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Mirror, Mirror on the Wall, Who's the Smartest One of All? Reflection as a strategy to foster medical students' acquisition of diagnostic competence Mamede S et al. Medical Education 2012; 46:464-472


Reviewed by Lavjay Butani

What was the study question?
This study explored whether structured reflection assisted medical students in learning about clinical presentations of disease.

How was the study done?
This was a three-phase study involving 46 Brazilian medical students in their 4th year of medical school (at this stage of their training, they had had minimal patient exposure and had not yet started their clerkship). The three phases were learning phase, immediate test phase, and delayed test phase one week later. There were three experimental groups - all students read six clinical cases and then some were asked to supply a single diagnosis, some were asked to supply a differential diagnoses and some were asked to engage in a reflective exercise. The students in the reflective group listed findings that both supported and refuted their diagnosis, and ranked their diagnosis and alternative diagnoses in terms of plausibility. The students' answers were scored after each phase of the study.

What were the results?
There were no baseline differences between the three groups regarding exposure to the clinical diagnoses being tested. In the learning and immediate testing phases of the study, the reflection group achieved lower mean scores than the other groups (statistically significant only during the immediate testing phase of the study). During the delayed testing phase, however, students in the reflection group scored better than the other two groups (statistically significant for both).

What are the implications of these findings?
This study shows the benefit of using structured reflection to promote clinical reasoning skills among novice learners. The authors consider that students in the reflective group may have been "cognitively overloaded" immediately after the learning phase and therefore did not do as well as their peers on the immediate test. Reflection, though, may have promoted more lasting learning by triggering the development and recall of more robust organizational strategies and richer illness scripts in the learners.

Editor's note: It is important to note that none of the students received feedback about their answers during any phase of the study. One wonders how much better the students would have done if they had received feedback following their reflective exercise. The next study that begs to be done is to explore whether this difference was maintained at an even later date (months later, for instance). This article's list of references provides an excellent overview of the key studies in clinical reasoning. (SLB)

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