A central cognitive tenet of the CATLM is that students must learn to integrate new information with their existing knowledge before they can apply knowledge to real-world problems. More specifically, in order for medical students to transfer diagnostic reasoning to medical situations, they must integrate (a) content knowledge, (b) situational knowledge, and (c) strategic knowledge [18–21] with their existing knowledge. Unfortunately, traditional medical education has tended to overemphasize content knowledge while underemphasizing situational and strategic knowledge. Nevertheless, all three types of knowledge are essential to appropriately address patient-care issues related to SGSH. In the following sections, we describe each knowledge type, explain its role in developing deep, meaningful learning, and present evidence-based instructional approaches that have been found to facilitate each knowledge type. We then describe how specific aspects of the MCBLMs were designed to facilitate the development of each knowledge type.
The content knowledge associated with SGSH education includes the facts, concepts, principles, and procedures that undergird this knowledge domain. Choi and Hannafin  recommend that designers consider content diversity and anchored instruction as ways of embedding meaningful content into authentic learning environments. Content diversity can be achieved by varying the situations in which students practice what they have learned . This helps students to learn at a level of generality that enables them to transfer knowledge and skills to new situations. Anchored instruction refers to problem-rich environments that encourage exploration and diversity of perspectives. Providing students with macro-contexts is one way to anchor instruction, so that learners can see and explore the interrelationships among content knowledge (e.g., relationships between SGSH concepts and principles). The Jasper Series, for example, provides students with contextually anchored videodisk mathematics and science problem-solving tasks. Students participating in these units can see the interrelationships between mathematical formula and scientific exploration .
Situational knowledge involves knowledge about the cultural and social contexts of real-world situations, problems, and activities. This knowledge represents the milieu in which content knowledge (e.g., facts, concepts, principles) is applied in the real world . Medical students must understand the dynamic cultural and social contexts of a medical situation before they can effectively apply medical content knowledge . The implication for medical education is that what is learned (e.g., facts, concepts, principles) should not be separated from the context in which it is intended to be used. One example of situational knowledge in heath care is understanding how patients’ cultural backgrounds can influence their perceptions about the cause of disease (e.g., punishment from God, the actions of others) and how these perceptions can influence individual differences in coping with disease and bereavement . This knowledge has obvious implications for appropriate interactions between health-care workers, patients, and their families.
Instructional environments such as problem and case-based learning have been found to facilitate students’ acquisition of situational knowledge. These environments are characterized by authentic tasks, the kinds of tasks performed by practitioners in real problem-solving situations. The authenticity of a task can be enhanced by embedding the task within cultural and social contexts similar to the real world. This enables students to reason like practitioners and to use contextual information to help them solve problems. The situational knowledge produced by these methods contrasts sharply with the abstract, decontextualized knowledge often produced in more formal educational settings [22, 28].
The development of situational knowledge also has important implications for assessment of student learning. Choi and Hannafin  recommend performance assessment as an effective way of measuring situated knowledge outcomes. Performance assessments involve asking students to produce things or to perform tasks that have some direct connection to the real world. Many researchers feel that standardized tests, criterion-referenced tests, and teacher-constructed tests do not adequately measure many important learning outcomes such as the degree of student understanding or the quality of their thinking process [29, 30]. Authentic assessment activities, such as performance assessment, not only represent valid assessments of situated knowledge, but they also contribute to the development of situational knowledge.
While situational knowledge involves contextual understanding of real-world situations, strategic knowledge involves understanding how to use this knowledge . Situational knowledge involves knowing what; strategic knowledge involves knowing how. This includes knowing how to use knowledge in new contexts, knowing how to reflect on plans and actions performed, and developing tacit knowledge. This tacit knowledge is characteristic of an expert’s ability to use domain knowledge (e.g., facts, concepts, and procedures) to solve problems within their area of expertise .
Choi and Hannafin  recommend providing students with scaffolding to support their strategic problem-solving and decision-making attempts. Scaffolding can take the form of any method, resource, or tool that supports novice learners in developing a deeper understanding of knowledge that is initially beyond their capacity to understand and apply . One example of scaffolding students’ understanding of domain knowledge is the contrasting cases method [33, 34]. This method is designed to guide and focus student attention on the salient aspects of an expository text or lecture.
One reason that texts and lectures are often ineffective learning methods is that students have insufficient background knowledge to effectively direct their attention toward salient information that needs to be integrated with existing knowledge. Without sufficient background knowledge, students often memorize surface information rather than relate complex conceptual knowledge with their prior knowledge . This obviously hampers students’ abilities to develop knowledge essential for diagnostic reasoning and problem-solving.
Contrasting cases involve juxtaposing carefully chosen dissimilar scenarios to highlight distinctions between cases that students might otherwise overlook . When contrasting cases have been employed before, rather than after, reading text or listening to a lecture, students can developed a robust understanding of the material [33, 34]. This method is particularly germane to SGSH education because of the compare and contrast nature of this knowledge domain.
Implementation of Knowledge Types in the SGSH modules
The MCBLMs emphasize situational knowledge by immersing learners in virtual patient-care situations. These virtual cases enable students to develop knowledge of concepts as they relate to particular medical situations. These case-based learning environments exhibit the same major elements and constraints typically experienced by medical professionals in their actual work environment. Each video case provides a learning environment that mimics a real medical situation involving a sex and gender-based issue.
The authenticity of the SGSH learning modules is preserved by introducing each medical case with patients interacting with medical care professionals about a medical problem. Patients and medical professionals are represented visually on a computer screen as animated characters who interact verbally via the voice recordings of professional voice actors. Medical students are further engaged in the SGSH cases by an on-screen guide (an aviator playing the role of a senior medical resident) who invites them to assume the role of a medical professional tasked with developing an appropriate medical care plan for each patient case.
After watching an SGSH case, the on-screen guide instructs the medical student to contact medical experts (again played by on-screen avatars) who can provide them with information needed to develop appropriate patient-care plans. The experts portray real medical professionals whose jobs require different medical expertise (e.g., basic scientists, practicing physicians, nurse practitioners). This further preserves the authenticity of the SGSH cases by requiring students to obtain the knowledge needed to solve the patient cases by contacting medical professionals known to possess the requisite knowledge in the real world.
The SGSH models incorporate authentic assessment by requiring students to perform medical diagnosis and recommend treatment plans in realistic patient-care situations. This process affords educators the ability to collect authentic assessment data related to the effectiveness of students’ performance based upon actual module goals. This form of assessment has high validity because the context of assessment is virtually the same as the context of the actual patient-care setting. Transfer of learning is also higher than in traditional classroom-based medical education because the students learn to focus their efforts on mastering authentic skills that are easily transferred to patient-care situations.
In addition to authentic assessment, the SGSH modules incorporate more traditional assessment items with feedback to help students master prerequisite knowledge in areas such as the basic medical sciences. This combination of assessment techniques provides each student with a rich database of information about their performance as a medical professional.
The SGSH modules contain robust usable content knowledge. This knowledge is developed by forming and utilizing subject-matter content committees in the design of each module. These committees consist of a diverse group of medical experts who can provide unique perspectives on each patient case.