title: Teaching metacognition in clinical decision-making using a novel mnemonic checklist: an exploratory study.
abstract: BACKGROUND
  Metacognition is a cognitive debiasing strategy that clinicians can use to deliberately detach themselves from the immediate context of a clinical decision, which allows them to reflect upon the thinking process. However, cognitive debiasing strategies are often most needed when the clinician cannot afford the time to use them. A mnemonic checklist known as TWED (T = threat, W = what else, E = evidence and D = dispositional factors) was recently created to facilitate metacognition. This study explores the hypothesis that the TWED checklist improves the ability of medical students to make better clinical decisions.
  
  
  METHODS
  Two groups of final-year medical students from Universiti Sains Malaysia, Malaysia, were recruited to participate in this quasi-experimental study. The intervention group (n = 21) received educational intervention that introduced the TWED checklist, while the control group (n = 19) received a tutorial on basic electrocardiography. Post-intervention, both groups received a similar assessment on clinical decision-making based on five case scenarios.
  
  
  RESULTS
  The mean score of the intervention group was significantly higher than that of the control group (18.50 ± 4.45 marks vs. 12.50 ± 2.84 marks, p < 0.001). In three of the five case scenarios, students in the intervention group obtained higher scores than those in the control group.
  
  
  CONCLUSIONS
  The results of this study support the use of the TWED checklist to facilitate metacognition in clinical decision-making.
authors.affiliation: Formerly from the School of Medical Sciences, Universiti Sains Malaysia, Malaysia.
authors.forename: Keng Sheng
authors.initials: KS
authors.lastname: Chew
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Durning
authors.affiliation: School of Health Education, Maastricht University, Maastricht, the Netherlands.
authors.forename: Jeroen Jg
authors.initials: JJ
authors.lastname: van Merriënboer
mesh_terms: D000328:Adult; D057189:Checklist; D000066491:Clinical Decision-Making / Q000379:methods*; D004501:Education, Medical / Q000379:methods*; D004521:Educational Measurement; D005260:Female; D006801:Humans; D008296:Malaysia; D008297:Male; D000067489:Metacognition; D011287:Prejudice; D015397:Program Evaluation; D013337:Students, Medical; D014495:Universities; D055815:Young Adult
keywords: checklist; cognitive bias; cognitive debiasing strategy; medical education; metacognition