Exploring the Effectiveness of Two Instructional Approaches to Diagnostic Reasoning Training: Case-based Learning and Gameful Learning

Concurrent Session 9

Session Materials

Brief Abstract

A research proposal investigating the effectiveness of gameful learning and case-based learning for diagnostic reasoning will be presented. Attendees will have an opportunity for a hands-on experience with the proposed gameful instructional strategy. The presenters are looking for other researchers and healthcare faculty who may be interested in collaborative opportunities.


I am a recent graduate of Capella University, earning my Ph.D in Education with the subspecialty of Instructional Design for Online Learning in 2018. I have an M.A. in biblical counseling from Southeastern Baptist Theological Seminary and a B.S. in computer science-mathematics from Furman University. My professional work experience includes computer programming, adjunct instructing in COBOL programming language and statistics. My passion is in research and academic writing. My desire is to be an agent of change in instructional design for online learning, particularly for counseling education.
Celina Byers-Lenius has 15+ years of Higher Education and Consulting experience in Training & Development. Her major research interests are innovative learning processes, assessment & evaluation, change and project management leadership, and application of technology to enhance learning experiences.

Extended Abstract

                                                                 Presentation Goals

  1. To introduce a proposal for a research study designed to assess the effectiveness of two instructional strategies to aid in developing illness scripts for diagnostic reasoning
  2. To allow attendees to have a hands-on experience with a proposed instructional tool that will offer a puzzle-like game for training in medical and non-medical complex problem-solving
  3. To invite interested attendees to collaborate with the research team by contributing research expertise or coordination efforts for a research site
  4. To allow attendees to sign up to follow the research progress through a researcher blog
  5. To offer attendees a tri-fold glossy brochure about the proposal, including key points from the Prezi presentation

                                                      Presentation Description


Medical training for diagnosticians requires a didactic phase and a clinical phase. Traditionally, the didactic phase instills in the student a knowledge base of disease processes and clinical reasoning skills, while the clinical phase offers the student diagnostic practice with actual patients (Schmidt & Mamede, 2015).  However, some medical programs are beginning to offer more diagnostic opportunities within the didactic phase with the goal of accelerating the process of diagnostic expertise to better prepare the student for the clinical phase (Leong et al., 2017).

Research studies have shown the effectiveness of specialty courses that teach diagnostic reasoning using a case-based approach (Harendza et al., 2017; Keemink et al., 2018). However, there is a shortage of instructional strategies that promote diagnostic reasoning, particularly strategies that manage cognitive load (Durning et al., 2013; Leppink & van den Heuvel, 2015).


Illness script theory explains the phenomena of the diagnostician’s ability to efficiently and accurately diagnose and manage disease processes by utilizing illness scripts. Illness scripts are mental schemas of disease cause and effect that facilitate the process of diagnostic reasoning (Charlin, Tardif, et al., 2000). Consequently, a key function of diagnostic training is to aid in the process of illness script development (Charlin et al., 2007).

The Clinical Integrative Puzzle (CIP) is an assessment for diagnostic reasoning (Ber, 2003). Capaldi et al. (2015) have suggested that the CIP may be a valuable tool to aid in the development of illness scripts while also managing cognitive load. A pilot study using the CIP as an online tool to develop illness scripts in novice diagnosticians has shown some promise of the effectiveness of the CIP used as an instructional strategy (Moore, in press).

Research exploring gameful learning as an instructional strategy indicated that students are willing to work harder in gameful learning environments and feel more responsible and in control of their grade outcomes (Aguilar, Holman & Fishman, 2018). Research also indicated that gameful learning can be an effective tool in medical education (Boeker et al., 2013; Corell et al., 2018).

The current design plan for this research proposal is a mixed-methods study comparing an existing approach with an innovative approach to diagnostic training in the didactic phase of medical education: the case-based approach vs. the CIP as an instructional strategy. The design of the study would ideally include three groups. One group would be participants in the case-based diagnostic course. A second group would be participants using the CIP tool for diagnostic training in a diagnostic course that does not use the case-based approach. A third group would be participants in the case-based diagnostic course that includes the CIP tool as an additional instructional strategy. All participants would be assessed for illness script development at the end of the study using the Script Concordance Test (SCT). The SCT compares illness scripts of the examinee with illness scripts of a panel of experts (Charlin, Roy et al., 2000). Quantitative data analysis would include the MANCOVA and multiple regression analysis. Qualitative data analysis would describe the participant experience using information gathered from a self-report questionnaire.


