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The influence of medical students' self-explanations on diagnostic performance: Chamberland M, St Onge C, Setrakian J, Lanthier L, Bergeron L, Bourget A, Mamede S, Schmidt H, Rikers R. Medical Education 2011; 45:688-695.

Reviewed by Susan Bannister

What was the study question?
Does the generation of "self-explanations" positively influence students' learning to enhance clinical reasoning?

How was the study done?
Third year medical students were divided into two groups: control and intervention. The students were asked to solve clinical problems on two occasions, one week apart. The intervention group was taught how to use "self-explanation" (basically just talking aloud to oneself about the problem) and encouraged to use this technique during the first test. No feedback was given to the students about their self-explanations (so they could have come up with an explanation that was wrong). The students in the control group were asked to solve the clinical problems in silence. One week later, both groups of students were given similar, but not identical, clinical cases to solve. Both groups of students were instructed to complete the cases in silence. The cases consisted of four cases about heart failure (deemed to be a topic the students knew a great deal about), four cases about jaundice (deemed to be a topic the students knew little about), and four "filler" topics.

What were the results?
The students in both groups had similar diagnostic accuracy and diagnostic performance scores on the first test at the beginning of the study. Both groups of students performed better on the heart failure cases than on the jaundice cases. One week later, though, the students who had been encouraged to use self-explanation on the first test performed better than their control peers on the jaundice cases (but not on the heart failure cases).

What are the implications of these findings?
Self-explanation helped the students perform better on topics that they knew less about (jaundice cases) but did not help them perform better on topics that they knew a great deal about already (heart failure cases). It may be that the self-explanations assisted the students in making sense of a clinical presentation they knew little about and caused the students to consolidate their knowledge in a way that could be accurately applied one week later. A fascinating finding of this study is that the benefit of self-explanation occurred in the absence of feedback. The authors point out that the students' self-explanations were not always correct but – somehow! - this process was still of benefit. This study attests to the power of "deep" learning and encourages us to empower our students to delve into clinical problems and think through the presentation in great depth. This study represents the first time self-explanations have been studied in the context of medical education. Previously, this technique has been shown to be effective in enhancing learning in chess, biology, physics, electricity, and magnetism!

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