Enhancing diagnostic competence with self-explanation prompts and adaptable feedback.

Context The fostering of diagnostic competence is an important goal of medical education. Worked-example cases with integrated errors represent a promising method of doing so. Objectives This study investigates whether the provision of self-explanation prompts and adaptable feedback fosters diagnostic competence in a computer-supported learning environment based on worked-example cases with integrated errors. Methods A total of 103 medical students participated in the study. After a test of prior diagnostic competence, learners studied worked examples with integrated errors for cases of heart failure of different causes in a computer-based learning environment. The worked examples started with the description of a clinical situation in which a student apprentice diagnoses a patient and commits errors in the conclusions he draws from the information presented. Participants were randomly assigned to four learning conditions that varied in two factors: self-explanation prompts and adaptable feedback. In the self-explanation prompts condition, students were prompted to reflect on the errors. Independently of the condition, the student apprentice in the worked example receives feedback on his diagnosis. In the adaptable feedback condition, students were able to adjust the level of elaboration of the feedback. A post-test of diagnostic competence was administered. Results Adaptable feedback had a positive effect on important aspects of diagnostic competence (strategic knowledge: F(1,93) = 4.15, p < 0.05, partial η2 = 0.04; decision-oriented practical knowledge: F(1,93) = 4.41, p < 0.05, partial η2 = 0.05), whereas self-explanation prompts did not further improve the effectiveness of the learning environment. Conclusions In the use of worked examples with integrated errors, the provision of adaptable feedback whereby learners have control over the amount of feedback they receive seems to be advantageous to the development of important decision-oriented aspects of diagnostic competence. Additional help to stimulate reflection about the error by self-explanation prompts does not seem to be critical.