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Factors affecting feeling-of-knowing in a medical intelligent tutoring system: the role of immediate feedback as a metacognitive scaffold

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Abstract

Previous studies in our laboratory have shown the benefits of immediate feedback on cognitive performance for pathology residents using an intelligent tutoring system (ITS) in pathology. In this study, we examined the effect of immediate feedback on metacognitive performance, and investigated whether other metacognitive scaffolds will support metacognitive gains when immediate feedback is faded. Twenty-three participants were randomized into intervention and control groups. For both groups, periods working with the ITS under varying conditions were alternated with independent computer-based assessments. On day 1, a within-subjects design was used to evaluate the effect of immediate feedback on cognitive and metacognitive performance. On day 2, a between-subjects design was used to compare the use of other metacognitive scaffolds (intervention group) against no metacognitive scaffolds (control group) on cognitive and metacognitive performance, as immediate feedback was faded. Measurements included learning gains (a measure of cognitive performance), as well as several measures of metacognitive performance, including Goodman–Kruskal gamma correlation (G), bias, and discrimination. For the intervention group, we also computed metacognitive measures during tutoring sessions. Results showed that immediate feedback in an intelligent tutoring system had a statistically significant positive effect on learning gains, G and discrimination. Removal of immediate feedback was associated with decreasing metacognitive performance, and this decline was not prevented when students used a version of the tutoring system that provided other metacognitive scaffolds. Results obtained directly from the ITS suggest that other metacognitive scaffolds do have a positive effect on G and discrimination, as immediate feedback is faded. We conclude that immediate feedback had a positive effect on both metacognitive and cognitive gains in a medical tutoring system. Other metacognitive scaffolds were not sufficient to replace immediate feedback in this study. However, results obtained directly from the tutoring system are not consistent with results obtained from assessments. In order to facilitate transfer to real-world tasks, further research will be needed to determine the optimum methods for supporting metacognition as immediate feedback is faded.

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Acknowledgments

Work on this project was supported by a grant from the National Library of Medicine (R01 LM007891). The work was conducted using the Protégé resource, which is supported by grant LM007885 from the United States National Library of Medicine. We thank Lucy Cafeo for editorial assistance.

Author information

Authors and Affiliations

  1. Department of Biomedical Informatics, University of Pittsburgh School of Medicine, UPMC Shadyside Cancer Pavilion, 5150 Centre Avenue, Pittsburgh, PA, 15232, USA

    Gilan M. El Saadawi, Melissa Castine, Velma Payne, Olga Medvedeva, Eugene Tseytlin, Elizabeth Legowski, Drazen Jukic & Rebecca S. Crowley

  2. Department of Health and Community Services, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA

    Gilan M. El Saadawi

  3. Department of Psychology, University of Memphis, Memphis, TN, USA

    Roger Azevedo

  4. Department of Dermatology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Drazen Jukic

  5. Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Drazen Jukic & Rebecca S. Crowley

  6. Intelligent Systems Program, University of Pittsburgh School of Arts and Sciences, Pittsburgh, PA, USA

    Rebecca S. Crowley

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  1. Gilan M. El Saadawi
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Correspondence to Rebecca S. Crowley.

Appendices

Appendix 1: metacognitive pseudo-dialog

During case

  1. 1.

    Having a strategy usually helps in solving any problem. What sentence would best describe your strategy at the beginning of a case?

    1. a.

      I try to place the case first in a general category of disease.

    2. b.

      I try to remember a similar case.

    3. c.

      I try to look at the whole slide and then focus on finding features.

    4. d.

      I like to hypothesize and then confirm or dispute my hypothesis.

  2. 2.

    At any given time in problem solving, it is usually helpful to have a strategy in place. What sentence would best describe your strategy during viewing a case?

    1. a.

      I try to look for a pathognomonic feature that would narrow the differential diagnosis as early as possible.

    2. b.

      I have a systematic approach that would narrow the differential diagnosis in a gradual step by step fashion.

    3. c.

      I identify all the features in the order I see them until I come up with a differential diagnosis.

    4. d.

      I ask for help to have an idea of features I should be looking for in the case.

    5. e.

      I try to place the case in a general schema (visual representation in my head) of concepts and diagnoses.

