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.

O que a pesquisa sobre raciocínio clínico tem a dizer a preceptores e professores de áreas clínicas? / What does research on clinical reasoning have to say to clinical teachers?

O raciocínio clínico é um fator determinante da performance do médico, crucial para chegar a um diagnóstico correto e possibilitar decisões terapêuticas adequadas. Ajudar seus estudantes a desenvolver o raciocínio clínico é um desafio diário de muitos professores e, para selecionar estratégias de ensino adequadas, pode ser útil conhecer um pouco dos resultados da pesquisa sobre raciocínio clínico que vem se desenvolvendo já há algumas décadas. Este artigo traz uma síntese de achados desta pesquisa que ajudam a compreender os processos cognitivos envolvidos no raciocínio clínico, a trajetória que leva o estudante de uma condição de "iniciante" `a de "expert" e abordagens instrucionais que têm se mostrado úteis para facilitar esta trajetória. O foco do artigo é o processo diagnóstico, porque é ele que tem sido o objeto central de pesquisa. Esta pesquisa indica que não há estratégias de raciocínio específicas, próprias do médico expert, que possam ser ensinadas ao estudante. É a existência de uma larga base de conhecimentos organizados na memória em scripts de doenças de diversos formatos que explica o melhor desempenho do expert. Quanto mais numerosos, mais ricos e melhor organizados são os scripts que um médico tem na memória, mais apto ele está para fazer diagnósticos acurados. Estes scripts são formados gradualmente ao longo dos anos de formação e para desenvolvê-los o estudante deve ser exposto a uma grande diversidade de problemas clínicos, com os quais ele deve interagir de forma ativa. Abordagens instrucionais que requerem que o estudante reflita de forma sistemática sobre os problemas, analisando diferenças e similaridades entre eles, explicando mecanismos subjacentes, comparando e contrastando diagnósticos alternativos têm se mostrado úteis para ajudar a refinar scripts de doenças e são ferramentas valiosas para os professores interessados no desenvolvimento do raciocínio clínico de seus estudantes.

Clinical reasoning is a crucial determinant of physicians' performance. It is key to arrive at a correct diagnosis, which substantially increases the chance of appropriate therapeutic decisions. Clinical teachers face the daily challenge of helping their students to develop clinical reasoning. To select appropriate teaching strategies, it may be useful to become acquainted with the results of the research on clinical reasoning that has been conducted over the last decades. This article synthesizes the findings of this research that help in particular to understand the cognitive processes involved in clinical reasoning, the trajectory that leads the student from novice to expert, and instructional approaches that have been shown to be useful to facilitating this trajectory. The focus of the article is the diagnostic process, because it is about it that most research has been conducted. This research indicates that there is not a particular reasoning strategy that is specific to expert physicians and could be taught to students. It is the availability of a large knowledge base organized in memory in illness scripts of different formats that explains the expert's better performance. The more, the richer, and the more well-structured are the illness scripts a physician has stored in memory, the more he/she would be able to make accurate diagnoses. These scripts are formed gradually over the years of education. To help develop them, students should be exposed to a wide variety of clinical problems, with which they must interact actively. Instructional approaches that require students to systematically reflect on problems, analyzing differences and similarities between them, explaining underlying mechanisms, comparing and contrasting alternative diagnoses, have proved useful to help refine disease scripts. These approaches are valuable tools for teachers concerned with the development of their students clinical reasoning.

Effects of deliberate reflection on diagnostic accuracy, confidence and diagnostic calibration in dermatology.

