Strengthening novice diagnostic problem solving through explicit metacognitive scaffolding in emergency medicine education

BACKGROUND: Metacognition is central to clinical diagnostic problem solving, yet few instructional models provide actionable guidance for embedding explicit metacognitive support into clinical training. OBJECTIVE: This study aimed to introduce and evaluate the Metacognition-Integrated Instruction for Novice Diagnostic (MIND) learning model, a structured framework that integrates explicit metacognitive prompts into authentic diagnostic tasks, and to examine its impact on students' metacognitive abilities and their structural relationships. DESIGN: A pre-post study was conducted among 127 sixth-year medical students during a two-week emergency medicine rotation. The intervention began with a one-day MIND-based workshop, followed by repeated reinforcement of metacognitive activation in real clinical settings to support recall and transfer. Metacognitive ability was assessed using a validated Inventory of Metacognitive Self-Regulation in Diagnostic Problem Solving. Partial least squares structural equation modeling (PLS-SEM) was applied to evaluate changes in five metacognitive dimensions and their structural relationships. RESULTS: Significant improvements were observed across all five metacognitive dimensions, with the largest gains in Objectivity and Monitoring, domains typically underdeveloped in novice diagnosticians. Structural analyses demonstrated invariance between pre- and post-intervention models, suggesting a stable underlying metacognitive structure. Knowledge of cognition and objectivity significantly predicted problem representation, which in turn predicted monitoring and evaluation. The direct path from objectivity to monitoring was not supported. No significant pre-post differences in path coefficients were identified, except for a strengthened effect of knowledge of cognition on problem representation. CONCLUSIONS: The MIND learning model provides a practice-embedded framework for strengthening diagnostic metacognition in novice physicians. By integrating explicit metacognitive scaffolds into authentic clinical encounters, the model enhances learners' awareness of their reasoning processes and supports more effective problem framing. These findings offer actionable guidance for clinical educators seeking to incorporate metacognitive instruction into workplace-based training.