gms | German Medical Science

Background: Clinical reasoning abilities can be enhanced by repeated formative testing with key feature questions. An analysis of wrong answers to key feature questions facilitates the identification of common misconceptions. This study assessed whether an elaboration task and individualised mailed feedback further improve student performance on clinical reasoning.

Methods: 143 fourth-year undergraduate medical students were invited to participate in a prospective cross-over trial. While participating in three consecutive modules on general medicine, they also sat one formative key feature examinations (e-seminars) per week over a period of ten weeks (training phase). For each student, some questions were shown as control items, i.e, in the format of a key feature question with a long menu. Intervention items were also made up of a key feature question with long menu, but this was followed by a short written elaboration task prompting students to differentiate the correct answer from a common misconception that had been noted in previous studies. One day after each e-seminar, students received individual emails containing their own answers and and expert comment that had also been available during the e-seminar. At the end of term (exit exam) as well as six months later (retention test), students took formative key feature examinations containing the same questions. The performance difference between intervention and control items was assessed using paired T-tests. Predictors of exam performance were assessed using multivariate regression analyses.

Results: In both the exit exam and the retention test, performance on intervention items was significantly better than performance on control items (exit exam: 71.3±19.8% vs. 66.4±21.3%; p=0.003; Cohen’s d=0.33; retention test: 67.1±20.8% vs. 62.9±21.6%; p=0.009; Cohen’s d=0.29). Retention test performance was predicted by intervention item scores during the training phase, and the percentage of correct free-text answers.

Conclusions: Elaboration of correct answers to key feature questions in contrast to common wrong answers with additional individual, mailed feedback elicited a sustained effect on student performance with regard to clinical reasoning. The results of multiple regression analyses showed that superior performance on elaboration tasks was associated with better retention.

Take home message: The effect of test-enhanced learning with key feature questions can be further ameliorated by prompting students to contrast correct answers with popular incorrect answers and sending them individual feedback.