  3. 3.

    What is the specific purpose for the strategy you are using?

    1. a.

      This strategy has worked in the past.

    2. b.

      This strategy is effective in this case.

    3. c.

      I don’t know of another strategy.

    4. d.

      I don’t have any strategy.

  4. 4.

    Did you set specific goals before viewing this case? What are they?

  5. 5.

    What features are most important to identify in this case? Why are they important?

  6. 6.

    Did you ask yourself questions about the case before you began? What were these questions?

  7. 7.

    What sentence would best describe your goals at this point?

    1. a.

      I have a hypothesis but I am not able to confirm or dispute it.

    2. b.

      I am trying to locate all the features on the slide before making a hypothesis.

    3. c.

      I am just looking around the slide trying to find something familiar.

    4. d.

      I am completely lost and I need help.

  8. 8.

    Did you slow down when you encountered important features like <random_feature>?

  9. 9.

    What features are possibly associated with the <random_hypothesis>?

  10. 10.

    One way that expertise can be acquired is to develop a schema or representation of concepts such as visual features and their relationships to different diagnoses. Do you have a schema (visual representation) in your head that helps you integrate the information you learn after each case?

  11. 11.

    Studies show the amount you learn is related to your motivation. How motivated are you to learn something new from the tutor?

  12. 12.

    It is important to identify ones intellectual strengths and build on them to account for ones weakness. What sentence would best describe your intellectual strengths and weaknesses?

    1. a.

      I am better at viewing the slide when I have studied and know the educational concepts for a case.

    2. b.

      I can learn how to diagnose the case even without knowing anything about the subject.

    3. c.

      I like to read a textbook before attempting to view cases.

    4. d.

      I cannot learn about a case until I have been taught the educational concepts for a case

  13. 13.

    Locking onto a salient feature at initial presentation and failing to shift from your first impression of the case is a common heuristic error used in medical decision making. Which of the following heuristics does this describe?

    1. a.

      Anchoring

    2. b.

      Pseudo-diagnosticity

    3. c.

      Satisficing

    4. d.

      Representativeness

    5. e.

      I do not know

  14. 14.

    A common heuristic error is the tendency to not search for other possible diagnoses once a satisfactory solution has been reached leading to premature diagnostic closure of the case. Which of the following heuristics does this describe?

    1. a.

      Anchoring

    2. b.

      Pseudo-diagnosticity

    3. c.

      Satisficing

    4. d.

      Representativeness

    5. e.

      I do not know

  15. 15.

    Seeking features that confirm an initial diagnosis but not seeking features that support a competing diagnosis is known as which of these options?

    1. a.

      Anchoring

    2. b.

      Pseudo-diagnosticity

    3. c.

      Satisficing

    4. d.

      Representativeness

    5. e.

      I do not know

  16. 16.

    A heuristic error commonly made through categorization of cases depending on one prototypical feature is known as which of these options?

    1. a.

      Anchoring

    2. b.

      Pseudo-diagnosticity

    3. c.

      Satisficing

    4. d.

      Representativeness

    5. e.

      I do not know

End of case

  1. 1.

    Are you consciously focusing your attention on important features? What are these features?

  2. 2.

    It is a good strategy to stop and review a case to help understand important relationships between features and diagnoses. How frequently are you reviewing the case to help understand these relationships?

  3. 3.

    Now that you have reached <random_diagnosis>, what sentence would best describe what you did?

    1. a.

      I think it would have been easier to reach the diagnosis if I had asserted a hypothesis earlier.

    2. b.

      I think I should have asked for more help.

    3. c.

      I think I should have studied the slide more carefully and identified more features before I attempted a hypothesis.

    4. d.

      I worked through the case efficiently and should not have done anything differently.

  4. 4.

    What sentence would best describe your asking for help?

    1. a.

      I ask for help only when I need it.

    2. b.

      I frequently ask for help to be sure of my work.

    3. c.

      I never ask for help.

    4. d.

      I only ask for help if everything else fails.

  5. 5.

    It is a good strategy to link relationships between features and diagnoses in different cases. Is a <random_feature> related to what you have already seen in previous cases? Explain.

  6. 6.

