Teaching metacognition in clinical decision-making using a novel mnemonic checklist: an exploratory study

Keng Sheng Chew*, Steven J. Durning, Jeroen J. G. van Merrienboer

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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INTRODUCTION Metacognition is a cognitive debiasing strategy that clinicians can use to deliberately detach themselves from the immediate context of a clinical decision, which allows them to reflect upon the thinking process. However, cognitive debiasing strategies are often most needed when the clinician cannot afford the time to use them. A mnemonic checklist known as TWED (T = threat, W = what else, E = evidence and D = dispositional factors) was recently created to facilitate metacognition. This study explores the hypothesis that the TWED checklist improves the ability of medical students to make better clinical decisions. METHODS Two groups of final-year medical students from Universiti Sains Malaysia, Malaysia, were recruited to participate in this quasi-experimental study. The intervention group (n = 21) received educational intervention that introduced the TWED checklist, while the control group (n = 19) received a tutorial on basic electrocardiography. Post-intervention, both groups received a similar assessment on clinical decision-making based on five case scenarios. RESULTS The mean score of the intervention group was significantly higher than that of the control group (18.50 +/- 4.45 marks vs. 12.50 +/- 2.84 marks, p <0.001). In three of the five case scenarios, students in the intervention group obtained higher scores than those in the control group. CONCLUSION The results of this study support the use of the TWED checklist to facilitate metacognition in clinical decision-making.
Original languageEnglish
Pages (from-to)694-700
JournalSingapore Medical Journal
Issue number12
Publication statusPublished - Dec 2016


  • checklist
  • cognitive bias
  • cognitive debiasing strategy
  • medical education
  • metacognition


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