Clinical reasoning in pharmacy: What do eye movements and verbal protocols tell us about the processing of a case task?

This study investigates pharmacy students' reasoning while solving a case task concerning an acute patient counselling situation in a pharmacy. Participants' (N = 34) reasoning processes were investigated with written tasks utilizing eye-tracking in combination with verbal protocols. The case was presented in three pages, each page being followed by written questions. Eye movements were recorded during case processing. Success in the task required differentiating the relevant information from the task redundant information, and initial activation of several scripts and verification of the most likely one, when additional information became available. 2nd (n = 16) and 3rd (n = 18)-year students' and better and worse succeeding students' processes were compared. The results showed that only a few 2nd-year students solved the case correctly, whereas almost all of the 3rd-year students were successful. Generally, the average total processing times of the case material did not differ between the groups. However, better-succeeding and 3rd-year students processed the very first task-relevant sentences longer, indicating that they were able to focus on relevant information. Differences in the written answers to the 2nd and 3rd question were significant, whereas differences regarding the first question were not. Thus, eye-tracking seems to be able to capture illness script activation during case processing, but other methods are needed to depict the script verification process. Based on the results, pedagogical suggestions for advancing pharmacy education are discussed.

Conceptual changes for and during working life.

Rapid and radical changes in science, technology and society may result in new scientific concepts and new workplace practices, which require fundamental restructuring of prior knowledge. Over the years a noteworthy body of research has documented the processes of conceptual change, the learning mechanisms involved, and the instructional methods and strategies that can promote conceptual changes. This research, however, focused young learners in school settings. Conceptual changes in working life go beyond traditional conceptual change consisting of processes and mechanisms that involve the interaction between expertise development and workplace learning processes.This Special Issue investigates whether and how conceptual change research can be extended from learning in schools to learning in professional life.

To guide or to follow? Teaching visual problem solving at the workplace.

Visual problem solving is essential to highly visual and knowledge-intensive professional domains such as clinical pathology, which trainees learn by participating in relevant tasks at the workplace (apprenticeship). Proper guidance of the visual problem solving of apprentices by the master is necessary. Interaction and adaptation to the expertise level of the learner are identified as key ingredients of this guidance. This study focuses on the effect of increased participation of the learner in the task on the interaction and adaptation of the guidance by masters. Thirteen unique dyads consisting of a clinical pathologist (master) and a resident (apprentice) discussed and diagnosed six microscope images. Their dialogues were analysed on their content. The dyads were divided in two groups according to the experience of the apprentice. For each dyad, master and apprentice both operated the microscope for half of the cases. Interaction was operationalised as the equal contribution of both master and apprentice to the dialogue. Adaptation was operationalised as the extent to which the content of the dialogues was adapted to the apprentice's level. The main hypothesis stated that the interaction and adaptation increase when apprentices operate the microscope. Most results confirmed this hypothesis: apprentices contributed more content when participating more and the content of these dialogues better reflected expertise differences of apprentices. Based on these results, it is argued that, for learning visual problem solving in a visual and knowledge-intensive domain, it is not only important to externalise master performance, but also that of the apprentice.

Expertise in clinical pathology: combining the visual and cognitive perspective.

Expertise studies in the medical domain often focus on either visual or cognitive aspects of expertise. As a result, characteristics of expert behaviour are often described as either cognitive or visual abilities. This study focuses on both aspects of expertise and analyses them along three overarching constructs: (1) encapsulations, (2) efficiency, and (3) hypothesis testing. This study was carried out among clinical pathologists performing an authentic task: diagnosing microscopic slides. Participants were 13 clinical pathologists (experts), 12 residents in pathology (intermediates), and 13 medical students (novices). They all diagnosed seven cases in a virtual microscope and gave post hoc explanations for their diagnoses. The collected data included eye movements, microscope navigation, and verbal protocols. Results showed that experts used lower magnifications and verbalized their findings as diagnoses. Also, their diagnostic paths were more efficient, including fewer microscope movements and shorter reasoning chains. Experts entered relevant areas later in their diagnostic process, and visited fewer of them. Intermediates used relatively high magnifications and based their diagnoses on specific abnormalities. Also, they took longer to reach their diagnosis and checked more relevant areas. Novices searched in detail, described findings by their appearances, and uttered long reasoning chains. These results indicate that overarching constructs can justly be identified: encapsulations and efficiency are apparent in both visual and cognitive aspects of expertise.

How and what do medical students learn in clerkships? Experience based learning (ExBL).

