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Med Educ. 2007 Mar;41(3):281-7.

The benefits of flexibility: the pedagogical value of instructions to adopt multifaceted diagnostic reasoning strategies.

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Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.



Building on the advice of previous research to avoid parsing diagnostic strategies too finely, recent studies have shown that teaching novices to utilise analytic and non-analytic reasoning strategies yields higher diagnostic accuracy than teaching either in isolation. This study assesses the extent to which students spontaneously adopt a combined approach and compares its benefits with those experienced with a contrastive learning strategy known to enhance analogical transfer.


A sample of 48 naïve students were trained to identify features on electrocardiograms (ECGs) and assign diagnoses. Half the participants learned in a standard manner, encountering diagnoses (and their associated features) in sequence. The remaining participants were explicitly instructed to draw comparisons between the diagnostic category being learned and another confusable diagnostic category (contrastive learning). Half the participants in both groups were further instructed to carefully identify all features while trusting guidance provided by feelings of familiarity (a combined reasoning strategy). The remaining participants were given no instructions on how to approach the diagnostic task.


Greater diagnostic accuracy was achieved following both contrastive learning and instructions to use a combined reasoning strategy relative to the control conditions. These variables did not interact with each other, nor did they interact with novelty of the test case. The effects were observed immediately after learning and following a 1-week delay.


The results emphasise the importance of explicitly empowering students to utilise multiple diagnostic strategies, including non-analytic approaches. In addition, this study reveals the benefit that can be gained from contrastive learning in a medical domain.

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