Comparing faded examples and cued reflection in teaching diagnostic reasoning

Clinical reasoning is essential for patient safety but challenging to teach. Deliberate reflection (DR), which involves systematically contrasting diagnostic hypotheses during case practice, improves diagnostic performance, yet the optimal level of guidance remains unclear. Faded-examples progressively reduce guidance and may enhance future case performance. This study compared the effects of faded-examples and cued reflection on medical students' diagnostic accuracy.

We conducted a two-arm experiment with sixth-year medical students. Students practiced DR using either faded-example or cued reflection. The study comprised a learning phase with six cases and a 15-day-later test phase with eight new cases, including studied and adjacent diseases. Outcomes included diagnostic accuracy, confidence, and recall of clinical information. We analyzed the data using a generalized mixed model with diagnostic accuracy as a dependent variable, group and disease type as fixed effects, confidence and recall as covariates, and participant as a random effect.

Seventy final-year medical students participated, and 59 completed both phases (51% women; mean age 24.8 years). No group differences were observed in diagnostic accuracy (p = .39) or confidence (p = .99) during learning. At test, diagnostic accuracy did not differ between instructional formats (p = .99), nor between studied and adjacent diseases (p = .32). Higher diagnostic accuracy was significantly associated with greater confidence (OR = 1.18, 95% CI [1.03, 1.35], p = .02) and with recall of a higher number of correct propositions (OR = 1.10, 95% CI [1.03, 1.17], p = .005). The contribution of recall to accuracy was weaker for adjacent than for studied diseases (OR = 0.74, 95% CI [0.12, 0.45], p < .001).

Both approaches promoted reflective processing and yielded comparable accuracy, consistent with expertise-reversal effects. Higher accuracy was associated with greater recall and confidence. Future studies should examine earlier trainees and longer fading sequences to optimize transfer.