Abstract
IntroductionClinical 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.MethodsOverall, 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.ResultsWe 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).ConclusionsThe 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.
Highlights
Clinical reasoning has been fostered with varying case formats including the use of virtual patients
We addressed the following research questions (RQ): RQ1: What are the effects of Virtual Patient (VP) case format and prior knowledge on strategic knowledge and diagnostic accuracy? Hypothesis 1: Students with high prior knowledge will gain more in strategic knowledge and a higher diagnostic accuracy compared to students with low prior knowledge, independent of the case format
Preliminary analyses The case format groups did not differ in terms of their age and gender, conceptual knowledge and or strategic knowledge pretest, Post-hoc tests confirmed that overall cognitive load did not differ between the two groups before they commenced working on the VPs
Summary
Clinical reasoning has been fostered with varying case formats including the use of virtual patients. We utilized VPs and compared two case formats (whole case or serial cue format) with respect to their potential to foster clinical reasoning for students with different levels of prior knowledge. When considering the interactions described by Huwendiek [4] and Cook [5], a special case format occurrence provides all information to the learners at once, requiring little to no interaction other than entering the diagnosis (whole case format). Such format differences across the VP taxonomy have the potential to induce very different learning processes and patterns of cognitive load. It has not yet been investigated how cognitive interactions may influence success in learning clinical reasoning processes
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