Exploring mechanisms underlying learning from deliberate reflection: An experimental study.

INTRODUCTION: Previous research suggests that, relative to generating a differential diagnosis, deliberate reflection during practice with clinical cases fosters learning from a subsequently studied scientific text and promotes interest in the subject matter. The present experiment aimed to replicate these findings and to examine whether motivational or cognitive mechanisms, or both, underlie the positive effects of reflection. METHODS: A total of 101 5th-year medical students participated in an experiment containing four phases: Students (a) diagnosed two clinical cases of jaundice-related diseases either through deliberate reflection or differential diagnosis; (b) reported their situational interest and awareness of knowledge gaps; (c) studied a text about jaundice, either under free or restricted time; and (d) recalled the text. Outcome measures were text-recall, situational interest and awareness of knowledge gaps. RESULTS: A main effect of diagnostic approach on recall of the text was found, with the reflection group recalling more studied material than the differential diagnosis group (means: 72.56 vs 58.80; P = .01). No interaction between diagnostic approach and study time (free or restricted) emerged, nor was there a main effect of the latter. Relative to the differential diagnosis group, students who reflected upon the cases scored significantly higher on both situational interest (means: 4.45 vs 3.99, P < .001) and awareness of knowledge gaps (means: 4.13 vs 3.85, P < .01). DISCUSSION: Relative to generating differential diagnoses, reflection upon clinical cases increased learning outcomes on a subsequent study task, an effect that was independent of study time, suggesting that cognitive mechanisms underlie this effect, rather than increases in motivation to study. However, higher scores on situational interest and awareness of knowledge gaps and a tendency towards larger gains when time was free suggest that higher motivation may also contribute to learning from reflection.

'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment.

BACKGROUND: Diagnostic errors have often been attributed to biases in physicians' reasoning. Interventions to 'immunise' physicians against bias have focused on improving reasoning processes and have largely failed. OBJECTIVE: To investigate the effect of increasing physicians' relevant knowledge on their susceptibility to availability bias. DESIGN, SETTINGS AND PARTICIPANTS: Three-phase multicentre randomised experiment with second-year internal medicine residents from eight teaching hospitals in Brazil. INTERVENTIONS: Immunisation: Physicians diagnosed one of two sets of vignettes (either diseases associated with chronic diarrhoea or with jaundice) and compared/contrasted alternative diagnoses with feedback. Biasing phase (1 week later): Physicians were biased towards either inflammatory bowel disease or viral hepatitis. Diagnostic performance test: All physicians diagnosed three vignettes resembling inflammatory bowel disease, three resembling hepatitis (however, all with different diagnoses). Physicians who increased their knowledge of either chronic diarrhoea or jaundice 1 week earlier were expected to resist the bias attempt. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy, measured by test score (range 0-1), computed for subjected-to-bias and not-subjected-to-bias vignettes diagnosed by immunised and not-immunised physicians. RESULTS: Ninety-one residents participated in the experiment. Diagnostic accuracy differed on subjected-to-bias vignettes, with immunised physicians performing better than non-immunised physicians (0.40 vs 0.24; difference in accuracy 0.16 (95% CI 0.05 to 0.27); p=0.004), but not on not-subjected-to-bias vignettes (0.36 vs 0.41; difference -0.05 (95% CI -0.17 to 0.08); p=0.45). Bias only hampered non-immunised physicians, who performed worse on subjected-to-bias than not-subjected-to-bias vignettes (difference -0.17 (95% CI -0.28 to -0.05); p=0.005); immunised physicians' accuracy did not differ (p=0.56). CONCLUSIONS: An intervention directed at increasing knowledge of clinical findings that discriminate between similar-looking diseases decreased physicians' susceptibility to availability bias, reducing diagnostic errors, in a simulated setting. Future research needs to examine the degree to which the intervention benefits other disease clusters and performance in clinical practice. TRIAL REGISTRATION NUMBER: 68745917.1.1001.0068.

