Feedback in clinical cases: what makes it useful

Mountains reflected in a turquoise lake

You finish a case, see the correct diagnosis and move on to the next one. It seems like you learned, but the following week you miss a similar case for the same reason. Knowing the answer is only the first layer of the feedback. What really teaches is understanding why that answer was the right one and where your path diverged from it.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This guide summarizes what research in medical education says about feedback after a clinical case: what changes when you receive only the diagnosis, what changes when you receive the explanation and what your role is so that the feedback becomes learning.

Key points

  • Seeing the correct diagnosis already helps, but the gain tends to be limited to very similar cases.
  • Explanations that say why each answer is right or wrong teach more than the answer alone.
  • Explaining the case to yourself before reading the feedback increases what you get out of it.
  • Having control over how much detail to read is an advantage, not a shortcut.
  • The best time to read the explanation is right after committing to a guess.

Summary

What feedback is in a clinical case

Three layers of feedback

After a case, the feedback can come in layers. The first says whether you got it right. The second shows what the diagnosis was. The third explains the reasoning: which findings pointed to the disease, why the closest alternatives fall behind and which data changed the list of guesses.

Each layer teaches something different. Knowing whether you got it right serves to calibrate your confidence. Knowing the diagnosis closes the doubt of that case. The explanation is the layer that carries the learning to the next case, because it shows the mechanism behind the answer.

Feedback and testing go together

Answering before seeing the answer is already a form of study, as the guide on reviewing by playing shows. In a crossover trial with fourth-year students, cases accompanied by questions about the key points yielded more on the retention test, nine months later, than reading the same case as a narrative (Raupach et al., 2016). The feedback comes right after that effort to answer.

Correct answer or explanation: what studies show

The correct answer helps in similar cases

In a trial with third-year students in Canada, those who received the correct diagnosis after each case, either right away or at the end of the series, got more right one week later than those who received no feedback (Chamberland et al., 2019). The gain appeared in cases with the same final diagnosis, but disappeared in cases with different diagnoses, and the authors suggest testing more elaborate feedback (Chamberland et al., 2019).

The explanation teaches beyond the case

In a course with online tests after each case, one class received only the answers and the following year's class received the answers with the explanation of why each alternative was right or wrong (Wojcikowski and Kirk, 2013). The class with the explanation performed better on the final biomedical content exam, in a pilot study that compared different years (Wojcikowski and Kirk, 2013).

In an experiment with residents in the Netherlands who read chest X-rays, both types of feedback improved the relationship between confidence and accuracy: the one that said only whether the answer was right and the one that added the reason the diagnosis was that one (Staal et al., 2024). The relationship between confidence and accuracy was closer in the group that received the explanation, although the summary does not say whether the difference between the two types was significant, and the authors note that part of it may come from the improvement in accuracy itself (Staal et al., 2024).

Feedback also matters in practical skills

A meta-analysis on simulation-based procedure training found a moderate effect of feedback on skills, with a combined effect size of 0.74 (Hatala et al., 2014). For beginners, feedback given at the end of the task seemed to yield more retention than feedback given during performance (Hatala et al., 2014).

Curved wooden boomerang on a white background.
The boomerang comes back to whoever throws it; the return of a case also needs to come back to your reasoning. Credit: Rama, Musée d'ethnographie de Genève, CC BY-SA 3.0 FR (license), via Wikimedia Commons (file page).

Self-explanation: your side of the feedback

Explaining the case to yourself

Self-explanation is saying, out loud or in writing, why each finding points to a hypothesis while you solve the case. In a study with third-year students, all of them solved cases explaining their own reasoning; one group then heard examples of self-explanation from residents accompanied by directed questions (Chamberland et al., 2015). One week later, that group did better than the control on cases different from the trained ones, and the authors conclude that active processing of the examples is what makes the difference (Chamberland et al., 2015).

Comparing your path with the explanation

Self-explanation prepares the ground for feedback. Whoever wrote down why they chose a hypothesis can compare point by point with the explanation: where the reasoning matched, which finding was read differently, which alternative was left out. When that note is missing, the explanation tends to be read as a new text, and the comparison stays in the vague memory of what was thought.

When and how much feedback

Timing matters less than people think

In the Canadian study with correct diagnosis as feedback, receiving the answer right after each case or at the end of the series gave similar results (Chamberland et al., 2019). What mattered was having feedback, not the short interval between answer and correction. In practice, the central point is to answer before seeing the solution and to return to the explanation while the case is still in your head.

Having control over the detail helps

In an experiment with worked examples that contained deliberate errors, students who could choose the level of detail of the feedback gained more in strategic knowledge and in practical knowledge for deciding (Heitzmann et al., 2015). The extra prompts to reflect on the error, in the same study, added little to the learning environment (Heitzmann et al., 2015).

This matches the experience of those who study: after a quick correct answer, checking the essentials is enough; after an error, it is worth reading the whole explanation and going back to the content.

Situation after the case How much of the feedback to read Why
Got it right early and can explain it The summary of the explanation Confirms the reasoning without spending time
Got it right, but does not know why The whole explanation The correct answer may have been luck or recognition without basis
Got it wrong, but came close The difference between your hypothesis and the correct one The detail that separates neighboring diseases is what is missing
Got it wrong by a lot The whole explanation and the content of the disease It may be a knowledge gap, not a reasoning gap
Water drop rising from the surface after impact, with circular ripples around it.
The drop falls and the water sends back a jet: every impact generates a response worth observing. Credit: Roger McLassus, CC BY-SA 3.0 (license), via Wikimedia Commons (file page).

