We identified two main clusters of themes about learner’s experiences with SE as an approach for developing their diagnostic reasoning: 1) the kinds of cognitive work required by the SE approach, and 2) how SE impacted knowledge. The data extracts illustrating these themes have been translated from French to English and confirmed by back translation.
Cognitive Work Required by the SE Approach
Participants described five elements related to the cognitive work they engage in when self‑explaining the clinical cases: 1) knowledge reactivation, 2) knowledge elaboration and organization, 3) increase awareness about gaps and ambiguities in knowledge, 4) recall of pathophysiological mechanisms, and 5) deliberate, systematic analysis of the elements of the clinical case.
Knowledge Reactivation
Participants described calling up prior knowledge to understand specific elements of the clinical case. We labeled this process knowledge reactivation. Participants stated that this reactivation was triggered and/or enhanced by having to explain the clinical cases to themselves:
“The exact metabolism of bilirubin, you know, I have little bit forgotten... but it came back to me during the session... it did bring back some prior knowledge, without the need to do anything else, it came to me spontaneously as I was trying to explain it to myself.” (Participant 06)
Knowledge Elaboration and Knowledge Organization
Participants engaged in a process of making connections between different pieces of information, a process we labeled as knowledge elaboration. Participants reported that, during SE, they made these links between the symptoms and the pathophysiological mechanisms of jaundice, as well as between the symptoms, the data from the physical examination, the laboratory work-ups, the diagnoses of other diseases presenting with jaundice, and even between elements of the different clinical cases solved.
“I associated the symptoms with my findings on the physical exam, depending on the different etiologies that I had in mind... then, well, with the work-ups... and then, I tried to figure out which pathology would best explain everything...” (Participant 06)
Participants also engaged in a process of dividing the information into subsets, and of constructing relationships between each of the subsets, in an order that was easy for them to understand. During SE of the different cases, for example, the participants subdivided the causes of jaundice into broad categories according to the pathophysiological mechanisms involved (e.g., conjugated and unconjugated hyperbilirubinemia). With each mechanism, they associated a diagnosis, in terms of symptoms, clinical signs, and paraclinical data. We defined these processes as knowledge organization.
“When I first started, I wrote on my paper ‘conjugated hyperbilirubinemia could mean...’ and ‘unconjugated could mean...’. Then, as I read through the case, if I saw a clue that made me think, ‘That doesn’t work with conjugated anymore,’ I’d make a little check mark next to ‘conjugated’ or ‘unconjugated.’(Participant 05)
Increase Awareness about Gaps and Ambiguities in Knowledge
All the participants described specific moments when, as they were attempting to self-explain, they became more aware of the status of their knowledge. Participants identified gaps, uncertainties or ambiguities and sometimes even erroneous understandings.
“I find that it helps us see where we struggle the most whereas if I have not
asked myself questions, I may have never realized that I had those gaps.” (Participant 05)
According to the participants, listening to the resident example contributed to their monitoring effort.
“[Listening to the resident’s example] enables me to learn and correct my mistakes, and to reassess my understanding which did not match the resident’s explanation.” (Participant 07)
Participants also perceived that being required to verbalize their self-explanations supported monitoring of their knowledge.
“Hearing yourself talk really does help. It, sort of, crystallizes what you are thinking. You listen to yourself talking and you think ‘OK, does what I’m saying make sense?’.”
(Participant 03)
Recall of Pathophysiological Mechanisms
Participants reported that, during the SE activity, they tended to explain the symptoms, physical signs, and results of laboratory tests presented in the clinical case to themselves based on the pathophysiological mechanisms of jaundice. This helped them better understand the elements of the clinical case. This process, which we labeled recall of the pathophysiological mechanisms, seems to have been enhanced by SE.
“It’s just that you don’t necessarily always think about the pathophysiological mechanisms. But when you’re self-explaining, you kind of have no choice but to go there.” (Participant 07)
The need to go back to underlying mechanisms seemed dependent on prior knowledge. If the participant had a solid understanding of the relevant biomedical knowledge, resorting to the pathophysiological mechanism became less necessary.
“I only do that if there are symptoms I don’t understand or something I can’t explain. That’s when I’ll try to explain the underlying mechanisms to myself.” (Participant 08)
Deliberate, Systematic Analysis of the Elements of the Problem
Participants described how SE required them to engage in a detailed, careful, and systematic analysis of the clinical cases. The participants reported focusing on each element of the clinical case. They explained having to engage deeply in questioning and exploring a variety of paths to solve the clinical cases. We called this process deliberate, systematic analysis of the elements of the problem.
“I think the strategy helps me to be more systematic in searching information, be more reflective, asking questions, and going a step further for a better understanding of things.” (Participant 01)
How SE Impacted Knowledge
Participants cited three different ways that SE contributed to the development of their knowledge about jaundice: 1) Interconnected knowledge, 2) Enrichment of illness scripts, 3) Knowledge retention and recall.
Interconnected Knowledge
The participants expressed surprise when realizing that, a week later in the second meeting, while diagnosing the new clinical cases of jaundice, they were able to make links between the physical signs and the mechanisms of jaundice, or between the physical signs and a clinical syndrome, without the need for additional and detailed explanations of each sign or symptom. We have defined this as interconnected knowledge.
“I saw ‘spider angioma,’ ‘portal hypertension,’ and ‘splenomegaly,’ so I immediately wrote ‘looks like cirrhosis’ next to them, whereas last week, I really got stuck on ‘spider angioma,’ then ‘splenomegaly,’ then...” (Participant 10)
Enrichment of Illness Scripts
The participants reported that, while solving the clinical cases on jaundice during the second meeting, their mental representations of the different diseases related to jaundice seemed more detailed, complete and clear. They were able to anticipate and look for key elements that pointed them in the direction of one diagnosis rather than another. We labeled this enrichment of illness scripts. Furthermore, they expressed that they had more differential diagnoses in mind for the jaundice.
“The first time, I really had to reason and interpret each sign. I had to think about things more, but now I’m quicker at recognizing patterns and linking between symptoms… I have spontaneously more diagnoses in my differential.” (Participant 06)
Listening to an example of SE by a junior resident seems to have contributed to the construction of illness scripts related to jaundice. In fact, according to the participants, the resident’s SE sometimes contained additional knowledge that students used as an external resource. Listening to the resident’s SE sometimes seems to have helped the participants to consider diagnoses they wouldn’t initially have raised in their own SE. Participants reported having integrated parts of the junior resident’s knowledge expressed while self-explaining with their prior knowledge, which helped them to build a good mental representation of jaundice-related diseases.
“Of course, self-explaining really helped me to think about the diagnoses, then the resident brought up the possibility of others, which I had to then try to understand and explain to myself. Explaining things to myself solidified what I already knew. It was more listening to the example that prompted me to consider other diagnoses.” (Participant 08)
Knowledge Retention and Recall
While solving the new clinical cases on jaundice one week later, participants reported recognizing the different clinical presentations of the disease. They compared the new clinical cases of jaundice with those seen during the first meeting and identified similarities and differences. They clearly remembered the links they had previously made, allowing them to solve the new clinical cases with greater confidence and certainty. Some students attributed the improved knowledge retention to the personal and active thinking work that SE required them to do. Some students were even amazed that they were able to solve the clinical cases without having to review the material. We defined this reinforced knowledge as knowledge retention and recall.
“I guess it’s the technique, but I was able to make the links faster. I guess I found things were much clearer. I don’t know if it’s because it’s recent or if the self-explanation really made a difference, but I had more knowledge, and it came to me faster. I found it was much clearer.” (Participant 02)