Thinking fast or slow? Functional magnetic resonance imaging reveals stronger connectivity when experienced neurologists diagnose ambiguous cases.

For ∼40 years, thinking about reasoning has been dominated by dual-process theories. This model, consisting of two distinct types of human reasoning, one fast and effortless and the other slow and deliberate, has also been applied to medical diagnosis. Medical experts are trained to diagnose patients based on their symptoms. When symptoms are prototypical for a certain diagnosis, practitioners may rely on fast, recognition-based reasoning. However, if they are confronted with ambiguous clinical information slower, analytical reasoning is required. To examine the neural underpinnings of these two hypothesized forms of reasoning, 16 highly experienced clinical neurologists were asked to diagnose two types of medical cases, straightforward and ambiguous cases, while functional magnetic resonance imaging was being recorded. Compared with reading control sentences, diagnosing cases resulted in increased activation in brain areas typically found to be active during reasoning such as the caudate nucleus and frontal and parietal cortical regions. In addition, we found vast increased activity in the cerebellum. Regarding the activation differences between the two types of reasoning, no pronounced differences were observed in terms of regional activation. Notable differences were observed, though, in functional connectivity: cases containing ambiguous information showed stronger connectivity between specific regions in the frontal, parietal and temporal cortex in addition to the cerebellum. Based on these results, we propose that the higher demands in terms of controlled cognitive processing during analytical medical reasoning may be subserved by stronger communication between key regions for detecting and resolving uncertainty.

Rehabilitation in a complex case of topographical disorientation.

This paper describes the rehabilitation process of a patient with severe topographical disorientation. The study demonstrates the sustained effects of a tailor-made, meticulous rehabilitation programme based on the gradual development of compensatory strategies. The patient (RB) had a memory impairment specific to environmental landmarks. He was able to recognise objects in his environment, but was unable to identify any salient object as a landmark and was also unable to derive any directional information from a chosen landmark. As such, his topographical disorientation syndrome was complex in that he had elements of both landmark agnosia and a heading disorientation, as described by Aguirre and D'Esposito (1999). Because of this dual damage to the exocentric framework, the tools and methods used in RB's rehabilitation programme were all based on his intact egocentric frame of reference. Remarkable training effects were found for routes he used frequently. After years of training he could walk these routes without the aid of the written information he had used previously, which can be interpreted as a form of implicit learning. In the 12 years we followed this patient some transfer occurred, as the patient was ultimately able to identify his own landmarks. However, RB remains dependent on other people to construct new routes for him on the basis of these landmarks.

Medical students' and teachers' perceptions of sexual misconduct in the student-teacher relationship.

Teachers are important role models for the development of professional behaviour of young trainee doctors. Unfortunately, sometimes they show unprofessional behaviour. To address misconduct in teaching, it is important to determine where the thresholds lie when it comes to inappropriate behaviours in student-teacher encounters. We explored to what extent students and teachers perceive certain behaviours as misconduct or as sexual harassment. We designed-with a reference group-five written vignettes describing inappropriate behaviours in the student-teacher relationship. Clinical students (n = 1,195) and faculty of eight different hospitals (n = 1,497) were invited to rate to what extent they perceived each vignette as misconduct or sexual harassment. Data were analyzed using t tests and Pearson's correlations. In total 643 students (54 %) and 551 teachers (37 %) responded. All vignettes were consistently considered more as misconduct than as actual sexual harassment. At an individual level, respondents differed largely as to whether they perceived an incident as misconduct or sexual harassment. Comparison between groups showed that teachers' and students' perceptions on three vignettes differed significantly, although the direction differed. Male students were more lenient towards certain behaviours than female students. To conclude, perceptions of misconduct and sexual harassment are not univocal. We recommend making students and teachers aware that the boundaries of others may not be the same as their own.

Which characteristics of written feedback are perceived as stimulating students' reflective competence: an exploratory study.

