Test-enhanced learning of clinical reasoning: a crossover randomised trial.
BACKGROUND
Clinical reasoning is an essential skill, the foundations of which should be acquired during undergraduate medical education. Student performance in clinical reasoning can be assessed using key feature examinations. However, within a paradigm of test-enhanced learning, such examinations may also be used to enhance long-term retention of procedural knowledge relevant to clinical reasoning.


OBJECTIVE
This study tested the hypothesis that repeated testing with key feature questions is more effective than repeated case-based learning in fostering clinical reasoning.


METHODS
In this randomised crossover trial, Year 4 medical students attended 10 weekly computer-based seminars during which patient case histories covering general medical conditions were displayed. The presentation format was switched between groups every week. In the control condition, students studied long case narratives. The intervention condition used the same content but augmented case presentation with a sequence of key feature questions. Using a within-subjects design, student performance on intervention and control items was assessed at 13 weeks (exit examination) and 9 months (retention test) after the first day of term.


RESULTS
A total of 87 of 124 eligible students provided complete data for the longitudinal analysis (response rate: 70.2%). In the retention test, mean ± standard deviation student scores on intervention items were significantly higher than those on control items (56.0 ± 25.8% versus 48.8 ± 24.7%; p < 0.001). The results remained unchanged after accounting for exposure time in a linear regression analysis that also adjusted for sex and general student performance levels.


CONCLUSIONS
This is the first study to demonstrate an effect of test-enhanced learning on clinical reasoning as assessed with key feature questions. In this randomised trial, repeated testing was more effective than repeated case-based learning alone. Curricular implementation of longitudinal key feature testing may considerably enhance student learning outcomes in relevant aspects of clinical medicine.
Department of Cardiology and Pneumology, Göttingen University Medical Centre, Göttingen, Germany.|Health Behaviour Research Centre, University College London, London, UK.
Tobias
T
Raupach
Department of Cardiology and Pneumology, Göttingen University Medical Centre, Göttingen, Germany.
Jil C
JC
Andresen
Department of Cardiology and Pneumology, Göttingen University Medical Centre, Göttingen, Germany.
Katharina
K
Meyer
Department of Cardiology and Pneumology, Göttingen University Medical Centre, Göttingen, Germany.
Lisa
L
Strobel
Department of Nephrology and Rheumatology, Göttingen University Medical Centre, Göttingen, Germany.
Michael
M
Koziolek
Department of Haematology and Oncology, Göttingen University Medical Centre, Göttingen, Germany.
Wolfram
W
Jung
Health Behaviour Research Centre, University College London, London, UK.
Jamie
J
Brown
Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
Sven
S
Anders
D000328:Adult; D002983:Clinical Competence / Q000592:standards; D000066491:Clinical Decision-Making; D003194:Computer-Assisted Instruction; D018592:Cross-Over Studies; D004504:Education, Medical, Undergraduate / Q000379:methods*; D004521:Educational Measurement; D005260:Female; D000068156:Formative Feedback; D005858:Germany; D006801:Humans; D008297:Male; D013337:Students, Medical; D013663:Teaching; D013997:Time Factors