Fostering novice students' diagnostic ability: the value of guiding deliberate reflection

BACKGROUND: Deliberate reflection when practising the diagnosis of clinical cases has been shown to develop medical students' diagnostic competence. Adding guidance by cueing reflection or providing modelling of reflection increased the benefits of reflection for advanced (Years 5–6) students. The present study investigated whether we could replicate and extend these findings by comparing the effects of free, cued and modelled reflection on novice students' diagnostic competence. METHODS: A total of 80 third‐year medical students participated in a two‐phase experiment. In the learning phase, students diagnosed nine clinical cases under one of three conditions: free reflection; cued reflection, and modelled reflection. Two weeks later, all students diagnosed four new examples of the diseases studied in the learning phase and four cases of non‐studied related diseases (‘adjacent diseases’). The main outcome measurements were diagnostic accuracy scores (range 0–1) on studied and adjacent diseases. RESULTS: For studied diseases, there was a significant effect of experimental condition on diagnostic accuracy (p < 0.02), with the cued‐reflection group (mean = 0.58, standard deviation [SD] = 0.23) performing significantly better than the free‐reflection group (mean = 0.41, SD = 0.20; p < 0.02). The cued‐reflection and modelled‐reflection groups (mean = 0.54, SD = 0.22) did not differ in diagnostic accuracy (p > 0.05), nor did the modelled‐reflection group perform better than the free‐reflection group (p > 0.05). For adjacent diseases, the three groups scored extremely low, without significant differences in performance (p > 0.05). Cued reflection and free reflection were rated as requiring similar effort (p > 0.05) and both were more demanding than studying examples of reflection (both p < 0.001) in the learning phase. CONCLUSIONS: Simply cueing novice students' reflection to focus it on relevant diseases was sufficient to increase diagnostic performance relative to reflection without any guidance. Cued reflection and studying examples of reflection appear to be equally useful approaches for teaching clinical diagnosis to novice students. Students found studying examples of reflection required less effort but cued reflection will certainly demand much less investment from teachers.