A Prezi presentation will be shown every ten minutes, highlighting the proposal. The attendees will be able to interact with the CIP. Multiple CIP choices will be available for medical and non-medical attendees.


            Collaboration opportunities will include researchers and healthcare faculty.


The attendees will be given a brochure of the presentation and a web link to our researchers’ blog to follow the progress of the study.


Aguilar, S. J., Holman, C., & Fishman, B. J. (2018). Game-inspired design: Empirical evidence in support of gameful learning environments. Games and Culture, 13(1), 44-70.

Ber, R. (2003). The CIP (comprehensive integrative puzzle) assessment method. Medical Teacher, 25(2), 171-176. doi:10.1080/0142159031000092571

Boeker, M., Andel, P., Vach, W., & Frankenschmidt, A. (2013). Game-Based E-Learning Is More Effective than a Conventional Instructional Method: A Randomized Controlled Trial with Third-Year Medical Students. PLoS ONE, 8(12), e82328. http://doi.org/10.1371/journal.pone.0082328

Capaldi, V. F., Durning, S. J., Pangaro, L. N., & Ber, R. (2015). The clinical integrative puzzle for teaching and assessing clinical reasoning: Preliminary feasibility, reliability, and validity evidence. Military Medicine, 180(4S), 54-60. doi: 10.7205/MILMED-D-14-00564

Charlin, B., Boshuizen, H. P. A., Custers, E. J., & Feltovich, P. J. (2007). Scripts and clinical reasoning. Medical Education, 41(12), 1178-1184. doi:10.1111/j.1365-2923.2007.02924.x

Charlin, B., Roy, L., Brailovsky, C., Goulet, F., & van der Vleuten, C. (2000). The script concordance test: A tool to assess the reflective clinician. Teaching and Learning in Medicine, 12(4), 189-195. doi:10.1207/S15328015TLM1204_5

Charlin, B., Tardif, J., & Boshuizen, H. P. (2000). Scripts and medical diagnostic knowledge: Theory and applications for clinical reasoning instruction and research. Academic Medicine: Journal of the Association of American Medical Colleges, 75(2), 182-190. doi:10.1097/00001888-200002000-00020

Corell, A., Regueras, L. M., Verdú, E., Verdú, M. J., & de Castro, J. P. (2018). Effects of competitive learning tools on medical students: A case study. PloS One, 13(3), e0194096. doi:10.1371/journal.pone.0194096

Durning, S. J., Ratcliffe, T., Artino, A. R., Vleuten, C., Beckman, T. J., Holmboe, E., . . . Schuwirth, L. (2013). How is clinical reasoning developed, maintained, and objectively assessed? Views from expert internists and internal medicine interns. Journal of Continuing Education in the Health Professions, 33(4), 215-223. doi:10.1002/chp.21188

Harendza, S., Krenz, I., Klinge, A., Wendt, U., & Janneck, M. (2017). Implementation of a Clinical Reasoning Course in the Internal Medicine trimester of the final year of undergraduate medical training and its effect on students’ case presentation and differential diagnostic skills. GMS Journal for Medical Education, 34(5), Doc66. http://doi.org/10.3205/zma001143

Keemink, Y., Custers, E. J. F. M., van Dijk, S., & ten Cate, O. (2018). Illness script development in pre-clinical education through case-based clinical reasoning training. International Journal of Medical Education, 9, 35–41. http://doi.org/10.5116/ijme.5a5b.24a9

Leong, S. L., Cangiarella, J., Fancher, T., Dodson, L., Grochowski, C., Harnik, V., . . . Pusic, M. (2017). Roadmap for creating an accelerated three-year medical education program. Medical Education Online, 22(1), 1396172-10. doi:10.1080/10872981.2017.1396172

Leppink, J., & van den Heuvel, A. (2015). The evolution of cognitive load theory and its application to medical education. Perspectives on Medical Education, 4(3), 119-127. doi:10.1007/s40037-015-0192-x

Moore, P. C. (in press). The effect of the clinical integrative puzzle on illness script development (Doctoral dissertation). Capella University, Minneapolis, MN.

Schmidt, H. G., & Mamede, S. (2015). How to improve the teaching of clinical reasoning: A                narrative review and a proposal. Medical Education, 49(10), 961-973. doi:10.1111/medu.12775