Exploring medical students' metacognitive and regulatory dimensions of diagnostic problem solving

Solving clinical problems requires an individual to apply not only domain-specific medical knowledge and cognitive skills for reasoning, but also to be consciously aware of, monitor, and evaluate their thinking processes (i.e., metacognition). The purpose of this study was to map critical metacognitive dimensions of clinical problem solving and to explore the structural relationships among them, which may help frame a conceptual framework and better pedagogy for effective intervention. A context-specific inventory was adapted and modified from a domain-general instrument to capture essential metacognitive skills for learning and solving clinical problems. This inventory was administered to 72 undergraduate medical students to survey their capabilities in five dimensions: knowledge of cognition, objectives, problem representation, monitoring, and evaluation. The interplay among these dimensions was further examined using partial least squares structural equation modeling.Our findings revealed that the medical students fell short of some expert-like, metacognitive, and regulatory competence, even after receiving years of medical education and on-site training. In particular, they did not know when a holistic understanding of a problem had been reached. Many of them often do not have a set of clear diagnostic procedures in mind, nor do they concurrently monitor their thinking during diagnostic reasoning. Moreover, their lack of self-improving approaches seemed to worsen their learning. Finally, the structural equation model indicated that knowledge of cognition and objectives significantly predicted problem representation, suggesting that medical learners' knowledge of and goals for learning are influential in framing the clinical problems at hand. A significant linear prediction path was observed from problem representation, monitoring, to evaluation, signifying a possible sequenced process of clinical problem solving. Metacognitive-based instruction can help improve clinical problem-solving skills and awareness of potential biases or errors.