have implications for teaching and assessment of clinical reasoning. By capturing the types of activities and their relative frequencies within and between these groups, this work adds to the deliberate practice literature.

Acquisition of clinical competence: Added value of clerkship real-life contextual experience

BACKGROUND

Medical students' limited access to patients induces a shift of learning activities from clinical wards to classrooms.

AIM

Identify clinical competencies specifically acquired during real-life contextual clerkship added to case-based tutorials, by a prospective, controlled study.

METHODS

Students entering our eight-week internal medicine (IM) clerkship attended paper case-based tutorials about 10 common presenting complaints and were assigned to an IM specialty ward. For each tutorial case, two groups of students were created: those assigned to a ward, the specialty of which was unrelated to the case (case-unrelated ward, CUW) and those assigned to a ward, the specialty of which was related to the case (case-related ward, CRW).

RESULTS

Forty-one students (30 CUW and 11 CRW) volunteered for the study. Both groups had similar previous experiences and pre-clerkship exam scores. The CRW students collected more relevant clinical information from the patient (69% vs. 55% of expected items, p=0.001) and elaborated charts of better quality (47% vs. 39% of expected items, p=0.05). Clinical-knowledge mean score was similar (70%) in both groups (p=0.92).

CONCLUSIONS

While paper-case tutorials did provide students with clinical knowledge, real contextual experience brought additional, specific competencies. This supports the preservation of clinical exposure with supervision and feedback.

Clinical reasoning processes: unravelling complexity through graphical representation

CONTEXT

Clinical reasoning is a core skill in medical practice, but remains notoriously difficult for students to grasp and teachers to nurture. To date, an accepted model that adequately captures the complexity of clinical reasoning processes does not exist. Knowledge-modelling software such as mot Plus (Modelling using Typified Objects [MOT]) may be exploited to generate models capable of unravelling some of this complexity.

OBJECTIVES

This study was designed to create a comprehensive generic model of clinical reasoning processes that is intended for use by teachers and learners, and to provide data on the validity of the model.

METHODS

Using a participatory action research method and the established modelling software (mot Plus), knowledge was extracted and entered into the model by a cognitician in a series of encounters with a group of experienced clinicians over more than 250 contact hours. The model was then refined through an iterative validation process involving the same group of doctors, after which other groups of clinicians were asked to solve a clinical problem involving simulated patients.

RESULTS

A hierarchical model depicting the multifaceted processes of clinical reasoning was produced. Validation rounds suggested generalisability across disciplines and situations.

CONCLUSIONS

The MOT model of clinical reasoning processes has potentially important applications for use within undergraduate and graduate medical curricula to inform teaching, learning and assessment. Specifically, it could be used to support curricular development because it can help to identify opportune moments for learning specific elements of clinical reasoning. It could also be used to precisely identify and remediate reasoning errors in students, residents and practising doctors with persistent difficulties in clinical reasoning.

Utilization of case presentations in medical microbiology to enhance relevance of basic science for medical students

BACKGROUND

Small-group case presentation exercises (CPs) were created to increase course relevance for medical students taking Medical Microbiology (MM) and Infectious Diseases (ID) METHODS: Each student received a unique paper case and had 10 minutes to review patient history, physical exam data, and laboratory data. Students then had three minutes to orally present their case and defend why they ruled in or out each of the answer choices provided, followed by an additional three minutes to answer questions.

RESULTS

Exam scores differed significantly between students who received the traditional lecture-laboratory curriculum (Group I) and students who participated in the CPs (Group II). In MM, median unit exam and final exam scores for Group I students were 84.4% and 77.8%, compared to 86.0% and 82.2% for Group II students (P<0.018; P<0.001; Mann-Whitney Rank Sum Test). Median unit and final ID exam scores for Group I students were 84.0% and 80.0%, compared to 88.0% and 86.7% for Group II students (P<0.001; P<0.001).

CONCLUSION

Students felt that the CPs improved their critical thinking and presentation skills and helped to prepare them as future physicians.

The influence of medical students' self-explanations on diagnostic performance

CONTEXT

Skill in clinical reasoning is a highly valued attribute of doctors, but instructional approaches to foster medical students' clinical reasoning skills remain scarce. Self-explanation is an instructional procedure, the positive effects of which on learning have been demonstrated in a variety of domains, but which remain largely unexplored in medical education.

OBJECTIVES

The purpose of this study was to investigate the effects of self-explanation on students' learning of clinical reasoning during clerkships and to examine whether these effects are affected by topic familiarity.

METHODS

An experimental study with a training phase and an assessment phase was conducted with 36 Year 3 medical students, randomly assigned to one of two groups. In the training phase, students solved 12 clinical cases (four cases on a less familiar topic; four on a more familiar topic; four on filler topics), either generating self-explanations (n = 18) or not (n = 18). The self-explanations were generated after minimal instructions and no feedback was provided to students. One week later, in the assessment phase, students were requested to diagnose 12 different, more difficult cases, similarly distributed among the same more familiar topic, less familiar topic and filler topics, and their diagnostic performance was assessed.

RESULTS

In the training phase the performance of the two groups did not differ. However, in the assessment phase 1 week later, a significant interaction was found between self-explanation and case topic familiarity (F(1,34) = 6.18, p < 0.05). Students in the self-explanation condition, compared with those in the control condition, demonstrated better diagnostic performance on subsequent clinical cases, but this effect emerged only for cases concerning the less familiar topic.

CONCLUSIONS

The present study shows the beneficial influence of generating self-explanations when dealing with less familiar clinical contexts. Generating self-explanations without feedback resulted in better diagnostic performance than in the control group at 1 week after the intervention.