Council on Medical Student Education in Pediatrics


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It’s ok to help
Effects of free, cued and modeled reflection on medical students’ diagnostic competence.  Ibiapina C et al.  Medical Education 2014;48:796-805
Reviewed by Rebecca Tenney Soeiro

What was the study question?
Does additional instructional guidance increase the benefits of reflection on medical students’ clinical reasoning?  Effects of free, cued, and modeled reflection on learning were compared. Free reflection required students to compete a table of the possible diagnoses for a clinical case with a column for the findings that support each possibility, the findings that go against each, and the findings that would be expected but were not present. Cued reflection included the same table with the list of possible diagnoses already filled in and modeled reflection included the table with all columns completed.

How was the study done?
The study was done in Brazil; two groups of students, one comprised of those who had not yet completed an internal medicine clerkship and another of those who were given 8 different cases to diagnose under different experimental conditions: free reflection, cued reflection, and modeled reflection. Students had a learning phase where they diagnosed cases under one of the three conditions. Learning was measured through tests requiring students to come up with a prioritized differential diagnoses for cases involving the same diseases at 30 minutes and 7 days after the learning phase.  Mental effort was also rated by all students.  Repeated measures ANOVA was performed on mean scores for diagnostic performance, as well as on mental effort ratings in each phase. 

What were the results?
Students from the modeled-reflection and cued-reflections groups did not differ in their diagnostic accuracy scores but both performed significantly better than free-reflection group.  Not surprisingly, significant effect based on year of training was identified. 

What are the implications of these findings? 
Students learn more with less effort when studying correct structured reflection than when reflecting without any instructional guidance.  Modeled and cued-reflection may represent a useful educational strategy for clinical teaching. 

Editor’s comment: In some ways these findings are counter-intuitive; we sometimes think that students will learn more if they have to puzzle through a case on their own. It is useful to know that showing a student a structure for working through a case, with all of the parts filled in, actually helps them in a significant way when they move on to making diagnoses on their own (LL).

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