Institute for Medical Education, University Hospital, LMU Munich, Munich, Germany.
Education and Educational Psychology, LMU Munich, Munich, Germany.
BMC Med Educ. 2020 Mar 14;20(1):73. doi: 10.1186/s12909-020-1987-y.
Clinical reasoning has been fostered with varying case formats including the use of virtual patients. Existing literature points to different conclusions regarding which format is most beneficial for learners with diverse levels of prior knowledge. We designed our study to better understand which case format affects clinical reasoning outcomes and cognitive load, dependent on medical students' prior knowledge.
Overall, 142 medical students (3 rd to 6 th year) were randomly assigned to either a whole case or serial cue case format. Participants worked on eight virtual patients in their respective case format. Outcomes included diagnostic accuracy, knowledge, and cognitive load.
We found no effect of case format on strategic knowledge scores pre- vs post-test (whole case learning gain = 3, 95% CI. -.01 to .01, serial cue learning gain = 3, 95% CI. -.06 to .00 p = .50). In both case formats, students with high baseline knowledge (determined by median split on the pre-test in conceptual knowledge) benefitted from learning with virtual patients (learning gain in strategic knowledge = 5, 95% CI .03 to .09, p = .01) while students with low prior knowledge did not (learning gain = 0, 95%CI -.02 to .02). We found no difference in diagnostic accuracy between experimental conditions (difference = .44, 95% CI -.96 to .08, p = .22), but diagnostic accuracy was higher for students with high prior knowledge compared to those with low prior knowledge (difference = .8, 95% CI 0.31 to 1.35, p < .01). Students with low prior knowledge experienced higher extraneous cognitive load than students with high prior knowledge (multiple measurements, p < .01).
The whole case and serial cue case formats alone did not affect students' knowledge gain or diagnostic accuracy. Students with lower knowledge experienced increased cognitive load and appear to have learned less from their interaction with virtual patients. Cognitive load should be taken into account when attempting to help students learn clinical reasoning with virtual patients, especially for students with lower knowledge.
临床推理已经通过各种病例格式得到了培养，包括使用虚拟患者。现有文献得出了不同的结论，即哪种格式对具有不同先前知识水平的学习者最有益。我们设计了这项研究，以便更好地了解哪种病例格式会影响临床推理结果和认知负荷，这取决于医学生的先前知识。
共有 142 名医学生（3 至 6 年级）被随机分配到完整病例或连续线索病例格式。参与者在各自的病例格式中处理了 8 个虚拟患者。结果包括诊断准确性、知识和认知负荷。
我们没有发现病例格式对前后测试的策略性知识分数有影响（整体病例学习增益=3，95%CI。-0.01 至.01，连续线索学习增益=3，95%CI。-0.06 至.00，p=.50）。在两种病例格式中，具有高基线知识（通过概念知识预测试的中位数划分确定）的学生从使用虚拟患者中受益（策略性知识的学习增益=5，95%CI.03 至.09，p=.01），而具有低先前知识的学生则没有（学习增益=0，95%CI。-0.02 至.02）。我们没有发现实验条件之间的诊断准确性有差异（差异=0.44，95%CI。-0.96 至.08，p=.22），但具有高先前知识的学生的诊断准确性高于具有低先前知识的学生（差异=0.8，95%CI。0.31 至 1.35，p <.01）。具有低先前知识的学生比具有高先前知识的学生经历了更高的分散认知负荷（多次测量，p <.01）。
单独使用完整病例和连续线索病例格式不会影响学生的知识增益或诊断准确性。知识水平较低的学生经历了更高的认知负荷，并且似乎从与虚拟患者的互动中学到的知识较少。在尝试使用虚拟患者帮助学生学习临床推理时，应考虑认知负荷，特别是对于知识水平较低的学生。