Clerkship education has been called a 'black box' because so little is known about what, how, and under which conditions students learn. Our aim was to develop a blueprint for education in ambulatory and inpatient settings, and in single encounters, traditional rotations, or longitudinal experiences. We identified 548 causal links between conditions, processes, and outcomes of clerkship education in 168 empirical papers published over 7 years and synthesised a theory of how students learn. They do so when they are given affective, pedagogic, and organisational support. Affective support comes from doctors' and many other health workers' interactions with students. Pedagogic support comes from informal interactions and modelling as well as doctors' teaching, supervision, and precepting. Organisational support comes from every tier of a curriculum. Core learning processes of observing, rehearsing, and contributing to authentic clinical activities take place within triadic relationships between students, patients, and practitioners. The phrase 'supported participation in practice' best describes the educational process. Much of the learning that results is too tacit, complex, contextualised, and individual to be defined as a set of competencies. We conclude that clerkship education takes place within relationships between students, patients, and doctors, supported by informal, individual, contextualised, and affective elements of the learned curriculum, alongside formal, standardised elements of the taught and assessed curriculum. This research provides a blueprint for designing and evaluating clerkship curricula as well as helping patients, students, and practitioners collaborate in educating tomorrow's doctors.

Expertise under the microscope: processing histopathological slides.

OBJECTIVES: Although the obvious goal of training in clinical pathology is to bring forth capable diagnosticians, developmental stages and their characteristics are unknown. This study therefore aims to find expertise-related differences in the processing of histopathological slides using a combination of eye tracking data and verbal data. METHODS: Participants in this study were 13 clinical pathologists (experts), 12 pathology residents (intermediates) and 13 medical students (novices). They diagnosed 10 microscopic images of colon tissue for 2 seconds. Eye movements, the given diagnoses, and the vocabulary used in post hoc verbal explanations were registered. Eye movements were analysed according to changes over trial time and the processing of diagnostically relevant areas. The content analysis of verbal data was based on a categorisation system developed from the literature. RESULTS: Although experts and intermediates showed equal levels of diagnostic accuracy, their visual and cognitive processing differed. Whereas experts relied on their first findings and checked the image further for other abnormalities, intermediates tended to double-check their first findings. In their explanations, experts focused on the typicality of the tissue, whereas intermediates mainly mentioned many specific pathologies. Novices looked less often at the relevant areas and were incomplete, incorrect and inconclusive in their explanations. Their diagnostic accuracy was correspondingly poor. CONCLUSIONS: This study indicates that in the case of intermediates and experts, different visual and cognitive strategies can result in equal levels of diagnostic accuracy. Lessons for training underline the relevance of the distinction between normal and abnormal tissue for novices, especially when the mental rotation of 2-D images is required. Intermediates need to be trained to see deviations in abnormalities. Feedback and an educational design that is specific to these developmental stages might improve training.

How clerkship students learn from real patients in practice settings.

PURPOSE: To explore how undergraduate medical students learn from real patients in practice settings, the factors that affect their learning, and how clerkship learning might be enhanced. METHOD: In 2009, 22 medical students in the three clerkship years of an undergraduate medical program in the United Kingdom made 119 near-contemporaneous audio diary entries reflecting how they learned from real patients. Nineteen attended focus groups; 18 were individually interviewed. The authors used a qualitative theory-building methodology with a conceptual orientation toward Communities of Practice theory. A learning theorist guided selective coding of a constant-comparative analysis. RESULTS: Participants learned informally by participating in the communicative practices of workplaces. Two overlapping practices, patient care and education, were identified. Patient care created learning opportunities, which were enriched when practitioners intentionally supported participants' learning. Education, however, was not always coupled with patient care. So, talk positioned the boundaries of two practices in three configurations: education without patient care, education within patient care, and patient care without education. The nature and quality of participants' learning depended on how practitioners entered dialogue with them and linked the dialogue to authentic patient care. CONCLUSIONS: Findings strongly suggest that medical students learn from real patients by participating in patient care within an educational practice. Their learning is affected by clinicians' willingness to engage in supportive dialogue. Promoting an informal, inclusive discourse of workplace learning might enhance clerkship education. This approach should take its place alongside-and perhaps ahead of-the currently dominant discourse of "clinical teaching."

The Handover Toolbox: a knowledge exchange and training platform for improving patient care.

