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



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.

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


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

Author information




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.

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Correspondence to Mary Kathryn Mutter.

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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).

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Mutter, M.K., Martindale, J.R., Shah, N. et al. Case-Based Teaching: Does the Addition of High-Fidelity Simulation Make a Difference in Medical Students’ Clinical Reasoning Skills?. Med.Sci.Educ. 30, 307–313 (2020).

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