Fostering clinical reasoning ability in preclinical students through an illness script worksheet approach in flipped learning: a quasi-experimental study – BMC Medical Education


Participants and procedures

This study was conducted at a medical school in Korea and was approved by the Dong-A Institutional Review Board (2-1040709-AB-N-01-202109-HR-070-04). This study used a one-group pre-posttest design, and participants were drawn from convenience sampling. Forty-two second-year medical students enrolled in the course, “Clinical reasoning method” were all invited to participate in this study. Medical schools in Korea have six-year programs (two-year pre-medical and four-year medical programs including two-year clinical clerkships). The first two-year curriculum of the medical program consists of integrated blocks of biomedical and clinical knowledge. The participants were in their final quarter of the second year, with only one quarter remaining before entering their clinical clerkship. The pre- and post-DTI assessments were administered online for two weeks before the class started and after the class ended. In addition, a learning experience survey was conducted with the post-DTI assessment to explore students’ learning experiences. Online informed consent was obtained from all participants before the pre-and post-DTI assessment.

Illness script worksheet

The illness script worksheets were modified from the one developed by Levin et al. [8] The illness script worksheet was composed of (1) a clinical case vignette, (2) its initial problem representation, (3) three possible differential diagnoses and their corresponding illness script constructions, (4) comparison and contrast of the illness scripts with the initial problem representation, and (5) development of a list of tests and their justification (Appendix 1). A clinical case vignette was presented in a format that reflects the way patients present in a doctor’s office, and then, the students were asked to make an initial problem representation, using semantic qualifiers. Thereafter, they were asked to provide the three most likely diagnoses for the case, starting from the highest likelihood, and fill in the illness script tables, including enabling conditions, pathophysiology, and consequences (signs and symptoms). They were then asked to compare and contrast the illness scripts with the initial problem representation, highlighting their similarities and differences. Finally, they were asked to develop a list of labs, tests, and imaging, and to justify how the suggested tests helped rule in/out each diagnosis. The students worked in groups and completed the worksheet as a group.

Levin et al. [8] created two versions (for students and facilitators) of the worksheet. In this study, the facilitators’ version was used as it included the comparison and contrast of illness scripts with the initial problem representation section, which was missing from the student version but was essential for clinical reasoning processes. Unlike Levin et al. [8], the students were asked to list three differential diagnoses in order, starting with the most likely one in the illness script tables. The illness script worksheet was presented to the students three times. First, it was presented in a completed form during the orientation session as an example and during class, it was presented as a guiding tool(scaffolding) for group work. Lastly, during the mini-lecture following group presentation, the professor’s completed worksheet was presented to students for cognitive feedback. This allowed students to reflect on and compare their works with expert-completed ones.

Course design

The course, “Clinical reasoning method”, was transitioned from a traditional lecture-oriented model to a flipped-classroom model to accommodate illness script worksheet activities. It was an eight-week long program with 17 classes, each lasting two hours. The students met once or twice per week with a different professor each time and worked with 15 clinical cases (e.g. jaundice, hypotension, abdominal, pain and diarrhea) (Appendix 2). They worked in small groups, with six students per group, in one classroom, and the group remained unchanged. The first and last classes were the orientation and test sessions, respectively. Each time, one professor who developed a clinical case facilitated seven groups in a single classroom.

Table 1 Professors’ and students’ activities in flipped learning

The structure of flipped learning, like other flipped learning, consists of before-class activities, class activities, and a wrap-up. Table 1 shows the professors’ and students’ activities in flipped learning. As shown in Table 1, the professors first developed a clinical case and uploaded assigned learning materials related to the clinical case to be discussed in class one week before a class online on the learning management system (LMS). They developed around three quizzes to check whether the students finished the assigned reading, and were ultimately prepared for class discussion. During the class, the professor let them take quizzes online through the LMS, then checked the answers as a class, and explained what the students did not understand. The professor then handed out the illness script worksheet to each group, and the students completed the worksheet through group discussions. An internet search was allowed during the discussion. While the students were discussing in a group, the professor went around the classroom and played as the facilitator role. They encouraged group discussions and answered the question as content experts. Each group then presented their completed worksheet in front of the class and the professor gave them feedback. Finally, the professor delivered a mini-lecture with the illness script worksheet completed by the professor to provide cognitive feedback by comparison. Finally, they had a Q&A session, and after the class the students wrote reflective journals regrading what they had learned, realized, or felt through their learning experience.


DTI, developed by Bordge et al. [20], consists of 41 questions. It was designed to measure self-assessed clinical reasoning ability and has two subscales; flexibility in thinking (FT, 21 items) and evidence of structure in memory independent of content (SM, 20 items). FT involves using multiple approaches to explore diagnostic possibilities based on key patient interview features or general inquiries when forceful features do not arise yet. In addition, SM refers to the availability and accessibility of organized knowledge stored in memory during clinical reasoning [20]. DTI is based on illness script theory, focusing on the organization and availability of medical knowledge stored in memory as the prime determinant of diagnostic thinking [20, 21]. Previous studies have demonstrated that this is a reliable and valid assessment tool for clinical reasoning ability [19,20,21,22,23,24]. Each item of DTI contains a stem followed by two semantically opposing statement (e.g. “When I am interviewing a patient, I often seem to get one idea stuck in my mind about what might be wrong, or I usually find it easy to explore various possible diagnosis) and the students indicate where they fall most often when they deal with cases on a 6-point Likert scale. Each item was scored based on the proximity of the response most closely associated with expert diagnostic thinking. Higher subcategories or overall DTI scores indicate a more advanced level of diagnostic reasoning, with a maximum of 246 for the total score, 126 for FT and 120 for SM [20].

Learning experience survey

A learning experience survey was administered to investigate the learners’ experiences during the newly developed course. The survey was adapted from a course evaluation survey conducted at the institution where this study was conducted, and it consisted of 11 questions on a 4-point Likert scale, including two open-ended questions regarding the strengths, and weaknesses of the course (Appendix 3).

Data analysis

The collected data were analyzed using the IBM SPSS 27. The reliability of the survey items was assessed using Cronbach’s alpha. Changes in learners’ DTI and subcategory scores before and after the intervention were examined using a dependent t-test. To examine the impact of this intervention based on students’ clinical reasoning ability, they were divided into high and low groups according to their pre-DTI scores, and group comparisons were conducted using an independent t-test. The significance level for this study was set at p < .05. The survey on learning experiences was analyzed using descriptive statistics and data from the open-ended questions were analyzed and categorized through content analysis.


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