How to get more from the explanation of each case

A four-step script

  1. Commit to a hypothesis before seeing any feedback.
  2. Write in one line the two findings that weighed most in your choice.
  3. Read the explanation looking for the difference: which finding does it highlight that you let slip?
  4. Write the rule you take to the next case, in one sentence.

An example of reading

Imagine a case of chest pain in which you bet on coronary syndrome and the diagnosis was pericarditis. The explanation highlights the pain that worsens when lying down and improves when leaning the trunk forward, and the pericardial friction rub. When comparing with your note, you realize that you read the pain as typical and did not give weight to the change with position. The rule that remains is simple: the relationship of the pain to position goes on the question list for every chest pain.

This type of reading is what the error notebook organizes over the weeks. The explanation of a case becomes a study line, and similar lines show a pattern.

The feedback for each guess in NEXO

In NEXO, feedback starts before the end of the case. Each guess shows the proximity in ICD-10 at five levels, from Exact ICD to another chapter, and the clues go up to six. A guess in the same category says that you are close and one detail is missing; a guess in another chapter asks you to review where the hypothesis started.

In the result, the clinical explanation of the case is the point of return to the content, and the comparison shows which range of the day you landed in. The details of access to each feature are on the NEXO Economy page. If a clue, the diagnosis or the explanation seems inaccurate, the player can report the problem on the case itself, and the report goes to review.

If you research feedback and explanation in medical education and want to study these topics with NEXO, check out NEXO Researcher. To bring NEXO to your medical school, student league or residency, there is NEXO Closer. Doctors who review the explanations of cases in their specialty take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What is feedback in medical education?

It is the information the student receives about their own performance in order to adjust what they do next. In a clinical case, it ranges from knowing whether you got it right to the explanation of why the diagnosis is that one.

Does seeing only the right answer help?

It helps, but with a short reach. In a trial with third-year students, receiving the correct diagnosis improved accuracy on cases with the same diagnosis, and the effect disappeared on different cases (Chamberland et al., 2019).

Is immediate feedback better than delayed feedback?

In the same trial, receiving the answer right after each case or at the end of the series gave similar results (Chamberland et al., 2019). The most important thing is to answer first and return to the explanation while the case is fresh.

What is self-explanation?

It is explaining to yourself why each finding points to a hypothesis while you solve the case. Combined with examples of reasoning and directed questions, it improved students' performance on new cases (Chamberland et al., 2015).

How does NEXO give feedback during the case?

NEXO shows the proximity in ICD-10 of each guess on five levels and brings the clinical explanation of the case in the result. To get to know the game, read what NEXO is.

Checklist to make the most of feedback

  1. Answer first before seeing any solution.
  2. Write down the two findings that weighed most in your hypothesis.
  3. Read the explanation looking for the difference, and not just the answer.
  4. Adjust how much you read: summary when you are sure you got it right, the whole text when you got it wrong.
  5. Write one rule for the next case.
  6. Return to the content when the error is far from the answer.
  7. Group similar rules together in an error notebook.
  8. Review the rules on new cases, and not only on the same ones.

Want to receive feedback on every guess? Play the case of the day on NEXO.

References

  1. Raupach T, Andresen JC, Meyer K, et al. Test-enhanced learning of clinical reasoning: a crossover randomised trial. Med Educ. 2016. https://pubmed.ncbi.nlm.nih.gov/27295475/
  2. Chamberland M, Setrakian J, St-Onge C, Bergeron L, Mamede S, Schmidt HG. Does providing the correct diagnosis as feedback after self-explanation improve medical students diagnostic performance? BMC Med Educ. 2019. https://pubmed.ncbi.nlm.nih.gov/31185971/
  3. Wojcikowski K, Kirk L. Immediate detailed feedback to test-enhanced learning: an effective online educational tool. Med Teach. 2013. https://pubmed.ncbi.nlm.nih.gov/24003913/
  4. Staal J, Katarya K, Speelman M, et al. Impact of performance and information feedback on medical interns' confidence-accuracy calibration. Adv Health Sci Educ Theory Pract. 2024. https://pubmed.ncbi.nlm.nih.gov/37329493/
  5. Hatala R, Cook DA, Zendejas B, Hamstra SJ, Brydges R. Feedback for simulation-based procedural skills training: a meta-analysis and critical narrative synthesis. Adv Health Sci Educ Theory Pract. 2014. https://pubmed.ncbi.nlm.nih.gov/23712700/
  6. Chamberland M, Mamede S, St-Onge C, Setrakian J, Bergeron L, Schmidt H. Self-explanation in learning clinical reasoning: the added value of examples and prompts. Med Educ. 2015. https://pubmed.ncbi.nlm.nih.gov/25626750/
  7. Heitzmann N, Fischer F, Kühne-Eversmann L, Fischer MR. Enhancing diagnostic competence with self-explanation prompts and adaptable feedback. Med Educ. 2015. https://pubmed.ncbi.nlm.nih.gov/26383071/

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