Learning by teaching basic life support: a non-randomized controlled trial with medical students.

BACKGROUND: Cardiopulmonary resuscitation is usually taught in universities through theoretical lectures and simulations on mannequins with low retention of knowledge and skills. New teaching methodologies have been used to improve the learning, placing the student at the center of the process. Likewise, the outside community knows next to nothing about cardiopulmonary resuscitation. Patients who have an out-of-hospital cardiac arrest will die if the effective maneuvers are not promptly done. Learning by teaching could be a way to answer both requirements. It was therefore decided to evaluate whether the medical students' cardiopulmonary resuscitation performance would improve when they teach other people, and if those people could learn with them effectively. METHODS: A non-randomized controlled trial was designed to assess whether teaching Basic Life Support would increase students' learning. Socially engaged, seeking to disseminate knowledge, 92 medical students were trained in Basic Life Support and who subsequently trained 240 community health professionals. The students performed theoretical and practical pre- and post-tests whereas the health professionals performed theoretical pre- and post-tests and one practical test. In order to assess the impact of teaching on students' learning, they were divided into two groups: a case group, with 53 students, reassessed after teaching health professionals, and a control group, with 39 students, reassessed before teaching. RESULTS: The practical students' performance of the case group went from 13.3 ± 2.1 to 15.3 ± 1.2 (maximum = 17, p < 0.001) and theoretical from 10.1 ± 3.0 to 16.4 ± 1.7 (maximum = 20, p < 0.001) while the performance of the control group went from 14.4 ± 1.6 to 14.4 ± 1.4 (p = 0.877) and from 11.2 ± 2.6 to 15.0 ± 2.3 (p < 0.001), respectively. The theoretical performance of the health professionals changed from 7.9 ± 3.6 to 13.3 ± 3.2 (p < 0.001) and the practical performance was 11.7 ± 3.2. CONCLUSIONS: The students who passed through the teaching activity had a theoretical and practical performance superior to that of the control group. The community was able to learn from the students. The study demonstrated that the didactic activity can be an effective methodology of learning, besides allowing the dissemination of knowledge. The University, going beyond its academic boundaries, performs its social responsibility.

Effects of deliberate reflection on students' engagement in learning and learning outcomes.

CONTEXT: Reflection in practice is assumed to enhance interest in knowing more about a topic, increasing engagement in learning and learning outcomes. However, this claim lacks empirical evidence, particularly in medical education. The authors investigated the effects of deliberate reflection upon clinical cases on medical students' engagement in a learning activity and learning outcomes. METHODS: A three-task (diagnostic task; learning activity; test) experiment was conducted in August 2017. Seventy-two fourth-year students from UNIFENAS-BH Medical School, Brazil, diagnosed two clinical cases with jaundice as the chief complaint, either by following a deliberate reflection procedure or making differential diagnosis. Subsequently, all participants received the same study material on the diagnosis of jaundice. Finally, they took a recall test on the study material. Outcome measurements were study time and test scores. RESULTS: There was a significant effect of experimental condition on students' engagement in the learning activity and on learning outcomes. Students who deliberately reflected upon the cases invested more time in studying the material than those who made a differential diagnosis (respectively, mean = 254.97, standard deviation = 115.45 versus mean = 194.96, standard deviation = 111.68; p = 0.02; d = 0.53). Deliberate reflection was also related to higher scores in the test relative to differential diagnosis (respectively, mean = 22.08, standard deviation = 14.94 versus mean = 15.75, standard deviation = 9.24; p = 0.03; d = 0.51). Medium effect sizes (Cohen's d) were observed in both measurements. CONCLUSIONS: Relative to making differential diagnosis, deliberate reflection while diagnosing cases fostered medical students' engagement in learning and increased learning outcomes. Teachers can employ this relatively easy procedure, possibly both with simulated and real scenarios, to motivate their students and help them expand their knowledge, an important requirement for their professional development.

