title: Effects of free, cued and modelled reflection on medical students' diagnostic competence.
abstract: BACKGROUND
  Structured reflection while practising the diagnosing of cases has been shown to improve medical students' learning of clinical diagnosis. The present study investigated whether additional instructional guidance increases the benefits of reflection by comparing the effects of free, cued and modelled reflection on learning.
  
  
  METHODS
  Fifty-eight Year 5 and 57 Year 6 medical students participated in a three-phase experiment. During the learning phase, participants diagnosed eight clinical cases under different experimental conditions: free reflection; cued reflection, and modelled reflection. In an immediate test and a delayed test administered 1 week later, they diagnosed new sets of eight different cases, four of which presented diseases they had studied during the learning phase. Learning was measured according to diagnostic accuracy on the cases that involved the four diseases that appeared in all phases.
  
  
  RESULTS
  Repeated-measures analysis of variance (anova) of mean scores for diagnostic accuracy (range: 0-1) showed a significant main effect of experimental condition (p < 0.001), year of training (p = 0.013), and performance moment (p = 0.003), without significant interaction effects. Overall, the modelled reflection group and the cued reflection group did not differ in performance (p = 1.00), but both outperformed the free reflection group (p < 0.001 for both comparisons). Overall performance increased in the delayed test relative to the immediate test (p = 0.004) and to the learning phase (p = 0.03), but did not differ in the latter two phases. Both Year 6 and Year 5 students rated studying examples of reflection as less effortful than either cued or free reflection in the learning phase (p < 0.001 for all comparisons).
  
  
  CONCLUSIONS
  Students apparently learn more with less effort by studying correct structured reflection while practising the diagnosing of cases than by reflecting without any instructional guidance. Examples of reflection and cued reflection were more beneficial for learning than free reflection and may represent a useful instructional strategy for clinical teaching.
authors.affiliation: Department of Paediatrics, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil; CAPES Foundation, Ministry of Education of Brazil, Brasilia/DF, Brazil.
authors.forename: Cassio
authors.initials: C
authors.lastname: Ibiapina
authors.forename: Sílvia
authors.initials: S
authors.lastname: Mamede
authors.forename: Alexandre
authors.initials: A
authors.lastname: Moura
authors.forename: Silvana
authors.initials: S
authors.lastname: Elói-Santos
authors.forename: Tamara
authors.initials: T
authors.lastname: van Gog
mesh_terms: D002983:Clinical Competence; D003937:Diagnosis, Differential; D019937:Diagnostic Techniques and Procedures; D004504:Education, Medical, Undergraduate / Q000379:methods*; D005260:Female; D006801:Humans; D007858:Learning; D008297:Male; D018794:Problem-Based Learning; D013337:Students, Medical / Q000523:psychology*; D013663:Teaching; D055815:Young Adult