摘要：Case-based teaching with real patient cases provides benefit of simulating real-world cognition. However, while clinical practice involves a prospective approach to cases, preclinical instruction typically involves full disclosure of case content to faculty, introducing hindsight bias into faculty teaching in medical curricula. During 2015–2018, we piloted an optional medical school curriculum involving 6–7 one-hour sessions over a 3-month period each year. New groups enrolled each year from first- and second-year classes. A facilitator provided a blinded physician discussant and blinded students with case information during and not in advance of each session, allowing prospective case-based discussions. Cases were based on real patients treated in the Department of Medicine. Clinical material was presented in the chronologic sequence encountered by treating physicians. Content covered a median of 5 patient visits/case (range: 2–10) spanning over months. A 14-item survey addressing components of the reporter-interpreter-manager-educator (RIME) scheme was developed and used to compare self-reported clinical skills between course participants and non-participant controls during the 2016 course iteration. This elective curriculum at Stanford School of Medicine involved 170 preclinical students (22.7% of 750 eligible). During the 2016 course iteration, a quasi-experimental study compared self-reported clinical skills between 29 course participants (response rate: 29/49 [59.2%]) and 35 non-participant controls (response rate: 35/132 [26.5%]); students self-assessed clinical skills via the RIME-based survey developed for the course. Two-sample t-tests compared the change in pre- and post-course skills between course participants and non-participants. Of 15 Department of Medicine faculty members invited as discussants, 12 (80%) consented to participate. Compared with controls, first-year participants self-assessed significantly greater improvement in understanding how clinicians reason through cases step-by-step to arrive at diagnoses (P = 0.049), work through cases in longitudinal settings (P = 0.049), and share information with patients (P = 0.047). Compared with controls, second-year participants self-assessed significantly greater improvement (P = 0.040) in understanding how clinicians reason through cases step-by-step to arrive at diagnoses. Prospective case-based discussions with blinding of faculty and students to clinical content circumvents hindsight bias and may impart real-world cognitive skills as determined by student self-report.