BACKGROUND: Deliberate reflection on initial diagnoses improved diagnostic accuracy in internal medicine and general practice, but it is unknown if the same occurs in specialties that rely mostly on visual perception, such as dermatology. Moreover, whether reflection influences diagnostic calibration has not been studied yet. Diagnostic calibration, the relationship between diagnostic accuracy and confidence in that accuracy, affects diagnostic performance because overconfidence tends to induce premature closure. This study evaluated the effects of deliberate reflection on diagnostic accuracy and diagnostic calibration in dermatology. METHODS: Sixty-one sixth-year students from a Brazilian medical school were allocated to either a reflection group (RG) or a control group (CG). In both groups, students worked with the same 12 dermatological images, presented sequentially, providing an initial diagnosis and confidence in that diagnosis. Subsequently, RG students reflected on the case using a structured procedure, while CG students performed a time-filler activity. All students then provided a final diagnosis and confidence in that diagnosis. Outcome measurements were diagnostic accuracy, confidence, and calibration. RESULTS: Reflection increased diagnostic accuracy relative to control (49.7 ± 12.1 vs 38.4 ± 14.6; p = 0.002) but did not affect confidence (64.3 ± 13.2 vs 58.9 ± 20.1; p = 0.228) nor calibration (0.15 ± 0.16 vs 0.20 ± 0.19, p = 0.197). Overall, case difficulty influenced calibration, with students showing more overconfidence on more difficult cases (p <0.001). CONCLUSIONS: Deliberate reflection increased diagnostic accuracy in dermatology but did not affect confidence and calibration. Calibration was worse on more difficult cases, suggesting that calibration is a knowledge-related phenomenon.

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.

Effect of reflection on medical students' situational interest: an experimental study.

CONTEXT: Reflection has been considered crucial to learning. Engaging in reflection while solving problems is expected to foster identification of knowledge gaps and interest in learning more about them, the latter being a major motivational force in learning. Although theoretically sound, this assumption still lacks empirical evidence. This experiment investigated whether reflection while diagnosing clinical cases of different levels of difficulty influences medical students' awareness of knowledge gaps and situational interest. METHODS: Forty-two fourth-year students from a Brazilian medical school were randomly allocated to diagnose six clinical cases (three difficult; three easy), either by following a structured reflection procedure (reflection group) or by giving alternative diagnoses (control group). Subsequently, for each case, all students rated their situational interest and awareness of knowledge gaps. RESULTS: Situational interest was significantly higher in the reflection group than in the control group (mean = 4.10, standard deviation = 0.50 versus mean = 3.65, standard deviation = 0.48, respectively; p = 0.003; range, 1-5). The effect size was large (d = 0.92). Awareness of knowledge gaps was higher in the reflection group than in the control group, but the difference was not significant. Case difficulty influenced both situational interest, which was significantly higher on easy than on difficult cases (mean = 3.96, standard deviation = 0.56 versus mean = 3.80, standard deviation = 0.55, respectively; p = 0.004), and awareness of knowledge gaps, with higher scores observed on difficult compared with easy cases (mean = 3.99, standard deviation = 0.46 versus mean = 3.66, standard deviation = 0.53, respectively; p < .001). No interaction between experimental condition and case difficulty emerged. CONCLUSION: Relative to providing alternative diagnoses while solving cases, structured reflection increased medical students' interest and may therefore be a useful tool for teachers concerned with enhancing students' motivation for learning. Surprisingly, easy cases promoted higher situational interest despite the higher awareness of knowledge gaps on difficult cases. This suggests the potential for case difficulty to inhibit students' interest in learning, a possibility that demands further investigation.

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.

Effectiveness of an online Problem-Based learning curriculum for training family medical doctors in Brazil.

BACKGROUND: Problem-based learning (PBL) and distance education (DE) have been combined as educational approaches in higher education. This combination has been called distributed PBL. In health professions education it has been called online PBL (OPBL). However, more research on the effectiveness of OPBL is needed. The present study aims at evaluating the effectiveness of an OPBL curriculum for training family medical doctors in Brazil. METHODS: We used a pretest-posttest control group design in this study. Thirty family physician participants were non-randomly assigned to the experimental group and the same number to the control group. Three instruments for collecting data were used: A multiple choice question knowledge test, an Objective Structural Clinical Examination (OSCE) for assessing the ability to apply the Mini Mental State Exam (MMSE) and a test based on clinical cases for assessing the ability to make an adequate differential diagnosis of dementia. Multivariate Analysis of Variance (MANOVA) and univariate tests were conducted to see if the difference between the two groups was significant. The effect size was measured by Cohen's d. RESULTS: A total of 50 participants completed the study. The results show significant effects of the course on participants' knowledge and diagnostic skills. DISCUSSION: The results may indicate that innovative pedagogical approaches such as PBL can be effective in an online environment in a low-resources context, with the advantages of DE approach.

Effects of 2 educational interventions on the management of hypertensive patients in primary health care.

