title: The effect of question format and task difficulty on reasoning strategies and diagnostic performance in Internal Medicine residents.
abstract: BACKGROUND
  Previous studies have suggested an association between reasoning strategies and diagnostic success, but the influence on this relationship of variables such as question format and task difficulty, has not been studied. Our objective was to study the association between question format, task difficulty, reasoning strategies and diagnostic success.
  
  
  METHODS
  Study participants were 13 Internal Medicine residents at the University of Calgary. Each was given eight problem-solving questions in four clinical presentations and were randomized to groups that differed only in the question format, such that a question presented as short answer (SA) to the first group was presented as extended matching (EM) to the second group. There were equal numbers of SA/EM questions and straightforward/difficult tasks. Participants performed think-aloud during diagnostic reasoning. Data were analyzed using multiple logistic regression.
  
  
  RESULTS
  Question format was associated with reasoning strategies; hypothetico-deductive reasoning being used more frequently on EM questions and scheme-inductive reasoning on SA questions. For SA question, non-analytic reasoning alone was used more frequently to answer straightforward cases than difficult cases, whereas for EM questions no such association was observed. EM format and straightforward task increased the odds of diagnostic success, whereas hypothetico-deductive reasoning was associated with reduced odds of success.
  
  
  CONCLUSIONS
  Question format and task difficulty both influence diagnostic reasoning strategies and studies that examine the effect of reasoning strategies on diagnostic success should control for these effects. Further studies are needed to investigate the effect of reasoning strategies on performance of different groups of learners.
authors.affiliation: Department of Medicine, Foothills Hospital, University of Calgary, Calgary, AB, Canada.
authors.forename: Laura
authors.initials: L
authors.lastname: Heemskerk
authors.forename: Geoff
authors.initials: G
authors.lastname: Norman
authors.forename: Sophia
authors.initials: S
authors.lastname: Chou
authors.forename: Marcy
authors.initials: M
authors.lastname: Mintz
authors.forename: Henry
authors.initials: H
authors.lastname: Mandin
authors.forename: Kevin
authors.initials: K
authors.lastname: McLaughlin
mesh_terms: D003430:Cross-Sectional Studies; D004503:Education, Medical, Graduate / Q000379:methods*; D004521:Educational Measurement; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D016015:Logistic Models; D011340:Problem Solving