Introduction
Developing clinical reasoning skills is one of the ultimate goals of medical schools. To develop clinical reasoning skills at all levels of medical students, curricula tailored to each stage of medical education are necessary. However, clinical reasoning training has often been confined to clinical clerkships, and the availability of the curriculum tailored to preclinical medical students remains limited [1].
It is widely acknowledged that cases-based learning is effective for the development of clinical reasoning skills [1,2]. However, dealing with real-life or authentic cases is often too complex and challenging for preclinical students with minimum clinical reasoning training. According to the cognitive load theory, if the intrinsic cognitive load is too high, imposed due to the inherent difficulty of a task, successful learning may not occur [3,4]. The cognitive load theory assumes that a human has a limited-capacity information processing system, and this limitation only applies to novel information [3]. To control the intrinsic cognitive load of novice learners in complex learning situations, the cognitive load theory suggests instructional strategies, including process worksheets, and collaborative learning [3]. Process worksheets illustrate a systematic approach to solving a task, which can alleviate task difficulty by providing procedural information. Additionally, collaborative learning potentially expands information processing capacity within a group. Consequently, intrinsic cognitive load can be distributed across group members, and sharing this load can alleviate their cognitive burden [3,4].
As an instructional method that incorporates authentic cases, process worksheets, and collaborative learning for preclinical students to develop their clinical reasoning skills, flipped learning is a viable option. Flipped learning requires students to engage in pre-learning activities before class and collaborative learning during the class with a focus on real-world tasks [5]. The process worksheets can be used to guide the clinical reasoning process during group discussions. While this intervention is deemed a suitable instructional method for clinical reasoning development in preclinical students, it has hardly been employed to develop clinical reasoning among preclinical students.
Therefore, as a preliminary study, this study aimed to develop and implement case-based flipped learning using process worksheets and investigate the responses of preclinical students and professors to the intervention in terms of its effectiveness, design, and implementation. The findings of this study offer valuable insights into effective flipped learning for fostering clinical reasoning skills in preclinical medical students.
Methods
1. Participants and procedure
This study was approved by the Institutional Review Board of Dong-A University (2-1040709-AB-N-01-202109-HR-070-04). This study was conducted at Dong-A University School of Medicine in Korea, where the “clinical reasoning method” course, originally a lecture-oriented course, was redesigned into a flipped learning and offered in the fourth quarter of the second-year medical program. The class was held once or twice per week, and 42 students worked in seven groups, with six students per group. The orientation for learners was conducted by a professor in the first class, and for the participating professors, the researcher conducted an orientation before the class, covering the overall structure of flipped learning, clinical case examples, worksheet examples, evaluation rubrics, and the role of the professor as a facilitator. Except for one professor who conducted the learner orientation, 14 professors participated in the flipped learning. Each professor created a clinical case (for example, edema, dizziness, dyspnea, and so forth) and developed their individual classes based on the guidelines and examples presented during the orientation session. Each professor conducted flipped learning once with their developed case and facilitated seven groups alone in one classroom.
Professor and student surveys were conducted online for 1 week after the class ended. One week after the survey, a focus group interview was also conducted with seven students to explore the students’ experiences in more detail. Three female and four male students voluntarily participated in the interview. The informed consent was obtained from all participants.
2. Flipped learning
Flipped learning was structured with activities before and during the class, as outlined in Table 1. Before the class, the professors were asked to develop a clinical case and the pre-learning materials. They were also asked to upload the pre-learning materials to the school’s learning management system a week before the class, and the students were asked to study them. The professors were also required to develop three online quizzes. During the class, they first presented them and checked the answers with the students. They then presented worksheets along with a clinical case and played a facilitator role during the group discussion. The students completed the worksheet through group discussions, and each group presented their completed worksheets in front of class. Internet searches were allowed during the discussion. The instructors provided feedback after the presentations, conducted a mini-lesson, and concluded with a question-and-answer session. After each class, they were required to write reflective journals. After the course, the students took a test designed to complete two illness script worksheets, each corresponding to a clinical case. Assessment of the reflective journal writing and test were performed using rubrics.
3. Illness script worksheet
The process worksheet utilized was adapted from the illness script worksheet developed by Levin et al. [6]. Clinicians possess a well-developed repertoire of illness scripts cultivated through learning and clinical experiences, and they make clinical decisions based on them in clinical situations [7]. These scripts are refined and elaborated based on their applications to clinical cases [7]. Therefore, novice learners start to develop their own illness scripts to enhance their ability to infer like experts. Consequently, illness script worksheets were employed in this study. They illustrate illness-script-based reasoning processes and were used to guide the group discussions. The worksheet includes a clinical case vignette, initial problem representation, three possible differential diagnoses, and an illness script table for each. It further includes comparing and contrasting the key features of the differential diagnoses and compiling a list of tests with their justification (Appendix 1). The illness script table incorporates enabling conditions, pathophysiological faults, and consequences (signs and symptoms), known as the components of illness scripts [6].
4. Student and professor surveys
Both surveys were adapted from previous research [6,8,9]. The student survey consisted of 14 items, including 10 items on a 4-point Likert scale (1: strongly disagree–4: strongly agree) (Table 2), two open-ended questions, and two demographic questions about age and gender. The professor survey focused on the design and implementation of flipped learning and consisted of 15 items, including 10 items on a 4-point Likert scale and five open-ended questions (Table 3). The focus group interview questions were about the beneficial aspects for the development of clinical reasoning and challenges encountered in the course (Appendix 2).
