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Context  Problem-solving in terms of clinical reasoning is regarded as a key competence of medical doctors. Little is known about the general cognitive actions underlying the strategies of problem-solving among medical students. In this study, a theory-based model was used and adapted in order to investigate the cognitive actions in which medical students are engaged when dealing with a case and how patterns of these actions are related to the correct solution.    Methods  Twenty-three medical students worked on three cases on clinical nephrology using the think-aloud method. The transcribed recordings were coded using a theory-based model consisting of eight different cognitive actions. The coded data was analysed using time sequences in a graphical representation software. Furthermore the relationship between the coded data and accuracy of diagnosis was investigated with inferential statistical methods.    Results  The observation of all main actions in a case elaboration, including evaluation, representation and integration, was considered a  complete model  and was found in the majority of cases (56%). This pattern significantly related to the accuracy of the case solution (φ = 0.55; p<.001). Extent of prior knowledge was neither related to the  complete model  nor to the correct solution.    Conclusions  The proposed model is suitable to empirically verify the cognitive actions of problem-solving of medical students. The cognitive actions  evaluation, representation  and  integration  are crucial for the  complete model  and therefore for the accuracy of the solution. The educational implication which may be drawn from this study is to foster students reasoning by focusing on higher level reasoning.

Cognitive Problem Solving Patterns of Medical Students Correlate with Success in Diagnostic Case Solutions