Case-Based Teaching: Does the Addition of High-Fidelity Simulation Make a Difference in Medical Students’ Clinical Reasoning Skills?

  • Mary Kathryn MutterEmail author
  • James R. Martindale
  • Neeral Shah
  • Maryellen E. Gusic
  • Stephen J. Wolf
Original research



Situativity theory posits that learning and the development of clinical reasoning skills are grounded in context. In case-based teaching, this context comes from recreating the clinical environment, through emulation, as with manikins, or description. In this study, we sought to understand the difference in student clinical reasoning abilities after facilitated patient case scenarios with or without a manikin.


Fourth-year medical students in an internship readiness course were randomized into patient case scenarios without manikin (control group) and with manikin (intervention group) for a chest pain session. The control and intervention groups had identical student-led case progression and faculty debriefing objectives. Clinical reasoning skills were assessed after the session using a 64-question script concordance test (SCT). The test was developed and piloted prior to administration. Hospitalist and emergency medicine faculty responses on the test items served as the expert standard for scoring.


Ninety-six students were randomized to case-based sessions with (n = 48) or without (n = 48) manikin. Ninety students completed the SCT (with manikin n = 45, without manikin n = 45). A statistically significant mean difference on test performance between the two groups was found (t = 3.059, df = 88, p = .003), with the manikin group achieving higher SCT scores.


Use of a manikin in simulated patient case discussion significantly improves students’ clinical reasoning skills, as measured by SCT. These results suggest that using a manikin to simulate a patient scenario situates learning, thereby enhancing skill development.


Simulation-based medical education Case-based teaching Undergraduate medical education Clinical reasoning Script concordance testing 



We thank Dr. Meredith Thompson for her significant contribution to this project.

Authors’ Contributions

All authors contributed to the study conception and design. Material preparation and data collection were performed by M. Kathryn Mutter, James R. Martindale, Neeral Shah, and Stephen J. Wolf. Data analysis was performed by James R. Martindale and M. Kathryn Mutter. Supervision was provided by James R. Martindale, Stephen J. Wolf, and Maryellen E. Gusic. The first draft of the manuscript was written by M. Kathryn Mutter, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.


This project was supported by an internal Educational Fellowship Award at the University of Virginia School of Medicine.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This research project was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The University of Virginia Institutional Review Board for Social and Behavioral Sciences declared the study exempt (Reference number 2018006700).

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

40670_2019_904_MOESM1_ESM.pdf (237 kb)
ESM 1 (PDF 236 kb)


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Copyright information

© International Association of Medical Science Educators 2020

Authors and Affiliations

  1. 1.Department of Emergency MedicineUniversity of Virginia School of MedicineCharlottesvilleUSA
  2. 2.University of Virginia School of MedicineCharlottesvilleUSA
  3. 3.Division of Gastroenterology and HepatologyUniversity of Virginia School of MedicineCharlottesvilleUSA
  4. 4.Department of Emergency Medicine, Denver Health Medical CenterUniversity of Colorado School of Medicine, Denver Health Medical CenterDenverUSA

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