Enhancing Cognitive Reflection in Medical Trainees and Physicians: An EBM–CBL–PBL Integrated Teaching Model

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Xianzhi Chen,1 Lei Xu,2 Manman Xu,2 Deshun Liu,3 Fang Yang,1 Guobao Xu,1 Qizhu Feng,4 Huaicheng Yang41Department of Thyroid and Breast Surgery, The First Hospital of Anhui University of Science & Technology, Huainan, Anhui, 232007, People’s Republic of China; 2Department of Nuclear Medicine, The First Hospital of Anhui University of Science & Technology, Huainan, Anhui, 232007, People’s Republic of China; 3Medical Imaging Department, The First Hospital of Anhui University of Science & Technology, Huainan, Anhui, 232007, People’s Republic of China; 4General Surgery, The First Hospital of Anhui University of Science & Technology, Huainan, Anhui, 232007, People’s Republic of ChinaCorrespondence: Lei Xu, Department of Nuclear Medicine, The First Hospital of Anhui University of Science & Technology, Huainan, Anhui, 232007, People’s Republic of China, Tel +86-0554-6616760, Email 619115747@qq.comBackground: Insufficient cognitive reflection in medical trainees and early-career physicians is a root cause of diagnostic errors, yet research on enhancing cognitive reflection in complex surgical settings remains limited. This study aimed to evaluate whether an integrated evidence-based medicine, case-based learning, and problem-based learning (EBM–CBL–PBL) teaching model can improve cognitive reflection.Methods: A two-phase design was employed. Cognitive reflection was assessed using the Cognitive Reflection Test (CRT). A generalized linear mixed model analyzed associations between sex, clinical experience, and CRT performance. In the intervention phase, trainees were randomized to traditional teaching (n = 18) or an EBM–CBL–PBL group (n = 18). CRT response patterns (intuitive vs. reflective) and teaching satisfaction were compared between groups.Results: 41.18% of medical trainees exhibited an “All-Reflective” response, whereas 11.76% exhibited an “All-Intuitive” response; among resident physicians, the corresponding rates were 51.85% and 14.81%, and among attending/consulting physicians, they were 57.14% and 8.57%, respectively. No significant overall gender difference was observed (P > 0.05); however, senior female physicians demonstrated significantly stronger analytical thinking (odds ratio [OR] = 5.92, P = 0.005). The “All-Reflective” response rate in the EBM-CBL-PBL group (61.11%) was significantly higher than that in the traditional teaching group (44.44%), with an OR of 3.39 (P = 0.003); furthermore, teaching satisfaction improved significantly in the EBM–CBL–PBL group (P < 0.001).Conclusion: Cognitive reflection ability improves with increasing clinical experience in clinical practice, with senior female physicians demonstrating the most pronounced enhancement. The integrated EBM–CBL–PBL teaching model adopted in the surgical field shows promise for fostering cognitive reflection. Sustained educational exposure and long-term clinical practice appear essential for consolidating these cognitive gains.Keywords: cognitive reflection test, clinical reasoning, medical education, generalized linear mixed model, dual-process theory

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