The effect of self-explanation of pathophysiological mechanisms of diseases on medical students' diagnostic performance.

Self-explanation while diagnosing clinical cases fosters medical students' diagnostic performance. In previous studies on self-explanation, students were free to self-explain any aspect of the case, and mostly clinical knowledge was used. Elaboration on knowledge of pathophysiological mechanisms of diseases has been largely unexplored in studies of strategies for teaching clinical reasoning. The purpose of this two-phase experiment was to investigate the effect of self-explanation of pathophysiology during practice with clinical cases on students' diagnostic performance. In the training phase, 39 4th-year medical students were randomly assigned to solve 6 criterion cases (3 of jaundice; 3 of chest pain), either self-explaining the pathophysiological mechanisms of the findings (n = 20) or without self-explaining (n = 19). One-week later, in the assessment phase, all students solved 6 new cases of the same syndromes. A repeated-measures analysis of variance on the mean diagnostic accuracy scores showed no significant main effects of study phase (p = 0.34) and experimental condition (p = 0.10) and no interaction effect (p = 0.42). A post hoc analysis found a significant interaction (p = 0.022) between study phase and syndrome type. Despite equal familiarity with jaundice and chest pain, the performance of the self-explanation group (but not of the non-self-explanation group) on jaundice cases significantly improved between training and assessment phases (p = 0.035) whereas no differences between phases emerged on chest pain cases. Self-explanation of pathophysiology did not improve students' diagnostic performance for all diseases. Apparently, the positive effect of this form of self-explanation on performance depends on the studied diseases sharing similar pathophysiological mechanisms, such as in the jaundice cases.

How can students' diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases.

PURPOSE: To develop diagnostic competence, students should practice with many examples of clinical problems to build rich mental representations of diseases. How to enhance learning from practice remains unknown. This study investigated the effects of reflection on cases compared with generating a single or differential diagnosis. METHOD: In 2012, during the learning phase, 110 fourth-year medical students diagnosed four cases of two criterion diseases under three different experimental conditions: structured reflection, single-diagnosis, or differential-diagnosis. One week later, they diagnosed two novel exemplars of each criterion disease and four cases of new diseases that were not among the cases of the learning phase but were plausible alternative diagnoses. RESULTS: Diagnostic performance did not differ among the groups in the learning phase. One week later, the reflection group obtained higher mean diagnostic accuracy scores (range: 0-1) than the other groups when diagnosing new exemplars of criterion diseases (reflection: 0.67; single-diagnosis: 0.36, P < .001; differential-diagnosis: 0.51, P = .014) and cases of new diseases (reflection: 0.44; single-diagnosis: 0.32, P = .010; differential-diagnosis: 0.33, P = .015). No difference was found between the single-diagnosis and the differential-diagnosis conditions. CONCLUSIONS: Structured reflection while practicing with cases enhanced learning of diagnosis both of the diseases practiced and of their alternative diagnoses, suggesting that reflection not only enriched mental representations of diseases practiced relative to more conventional approaches to clinical learning but also influenced the representations of adjacent but different diseases. Structured reflection seems a useful addition to the existing clinical teaching methods.

Improving communication skill training in patient centered medical practice for enhancing rational use of laboratory tests: The core of bioinformation for leveraging stakeholder engagement in regulatory science.

Requests for laboratory tests are among the most relevant additional tools used by physicians as part of patient's health problemsolving. However, the overestimation of complementary investigation may be linked to less reflective medical practice as a consequence of a poor physician-patient communication, and may impair patient-centered care. This scenario is likely to result from reduced consultation time, and a clinical model focused on the disease. We propose a new medical intervention program that specifically targets improving the patient-centered communication of laboratory tests results, the core of bioinformation in health care. Expectations are that medical students training in communication skills significantly improve physicians-patient relationship, reduce inappropriate use of laboratorial tests, and raise stakeholder engagement.