BACKGROUND: Teacher feedback on student reflective writing is recommended to improve learners' reflective competence. To be able to improve teacher feedback on reflective writing, it is essential to gain insight into which characteristics of written feedback stimulate students' reflection processes. Therefore, we investigated (1) which characteristics can be distinguished in written feedback comments on reflective writing and (2) which of these characteristics are perceived to stimulate students' reflection processes. METHODS: We investigated written feedback comments from forty-three teachers on their students' reflective essays. In Study 1, twenty-three medical educators grouped the comments into distinct categories. We used Multiple Correspondence Analysis to determine dimensions in the set of comments. In Study 2, another group of twenty-one medical educators individually judged whether the comments stimulated reflection by rating them on a five-point scale. We used t-tests to investigate whether comments classified as stimulating and not stimulating reflection differed in their scores on the dimensions. RESULTS: Our results showed that characteristics of written feedback comments can be described in three dimensions: format of the feedback (phrased as statement versus question), focus of the feedback (related to the levels of students' reflections) and tone of the feedback (positive versus negative). Furthermore, comments phrased as a question and in a positive tone were judged as stimulating reflection more than comments at the opposite side of those dimensions (t = (14.5) = 6.48; p = < .001 and t = (15) = -1.80; p < .10 respectively). The effect sizes were large for format of the feedback comment (r = .86) and medium for tone of the feedback comment (r = .42). CONCLUSIONS: This study suggests that written feedback comments on students' reflective essays should be formulated as a question, positive in tone and tailored to the individual student's reflective level in order to stimulate students to reflect on a slightly higher level. Further research is needed to examine whether incorporating these characteristics into teacher training helps to improve the quality of written feedback comments on reflective writing.

The effect of implementing undergraduate competency-based medical education on students' knowledge acquisition, clinical performance and perceived preparedness for practice: a comparative study.

BACKGROUND: Little is known about the gains and losses associated with the implementation of undergraduate competency-based medical education. Therefore, we compared knowledge acquisition, clinical performance and perceived preparedness for practice of students from a competency-based active learning (CBAL) curriculum and a prior active learning (AL) curriculum. METHODS: We included two cohorts of both the AL curriculum (n=453) and the CBAL curriculum (n=372). Knowledge acquisition was determined by benchmarking each cohort on 24 interuniversity progress tests against parallel cohorts of two other medical schools. Differences in knowledge acquisition were determined comparing the number of times CBAL and AL cohorts scored significantly higher or lower on progress tests. Clinical performance was operationalized as students' mean clerkship grade. Perceived preparedness for practice was assessed using a survey. RESULTS: The CBAL cohorts demonstrated relatively lower knowledge acquisition than the AL cohorts during the first study years, but not at the end of their studies. We found no significant differences in clinical performance. Concerning perceived preparedness for practice we found no significant differences except that students from the CBAL curriculum felt better prepared for 'putting a patient problem in a broad context of political, sociological, cultural and economic factors' than students from the AL curriculum. CONCLUSIONS: Our data do not support the assumption that competency-based education results in graduates who are better prepared for medical practice. More research is needed before we can draw generalizable conclusions on the potential of undergraduate competency-based medical education.

[Supervising students according to the STAMPPOT method: efficient integration of patient care and clinical teaching]. / Supervisie volgens de STAMPPOT-methode: efficiënte integratie van patiëntenzorg en klinisch onderwijs.

During the supervision of a registrar or house officer who has taken the history from a patient and has performed a physical examination, optimal patient care and education should be integrated. The 'One-Minute Preceptor Method' has already been described as a method that is suitable for this task. We have expanded on this method. The new method is comprised of the following steps: summarizing ('Samenvatten') the medical history, narrowing ('Toespitsen') and analyzing ('Analyseren') the differential diagnosis, based on medical ('Medische') questions: providing pearls ('Pareltjes') of wisdom to the student, establishing a patient plan ('Plan'), giving an assignment ('Opdracht') for further study and testing ('Toetsen') this new insight at a later point in time. These steps form the acronym 'STAMPPOT' in Dutch (which is a common mashed potato and vegetable dish in the Netherlands). Clinical supervisors find the STAMPPOT method easy to learn; it is also highly appreciated by registrars and house officers as it helps them to better understand and improve their clinical diagnostic skills.

[The role of gut instinct is an important subject]. / 'Pluis/niet-pluis': een valide denkmethode.

The role of gut instinct in general practice is an important topic. The reliance on gut instinct by experienced doctors is thought to be a form of intuitive decision-making which fits in with System 1 processes in the dual process model in higher cognition. Special mention is made of the theories on intuitive decision-making by the famous Dutch psychologist De Groot, who, when investigating thought processes of chess masters more than half a century ago, developed a fundamental theory on intuitive heuristics. Further studies on the determinants and conditions under which heuristics, such as the reliance on gut instinct, are applied in clinical practice are very welcome.