    It is a good strategy to stop and reevaluate your actions to ensure that they are consistent with your goal. How did you reevaluate <random_hypothesis>?

  7. 7.

    What sentence would best describe how you learn?

    1. a.

      I have a schema (visual representation in my head) for features and their relationships with a diagnosis.

    2. b.

      I just take each case individually.

    3. c.

      I try to remember previous cases and link them to what is in the slide.

    4. d.

      I try to remember what I read about the subject.

  8. 8.

    What sentence would best describe how correct you are in identifying the features and reaching a diagnosis?

    1. a.

      I am always sure when I am correct and when I am incorrect.

    2. b.

      Most of the time, I am sure when I am correct.

    3. c.

      Most of the time, I am sure when I am incorrect.

    4. d.

      I am never sure how correct or incorrect I am.

  9. 9.

    What sentence would best describe how much you learned in comparison to what the tutor expected you to learn in this case?

    1. a.

      I think I learned most of what the tutor wanted me to learn.

    2. b.

      I don’t think I learned what the tutor wanted me to learn.

    3. c.

      I think I got some of what the tutor wanted me to learn.

    4. d.

      I don’t think the tutor was teaching me anything new.

  10. 10.

    Did you ever lock onto a salient feature at initial presentation and fail to shift from your first impression of the case? This is a common heuristic error made in the medical field and is known as Anchoring.

  11. 11.

    Did you consider multiple hypotheses for the case? A common heuristic error known as Satisficing is the tendency to not search for other possible diagnoses once a satisfactory solution has been reached leading to premature diagnostic closure of the case.

  12. 12.

    When trying to reach your definitive diagnosis from the list of hypotheses, did you seek both confirming and disputing findings? A common heuristic error known as Pseudo-diagnosticity occurs when data is sought that confirms one but not other competing hypotheses.

  13. 13.

    Do you try to identify multiple features to support a hypothesis? Representativeness is one of the heuristic errors commonly made through categorization of cases depending on one prototypical feature.

Inspectable student model (knowledge explorer) questions at end of case

  1. 1.

    Using the Knowledge Explorer, can you tell if you were right or wrong about <wrong_diagnosis_or_hypothesis>? If you were wrong, what error did you make?

  2. 2.

    Looking at the Knowledge Explorer, what things have you seen but haven’t learned?

  3. 3.

    Click on the Self Check Summary tab. For items you were wrong or unsure about (refer to the self check column), how much knowledge does the tutor think you have about it?

Appendix 2: foil dialog

Early in case

  1. 1.

    Why do you need high power for the diagnosis of this case?

  2. 2.

    Why do you need low/medium power for the diagnosis of this case?

  3. 3.

    Do you have a set of feature(s) you look for in this kind of case? If yes, please list.

  4. 4.

    Why did you feel feature x was important in coming to a diagnosis?

  5. 5.

    What other feature(s) can you confuse with feature X?

  6. 6.

    What is the differential diagnosis you think of when you see feature X?

  7. 7.

    What are some important features related to hypothesis X?

  8. 8.

    Does the attribute Z of feature X have other values?

  9. 9.

    What are the hypotheses supported by feature X?

Later in case (have suggested at least one diagnosis):

  1. 1.

    What feature(s) do you think is the most crucial in coming to the diagnosis of this case?

  2. 2.

    What are some important features that you have learned in diagnosing diagnosis x?

  3. 3.

    What do you think is the stain used in this slide? When you sign-out, would you like to have more stains done on the same specimen?

  4. 4.

    What are the features easily identified by using H&E?

  5. 5.

    What are the features easily identified by using Pas D?

  6. 6.

    What are the features easily identified by using colloidal iron ?

  7. 7.

    If you had to sign out this case, are there any additional information/tests/that you would like to have completed? If so, why?

  8. 8.

    Are there any additional features that you would have liked to identify in coming to the diagnosis that were not in the tutor?

  9. 9.

    The diagnosis X is supported by presence of what features?

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El Saadawi, G.M., Azevedo, R., Castine, M. et al. Factors affecting feeling-of-knowing in a medical intelligent tutoring system: the role of immediate feedback as a metacognitive scaffold. Adv in Health Sci Educ 15, 9–30 (2010). https://doi.org/10.1007/s10459-009-9162-6

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