Exploring clinical reasoning in novices: a self-regulated learning microanalytic assessment approach

OBJECTIVES: The primary objectives of this study were to examine the regulatory processes of medical students as they completed a diagnostic reasoning task and to examine whether the strategic quality of these regulatory processes were related to short-term and longer-term medical education outcomes. METHODS: A self-regulated learning (SRL) microanalytic assessment was administered to 71 second-year medical students while they read a clinical case and worked to formulate the most probable diagnosis. Verbal responses to open-ended questions targeting forethought and performance phase processes of a cyclical model of SRL were recorded verbatim and subsequently coded using a framework from prior research. Descriptive statistics and hierarchical linear regression models were used to examine the relationships between the SRL processes and several outcomes. RESULTS: Most participants (90%) reported focusing on specific diagnostic reasoning strategies during the task (metacognitive monitoring), but only about one-third of students referenced these strategies (e.g. identifying symptoms, integration) in relation to their task goals and plans for completing the task. After accounting for prior undergraduate achievement and verbal reasoning ability, strategic planning explained significant additional variance in course grade (ΔR(2) = 0.15, p < 0.01), second-year grade point average (ΔR(2) = 0.14, p < 0.01), United States Medical Licensing Examination Step 1 score (ΔR(2) = 0.08, p < 0.05) and National Board of Medical Examiner subject examination score in internal medicine (ΔR(2) = 0.10, p < 0.05). CONCLUSIONS: These findings suggest that most students in the formative stages of learning diagnostic reasoning skills are aware of and think about at least one key diagnostic reasoning process or strategy while solving a clinical case, but a substantially smaller percentage set goals or develop plans that incorporate such strategies. Given that students who developed more strategic plans achieved better outcomes, the potential importance of forethought regulatory processes is underscored.