INTRODUCTION: Experimental studies on the effectiveness of educational interventions to improve patient care are scarce, especially for low-resources settings. This study investigated the effects of 2 educational interventions on the treatment of hypertensive patients in primary health care in Brazil. METHODS: Forty-one physicians were randomly assigned either to an "active educational intervention" (21 physicians) or to a "passive educational intervention" (20 physicians). The former comprised 1 small group discussion of routine practices, 1 outreach visit, and 3 reminders. The latter consisted of delivery of printed guidelines. Measures of quality of treatment provided for hypertensive patients (181 patients of physicians from the active intervention; 136 patients of physicians from the passive intervention) were obtained through patient interview and charts review, before and 3 months after the intervention. Chi-square and independent t-tests were performed for comparison between the conditions. RESULTS: The groups did not differ before the study. After the intervention, the active intervention group outperformed the passive intervention group in several measures, such as improved prescription of antihypertensive drugs (80% of patients of physicians from the active intervention vs 51% patients of physicians from the passive intervention; p < .01), prescription of aspirin (18% vs 6%; p < .01) and hypolipidemic drugs for high-risk patients (39% vs 21%; p < .01), dietary counseling (76% vs 61%; p < .01), guidance on cardiovascular risk (20% vs 3%; p < .01). Patient outcomes did not differ. DISCUSSION: A multifaceted intervention based on review of practices improved treatment of hypertensive patients in a low-resource setting whereas delivery of guidelines did not help. None of the interventions affected patient outcomes.

Effects of free, cued and modelled reflection on medical students' diagnostic competence.

CONTEXT: Structured reflection while practising the diagnosing of cases has been shown to improve medical students' learning of clinical diagnosis. The present study investigated whether additional instructional guidance increases the benefits of reflection by comparing the effects of free, cued and modelled reflection on learning. METHODS: Fifty-eight Year 5 and 57 Year 6 medical students participated in a three-phase experiment. During the learning phase, participants diagnosed eight clinical cases under different experimental conditions: free reflection; cued reflection, and modelled reflection. In an immediate test and a delayed test administered 1 week later, they diagnosed new sets of eight different cases, four of which presented diseases they had studied during the learning phase. Learning was measured according to diagnostic accuracy on the cases that involved the four diseases that appeared in all phases. RESULTS: Repeated-measures analysis of variance (anova) of mean scores for diagnostic accuracy (range: 0-1) showed a significant main effect of experimental condition (p < 0.001), year of training (p = 0.013), and performance moment (p = 0.003), without significant interaction effects. Overall, the modelled reflection group and the cued reflection group did not differ in performance (p = 1.00), but both outperformed the free reflection group (p < 0.001 for both comparisons). Overall performance increased in the delayed test relative to the immediate test (p = 0.004) and to the learning phase (p = 0.03), but did not differ in the latter two phases. Both Year 6 and Year 5 students rated studying examples of reflection as less effortful than either cued or free reflection in the learning phase (p < 0.001 for all comparisons). CONCLUSIONS: Students apparently learn more with less effort by studying correct structured reflection while practising the diagnosing of cases than by reflecting without any instructional guidance. Examples of reflection and cued reflection were more beneficial for learning than free reflection and may represent a useful instructional strategy for clinical teaching.

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.

Effects of reviewing routine practices on learning outcomes in continuing education.

CONTEXT: Conventional continuing medical education (CME) has been shown to have modest effects on doctor performance. New educational approaches based on the review of routine practices have brought better results. Little is known about factors that affect the outcomes of these approaches, especially in middle-income countries. This study aimed to investigate factors that influence the learning and quality of clinical performance in CME based on reflection upon experiences. METHODS: A questionnaire and a clinical performance test were administered to 165 general practitioners engaged in a CME programme in Brazil. The questionnaire assessed behaviours related to four input variables (individual reflection on practices, peer review of experiences, self-regulated learning and learning skills) and two mediating variables (identification of learning needs and engagement in learning activities, the latter consisting of self-study of scientific literature, consultations about patient problems, and attendance at courses). Structural equation modelling was used to test a hypothesised model of relationships between these variables and the outcome variable of clinical performance, measured by the clinical performance test. RESULTS: After minor adjustments, the hypothesised model fit the empirical data well. Individual reflection fostered identification of learning needs, but also directly positively influenced the quality of clinical performance. Peer review did not affect identification of learning needs, but directly positively affected clinical performance. Learning skills and self-regulation did not help in identifying learning needs, but self-regulation enhanced study of the scientific literature, the learning activity that most positively influenced clinical performance. Consultation with colleagues, the activity most frequently triggered by the identification of learning needs, did not affect performance, and attendance of courses had only limited effect. CONCLUSIONS: This study shed light on the factors that influence learning and performance improvement in continuing education based on the review of routine practices in middle-income settings. The findings support the importance of reflection on practices as an instrument for enhancing clinical performance.