5. Data analysis
The collected data were analyzed utilizing IBM SPSS ver. 27.0 (IBM Corp., Armonk, USA). The survey items were assessed using Cronbach’s α and descriptive statistics. Data from the open-ended questions and the focus group interview were analyzed and categorized using content analysis by both the researcher and a research assistant. They independently reviewed and any discrepancies in their analyses were resolved through discussion.
Results
1. Participants’ characteristics
Among the 42 students enrolled in the course, 37 (88%) participated in the survey: 15 female students (40.5%) and 22 male students (59.5%). The age range was 23–27 years (mean: 24.35 years). In total, seven out of 15 professors (47%) responded to the survey. The reliability of the student survey was 0.90 (Cronbach’s α), and the professor survey was 0.87, both demonstrating a high level of internal consistency.
2. Survey results
The survey results are presented in Tables 2 and 3. For the student survey, the mean score for all items is 3.13. In response to the open-ended question about whether the course helped develop clinical reasoning skills, 25 students answered affirmatively, while others expressed challenges such as time constraints, task difficulty, and a lack of medical knowledge. Suggestions for improvement included the exam format, frequency of classes, time constraints, quantity of pre-learning materials, and quality of orientation. For the professor survey, the average score for all items is 3.43, and the results of the open-ended questions are presented in Table 3.
3. Focus group interview
The results of the focus group interview are presented in Appendix 2. The students indicated the beneficial aspects for the development of clinical reasoning as authentic clinical cases, collaborative learning, professors’ feedback, worksheet completion, reflective journal writing, and appropriate difficult level, and as challenges in the course, the quantity and upload timing of pre-learning materials, quality of orientation, too many learning activities, and time constraints.
Discussion
The study’s findings and corresponding design and implementation suggestions are as follows. Preclinical medical students generally expressed a positive view of the intervention. They indicated that the course was effective in developing clinical reasoning development and utilizing the illness script worksheet and authentic cases provided valuable learning experiences. These findings align with previous research [5,6,8,10] demonstrating the effectiveness of flipped learning or the illness script worksheet approach in terms of clinical reasoning development in preclinical students.
Furthermore, they expressed that collaborative learning was highly beneficial. As expected, working with group members was advantageous as they could share their cognitive burden with group members and simultaneously exposed them to diverse perspectives. These findings align with prior research suggesting that collaborative learning can be an effective way for novice learners in complex learning situations [3].
In addition, this study demonstrated that the intervention not only serves as an effective method for developing preclinical students’ clinical reasoning but also offers a more efficient approach to class delivery. Levin et al. [6] developed an illness script worksheet to guide preclinical students’ clinical reasoning process in small group settings, but in their study, students in groups of 15 completed the worksheet step-by-step with a facilitator. However, the implementation of the worksheet and collaborative learning in flipped learning enabled novice learners to collaboratively solve a complex problem with minimal facilitator assistance due to the reduced task difficulty. Consequently, one facilitator can efficiently oversee multiple groups in one classroom, allowing for multiple iterations of this intervention, unlike the one-time or short-term nature of previous studies [6,7].
The professors also revealed an overall positive teaching experience. Although they felt apprehension and were challenged, they thought they implemented it seamlessly, and the class was an effective method to develop the clinical reasoning skills of preclinical students. In addition, the findings indicated that the orientation session was particularly important for them to develop and deliver the course, and providing ample teaching assistance is recommended to reduce their burden, as flipped learning involves a subnational workload.
Both students and professors pointed out the time constraint as a significant drawback. Each class lasted 2 hours, but extending it beyond 2 hours per class seemed necessary to allow for a rich discussion and enough feedback from the professors. Additionally, there was a comment that twice a week was challenging. Given the course load, it is suggested that a once-a-week format would be more appropriate.
The students indicated the quantity and uploading timing of pre-learning materials, quality of orientation, and too many learning activities as challenges. For effective flipped learning, the quantity and upload timing of pre-learning materials is important. An excessive amount of pre-learning materials is not appropriate and it is suggested to upload them at least a week before the class. In addition, the quiz conducted at the beginning of the course were intended to ensure that the students read the pre-learning materials and were prepared for class discussion. Therefore, it is inappropriate to present overly challenging quizzes; instead, two or three questions that all pre-learners can answer should be provided. In addition, as the learners may find flipped learning unfamiliar, the quality of the orientation is critical for successful learning. Thus, it is necessary to provide detailed guidance on flipped learning, assessment methods, and illness scrip worksheets including an example on the orientation session.
Regarding the assessment, the students stated that taking a test was very challenging. An alternative approach to assessment is to replace a test with reflective journal writing. Reflective journal writing aims to explore students’ conceptualization and meaning-making regarding what they have learned. Thus, reflective journal writing can serve as an effective assessment method. In this study, both reflective journal writing and a test were employed, which appeared to be overwhelming for the students.
During group presentations, the professor indicated that the students did not focus when other groups were presenting. To address this issue, the professors can encourage questions following group presentations and, at the same time, assign one group to pose questions before each presentation, rotating the responsibility among the groups.
In conclusion, the responses of preclinical students and professors to case-based flipped learning using illness script worksheets were generally positive, and this intervention is thought to be an effective instructional method for fostering clinical reasoning skills in preclinical medical students. As expected, illness script worksheets and collaborative learning in flipped learning appeared to alleviate the cognitive burden of novice students. However, this study is preliminary in nature, and further experimental research is crucial to validate these findings. As a limitation of this study, it involved a relatively small number of participants from a single university. In addition, this study relied on self-reported data, and despite the anonymity of the survey, potential social desirability bias could have influenced the students’ responses.