Council on Medical Student Education in Pediatrics


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Greatly enhancing diagnostic accuracy - No faculty needed
How can students' diagnostic competence benefit most from practice with clinical cases? The effect of structured reflection on future diagnosis of the same and novel diseases. Mamede S, et al. Academic Medicine 2014; 89(1): 121-127.
Reviewed by Karen Forbes

What was the study question?
Does structured reflection on clinical cases make students better at diagnosing the same and new conditions?

How was the study done?
Medical students from Belo Horizonte, Brazil participated in a voluntary study just prior to their clinical clerkships. There were two phases of the study. In the learning phase, students were randomized into one of three groups. Students in all groups were asked to diagnose seven clinical cases presented randomly in a booklet (four criterion cases and three filler cases). Group A provided a single-diagnosis. Group B provided the most likely diagnosis and alternative diagnoses. Group C provided the most likely diagnosis and reflected on the case in a structured format. One week later, in the testing phase, students were tested with nine new clinical cases which consisted of one new example of each criterion disease and four cases of new diseases that were not among the initial cases but had been plausible alternatives. Performance on this test was compared among groups.

What were the results?
Students in the three groups did not significantly differ in diagnostic performance in the learning phase. Students who took part in structured reflection performed better than students in both the single diagnosis and differential diagnoses groups in the testing phase. This difference was noted for novel exemplars or plausible alternatives of the previously studied disease as well as for overall accuracy.

What are the implications of these findings?
This study demonstrates that students engaging in reflection on cases can experience deeper learning than by providing a single diagnosis or differential diagnosis. The authors attribute the positive results of the structured reflection as being a result of the enrichment of students' mental representations of diseases practiced, and note that these can enhance the representations of adjacent but different diseases. For teachers and clinical educators, this provides support for the value of facilitating reflective activities and discussions as a means of deepening students' learning in clinical reasoning.

Editor's note: This well done, valuable study "shakes up" our common teaching practice of asking trainees to develop differential diagnoses. Asking them, instead, to reflect upon their patient's story (by listing the finding that both support and don't support this and alternate diagnoses) would likely result in deeper learning and greater future diagnostic accuracy. That such greater diagnostic accuracy can be accomplished with no faculty time or training makes this method even more powerful (SLB).

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