Effects of reflective practice on the accuracy of medical diagnoses.

CONTEXT: Reflective practice has been suggested to be an important instrument in improving clinical judgement and developing medical expertise. Empirical evidence supporting this suggestion, however, is absent. This paper reports on an experiment conducted to study the effects of reflective practice on diagnostic accuracy. METHODS: Participants were 42 internal medicine residents in hospitals in 2 states in the northeast of Brazil. They diagnosed 16 clinical cases. The experiment employed a repeated measures design, with 2 independent variables: the complexity of clinical cases (simple or complex), and the reasoning approach induced to diagnose the case (participants were instructed to diagnose each case either through pattern recognition or reflective reasoning). The dependent variable was the accuracy of the diagnosis provided for each case. All participants participated in each of the 2 levels of both independent variables. RESULTS: A main effect of case complexity emerged. There was no statistically significant main effect of reflective practice. However, a significant interaction effect was found between case complexity and mode of processing (F[1,41] = 4.48, P < 0.05), indicating that although reflective practice did not make a difference to accuracy of diagnosis in simple cases, it had a positive effect when diagnosing complex cases. CONCLUSIONS: Reflective practice had a positive effect on diagnosis of complex, unusual cases. Non-analytical reasoning was shown to be as effective as reflective reasoning for diagnosing routine clinical cases. Findings support the idea that reflective practice may particularly improve diagnoses in situations of uncertainty and uniqueness, reducing diagnostic errors.

Influence of perceived difficulty of cases on physicians' diagnostic reasoning.

PURPOSE: While diagnosing problems, physicians frequently switch from nonanalytical to reflective reasoning. The conditions inducing doctors to reflect are largely unknown. The authors investigated whether a shift to reflection occurs when physicians perceive a case as problematic, and its effects on diagnostic accuracy. METHOD: The authors conducted two within-subjects experiments in Brazilian teaching hospitals in 2007. In Experiment 1, 20 medical residents diagnosed the same 10 clinical cases under two experimental conditions: a nonproblematic versus a problematic context. (The latter was created by informing participants that other physicians failed to diagnose the case previously.) In addition, participants judged whether a set of medical concepts were related to the case, and response time was measured. In Experiment 2, 18 residents diagnosed two cases while thinking aloud. The authors hypothesized that a case perceived as problematic would trigger reflection, leading to higher diagnostic accuracy, lower response times for recognizing concepts (Experiment 1), more time for diagnosing, and more elaborate think-aloud protocols (Experiment 2). RESULTS: Experiment 1: Accuracy of diagnosis was significantly higher within the problematic context, and participants were faster in deciding whether concepts were related to the case. The same cases were evaluated as more complex and less frequently seen. Experiment 2: Time spent on diagnosis, memory for case findings, and inferences derived from the cases were significantly higher within the problematic context. CONCLUSIONS: A context perceived as problematic induced reflection in the participating clinicians, as indicated by lower response times, more time spent on diagnosis, and more elaborate protocols. Reflective reasoning comprised more careful analysis of findings and alternative diagnoses, and increased diagnostic accuracy.

Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning.

