title: How can students' diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases.
abstract: OBJECTIVE
  To develop diagnostic competence, students should practice with many examples of clinical problems to build rich mental representations of diseases. How to enhance learning from practice remains unknown. This study investigated the effects of reflection on cases compared with generating a single or differential diagnosis.
  
  
  METHODS
  In 2012, during the learning phase, 110 fourth-year medical students diagnosed four cases of two criterion diseases under three different experimental conditions: structured reflection, single-diagnosis, or differential-diagnosis. One week later, they diagnosed two novel exemplars of each criterion disease and four cases of new diseases that were not among the cases of the learning phase but were plausible alternative diagnoses.
  
  
  RESULTS
  Diagnostic performance did not differ among the groups in the learning phase. One week later, the reflection group obtained higher mean diagnostic accuracy scores (range: 0-1) than the other groups when diagnosing new exemplars of criterion diseases (reflection: 0.67; single-diagnosis: 0.36, P < .001; differential-diagnosis: 0.51, P = .014) and cases of new diseases (reflection: 0.44; single-diagnosis: 0.32, P = .010; differential-diagnosis: 0.33, P = .015). No difference was found between the single-diagnosis and the differential-diagnosis conditions.
  
  
  CONCLUSIONS
  Structured reflection while practicing with cases enhanced learning of diagnosis both of the diseases practiced and of their alternative diagnoses, suggesting that reflection not only enriched mental representations of diseases practiced relative to more conventional approaches to clinical learning but also influenced the representations of adjacent but different diseases. Structured reflection seems a useful addition to the existing clinical teaching methods.
authors.affiliation: Dr. Mamede is associate professor, Institute of Medical Education Research Rotterdam, Erasmus Medical Centre, and associate professor, Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands. Dr. Van Gog is professor, Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands. Dr. Moura is assistant professor, Department of Medical Education Development, Medical School, José do Rosário Vellano University (UNIFENAS), Belo Horizonte, Brazil. Dr. de Faria is assistant professor, Department of Medical Education Development, Medical School, José do Rosário Vellano University (UNIFENAS), Belo Horizonte, Brazil. Dr. Peixoto is assistant professor, Department of Medical Education Development, Medical School, José do Rosário Vellano University (UNIFENAS), Belo Horizonte, Brazil. Dr. Schmidt is professor, Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands.
authors.forename: Sílvia
authors.initials: S
authors.lastname: Mamede
authors.forename: Tamara
authors.initials: T
authors.lastname: van Gog
authors.forename: Alexandre Moura
authors.initials: AM
authors.lastname: Sampaio
authors.forename: Rosa Malena Delbone
authors.initials: RM
authors.lastname: de Faria
authors.forename: José Peixoto
authors.initials: JP
authors.lastname: Maria
authors.forename: Henk G
authors.initials: HG
authors.lastname: Schmidt
mesh_terms: D000328:Adult; D001938:Brazil; D002983:Clinical Competence; D003937:Diagnosis, Differential; D019937:Diagnostic Techniques and Procedures; D004504:Education, Medical, Undergraduate / Q000379:methods*; D004521:Educational Measurement; D005260:Female; D006801:Humans; D008297:Male; D018794:Problem-Based Learning