gms | German Medical Science

Research in Medical Education – Chances and Challenges International Conference

20.05. - 22.05.2009, Heidelberg

Case-based learning with worked examples fosters medical students` diagnostic competence: Results replicated

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Research in Medical Education - Chances and Challenges 2009. Heidelberg, 20.-22.05.2009. Düsseldorf: German Medical Science GMS Publishing House; 2009. Doc09rmeK2

doi: 10.3205/09rme60, urn:nbn:de:0183-09rme608

Published: May 5, 2009

© 2009 Kopp et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Background and questions: To foster medical students’ diagnostic competence a case-based worked-example approach was implemented in the context of a computer-based learning environment. A worked-example consists of a problem, several solution steps, and the final solution (correct diagnosis). In order to test the effectiveness of erroneous examples and elaborated feedback in this context, both factors were varied experimentally. In the domain of hypertension, the combination of erroneous examples and elaborated feedback worked best, whereas combining erroneous examples with knowledge of result (KOR)-feedback impaired learning [1]. In this study, we tested whether these effects can be replicated when more complex examples in the domain of hyperthyroidism were used. Additionally, effects on students’ acceptance and subjective learning outcomes were investigated.

Methods: A computer-based learning environment dealing with symptoms of hyperthyroidism was conceptualized. It consisted primarily of six worked examples representing relevant patient cases and detailed steps of diagnostic reasoning. A total of 124 medical students were randomly assigned to the four conditions of a 2x2-factor design (with errors vs. without errors; elaborated feedback vs. KOR-feedback). Diagnostic competence was assessed by a multiple choice test which was also used to record prior knowledge, operationalizing conceptual knowledge, by key feature problems operationalizing strategic knowledge, and by specific problem-solving tasks operationalizing strategic and teleological knowledge. Acceptance and subjective learning outcomes were assessed by two questionnaire scales. Time-on-task was registered automatically. After a short introduction, students completed the prior knowledge test, worked through the learning session and finally worked on the post-tests and the questionnaire.

Results: Prior knowledge and time-on-task were controlled statistically. Results show that conceptual, strategic and teleological knowledge were fostered by elaborated feedback. Additionally, an interaction effect occurred with regards to strategic knowledge. The combination of erroneous examples and elaborated feedback was the most effective learning condition, whereas erroneous examples with KOR-feedback impaired knowledge acquisition, at least for strategic and teleological knowledge. These results replicate the key findings of the first study.

Concerning acceptance and subjective learning outcomes, the mean scores were rather high in all groups. Students in conditions with elaborated feedback assessed their learning outcome significantly higher than students receiving only KOR-feedback.

Conclusions: By providing erroneous examples in combination with elaborated feedback in a computer-based learning environment, diagnostic competence was fostered economically. The successful approach “learning by worked examples” can be adapted to complex domains and the acquisition of complex competencies.


Kopp V, Stark R, Fischer MR. Fostering diagnostic knowledge through computer-supported, case-based worked examples: Effects of erroneous examples and feedback. Med Educ. 2008;42(8):823-829. DOI: 10.1111/j.1365-2923.2008.03122.x. External link