CONTEXT: Two modes of case processing have been shown to underlie diagnostic judgements: analytical and non-analytical reasoning. An optimal form of clinical reasoning is suggested to combine both modes. Conditions leading doctors to shift from the usual mode of non-analytical reasoning to reflective reasoning have not been identified. This paper reports a study aimed at exploring these conditions by investigating the effects of ambiguity of clinical cases on clinical reasoning. METHODS: Participants were 16 internal medicine residents in the Brazilian state of Ceará. They were asked to diagnose 20 clinical cases and recall case information. The independent variable was the degree of ambiguity of clinical cases, with 2 levels: straightforward (i.e. non-ambiguous) and ambiguous. Dependent variables were processing time, diagnostic accuracy and proposition per category recalled. Data were analysed using a repeated measures design. RESULTS: Participants processed straightforward cases faster and more accurately than ambiguous ones. The proportion of text propositions recalled was significantly lower (t[15] = 2.29, P = 0.037) in ambiguous cases, and an interaction effect between case version and proposition category was also found (F[5, 75] = 4.52, P = 0.001, d = 0.232, observed power = 0.962). Furthermore, participants recalled significantly more literal propositions from the ambiguous cases than from the straightforward cases (t[15] = 2.28, P = 0.037). CONCLUSIONS: Ambiguity of clinical cases was shown to lead residents to switch from automatic to reflective reasoning, as indicated by longer processing time, and more literal propositions recalled in ambiguous cases.

Diagnostic errors and reflective practice in medicine.

BACKGROUND: Adverse effects of medical errors have received increasing attention. Diagnostic errors account for a substantial fraction of all medical errors, and strategies for their prevention have been explored. A crucial requirement for that is better understanding of origins of medical errors. Research on medical expertise may contribute to that as far as it explains reasoning processes involved in clinical judgements. The literature has indicated the capability of critically reflecting upon one's own practice as a key requirement for developing and maintaining medical expertise throughout life. OBJECTIVES: This article explores potential relationships between reflective practice and diagnostic errors. METHODS: A survey of the medical expertise literature was conducted. Origins of medical errors frequently reported in the literature were explored. The potential relationship between diagnostic errors and the several dimensions of reflective practice in medicine, brought to light by recent research, were theoretically explored. RESULTS AND DISCUSSION: Uncertainty and fallibility inherent to clinical judgements are discussed. Stages in the diagnostic reasoning process where errors could occur and their potential sources are highlighted, including the role of medical heuristics and biases. The authors discuss the nature of reflective practice in medicine, and explore whether and how the several behaviours and reasoning processes that constitute reflective practice could minimize diagnostic errors. Future directions for further research are discussed. They involve empirical research on the role of reflective practice in improving clinical reasoning and the development of educational strategies to enhancing reflective practice.

Innovations in problem-based learning: what can we learn from recent studies?

This article aims at discussing the six papers included in this special issue on innovations in Problem-based learning (PBL). The papers address different aspects related to the implementation and the development of PBL. This discussion article highlights the relevance of the theme explored by each of the papers, the contributions emerging from the study to what is already known about that topic, and its limitations, particularly those that suggest directions for future research. Emphasis is given to new insights brought by the papers for better understanding tutorial group processes and self-study phase in PBL. The contributions provided by the papers are discussed in the light of pertinent literature and also in relation to their companion articles in this issue when indicated.

Correlates of reflective practice in medicine.

BACKGROUND: The ability of physicians to critically reflect on their professional practice has been increasingly valued. Previous research brought to light the multidimensional structure of reflective practice in medicine. It comprises at least five sets of behaviours in response to complex medical problems encountered in professional practice. Factors associated to reflective practice among physicians have, as far as we know, not yet been explored by empirical study. PURPOSE: To study factors correlated to reflective practice among physicians. METHODS: A questionnaire exploring characteristics of professional practice and educational experiences was administered to primary health care physicians. Measurements were related to scores on a reflective practice measuring instrument developed previously. Associations between variables were examined by statistical analysis with tests of correlation and analysis of variance. RESULTS: Reflective practice is negatively correlated to physician's age and number of years of clinical practice. Working mainly in hospitals and attendance to medical residency programmes in some specialties apparently have a positive effect on reflective practice. CONCLUSION: Reflective practice tends to decrease with experience. Findings are consistent with the literature on medical expertise that shows a decline of analytical reasoning in proportion to the increase in experience. Some specialty programmes seems to enhance concerns with the scientific basis to professional practice, thereby favouring reflective approaches. Local features of primary health care settings probably explain their negative effect on reflective practice. Strategies to develop reflective practice among physicians should be explored by further research.