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In Reply to Maholtz

Andrews, Mary A., MD, MPH; Kelly, William F., MD; DeZee, Kent J., MD, MPH

doi: 10.1097/ACM.0000000000002527
Letters to the Editor

Associate professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland; mary.andrews@usuhs.edu.

Professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland.

Professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland.

Disclosures: None reported. The views expressed in this letter are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.

We thank the author for these comments. We agree that medical educators need more theoretically sound and well-studied methods of remediating struggling learners. Ideally, we would like to identify learners who are likely to benefit from this intervention before they fail a high-stakes examination, which is why we applied our intervention to residents based on in-training examination scores rather than waiting to use it with those who failed the certification examination.1 While the intervention requires only a modest amount of face-to-face faculty time (about 60–90 minutes per learner), this time is valuable, and applying the intervention to those who are not struggling may be inefficient. Furthermore, it is possible that a learner who has already internalized and automated his self-regulatory processes may be hindered by requiring explicit enactment of steps of the self-regulated learning cycle. Therefore, we consider the method we described to be most appropriate for learners who are deemed to be at risk of poor test performance, usually based on a screening examination or pretest. We agree that focusing on the development of disease scripts early in medical education will benefit learners, although we believe that this should be done in the context of a broader clinical reasoning curriculum that teaches a variety of clinical reasoning components and strategies.2 , 3 Disease script recognition is one tool in the clinical reasoning toolbox, aptly suited for timed vignette-based test questions and many clinical encounters, but physicians also need other strategies for atypical presentations observed in daily practice.

Mary A. Andrews, MD, MPH

Associate professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland; mary.andrews@usuhs.edu.

William F. Kelly, MD

Professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland.

Kent J. DeZee, MD, MPH

Professor, Department of Medicine, Uniformed Services University, Bethesda, Maryland.

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References

1. Andrews MA, Kelly WF, DeZee KJ. Why does this learner perform poorly on tests? Using self-regulated learning theory to diagnose the problem and implement solutions. Acad Med. 2018;93:612–615.
2. Charlin B, Boshuizen HP, Custers EJ, Feltovich PJ. Scripts and clinical reasoning. Med Educ. 2007;41:1178–1184.
3. Young ME, Dory V, Lubarsky S, Thomas A. How different theories of clinical reasoning influence teaching and assessment. Acad Med. 2018;93:1415.
© 2019 by the Association of American Medical Colleges