Background: Differential diagnosis (DDx) is one of the key cognitive skills that medical learners must develop. However, little is known regarding the best methods for teaching DDx skills. As metacognition plays a fundamental role in the diagnostic process, we hypothesized that the teaching of specific heuristics and mnemonics collectively termed metamemory techniques (MMTs) would enhance the capacity of medical students to generate differential diagnoses. Methods: In a 90-min DDx workshop, third-year medical students (N = 114) were asked to generate differentials before and after learning each of four MMTs. Differential sizes were compared using a linear mixed-effect model. Students also completed a post-session questionnaire which included a subjective ranking of the MMTs, as well as Likert-scale and freetext sections for course feedback. Results: One MMT (the Mental CT Scan, an anatomic visualization technique) significantly increased the size of student differentials (+13.3%, p =.0005). However, a marked cumulative increase across all four MMTs was noted (+36.5%, p <.0001). A majority of students ranked the Mental CT Scan the most useful MMT (51.5%). They found the workshop both worthwhile (4.51/5, CI 4.33-4.69) and enjoyable (4.33/5, CI 4.12-4.55), and considered the MMTs they learned useful and practical (4.49/5, CI 4.32-4.67). Conclusion:The MMT-based DDx workshop was effective in enhancing the skill of DDx generation, and was rated very favorably by students.

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Medical education has taken a decided turn toward the “flipped classroom,” in which in-class lectures are de-emphasized and engaged learning is promoted. The time has also come to make some changes in what is being taught in clinical medicine, specifically with respect to the patient-physician interaction. Because the daily management of chronic illness is primarily the responsibility of the patient, clinical encounters that prioritize patient engagement and activation are critical. The traditional medical encounter, characterized by data gathering to make a diagnosis followed by prescribing or recommending treatment to the patient, can work well for acute illnesses or injuries, but effective chronic disease management requires substantial patient ownership of their health. In a “flipped exam room,” interactions with patients emphasize patient responsibility for health, such that priority is given to eliciting patient goals, what the patient knows, and how they desire to proceed with management of their health concerns and conditions. Just as medical students find engaged learning approaches to be more acceptable and satisfying, patients find collaborative interaction approaches on the part of their physicians to be more satisfying, and such approaches are associated with better outcomes. More attention to training students and residents in “flipped exam room” patient interaction skills is necessary.

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