BACKGROUND: Safe and effective patient handovers remain a global organisational and training challenge. Limited evidence supports available handover training programmes. Customisable training is a promising approach to improve the quality and sustainability of handover training and outcomes. OBJECTIVE: We present a Handover Toolbox designed in the context of the European HANDOVER Project. The Toolbox aims to support physicians, nurses, individuals in health professions training, medical educators and handover experts by providing customised handover training tools for different clinical needs and contexts. METHODS: The Handover Toolbox uses the Technology Enhanced Learning Design Process (TEL-DP), which encompasses user requirements analysis; writing personas; group concept mapping; analysis of suitable software; plus, minus, interesting rating; and usability testing. TEL-DP is aligned with participatory design approaches and ensures development occurs in close collaboration with, and engagement of, key stakeholders. RESULTS: Application of TEL-DP confirmed that the ideal formats of handover training differs for practicing professionals versus individuals in health profession education programmes. Training experts from different countries differed in their views on the optimal content and delivery of training. Analysis of suitable software identified ready-to-use systems that provide required functionalities and can be further customised to users' needs. Interest rating and usability testing resulted in improved usability, navigation and uptake of the Handover Toolbox. CONCLUSIONS: The design of the Handover Toolbox was based on a carefully led stakeholder participatory design using the TEL-DP approach. The Toolbox supports a customisable learning approach that allows trainers to design training that addresses the specific information needs of the various target groups. We offer recommendations regarding the application of the Handover Toolbox to medical educators.

Mapping and assessing clinical handover training interventions.

BACKGROUND: The literature reveals a patchwork of knowledge about the effectiveness of handover and transfer of care-training interventions, their influence on handover practices and on patient outcomes. We identified a range of training interventions, defined their content, and then proposed practical measures for improving the training effectiveness of handover practices. METHODS: We applied the Group Concept Mapping approach to identify objectively the shared understanding of a group of experts about patient handover training interventions. We collected 105 declarative statements about handover training interventions from an exhaustive literature review, and from structured expert interviews. The statements were then given to 21 healthcare and training design specialists to sort the statements on similarity in meaning, and rate them on their importance and feasibility. RESULTS: We used multidimensional scaling and hierarchical cluster analysis to depict the following seven clusters related to various handover training issues: standardisation, communication, coordination of activities, clinical microsystem care, transfer and impact, training methods and workplace learning. CONCLUSIONS: Ideas on handover training interventions, grouped in thematic clusters, and prioritised on importance and feasibility creates a repository of approaches. This allows healthcare institutions to design and test concrete solutions for improving formal training and workplace learning related to handovers, and addressing informal social learning at the organisational level, with the aim of increasing impact on handover practice and patient outcomes. Measures need to be taken to assure a continuum of handover training interventions from formal training through workplace learning through less formal social learning, and to embed this training in the design of the clinical microsystem.

Manchester Clinical Placement Index (MCPI). Conditions for medical students' learning in hospital and community placements.

The drive to quality-manage medical education has created a need for valid measurement instruments. Validity evidence includes the theoretical and contextual origin of items, choice of response processes, internal structure, and interrelationship of a measure's variables. This research set out to explore the validity and potential utility of an 11-item measurement instrument, whose theoretical and empirical origins were in an Experience Based Learning model of how medical students learn in communities of practice (COPs), and whose contextual origins were in a community-oriented, horizontally integrated, undergraduate medical programme. The objectives were to examine the psychometric properties of the scale in both hospital and community COPs and provide validity evidence to support using it to measure the quality of placements. The instrument was administered twice to students learning in both hospital and community placements and analysed using exploratory factor analysis and a generalizability analysis. 754 of a possible 902 questionnaires were returned (84% response rate), representing 168 placements. Eight items loaded onto two factors, which accounted for 78% of variance in the hospital data and 82% of variance in the community data. One factor was the placement learning environment, whose five constituent items were how learners were received at the start of the placement, people's supportiveness, and the quality of organisation, leadership, and facilities. The other factor represented the quality of training-instruction in skills, observing students performing skills, and providing students with feedback. Alpha coefficients ranged between 0.89 and 0.93 and there were no redundant or ambiguous items. Generalisability analysis showed that between 7 and 11 raters would be needed to achieve acceptable reliability. There is validity evidence to support using the simple 8-item, mixed methods Manchester Clinical Placement Index to measure key conditions for undergraduate medical students' experience based learning: the quality of the learning environment and the training provided within it. Its conceptual orientation is towards Communities of Practice, which is a dominant contemporary theory in undergraduate medical education.

When only the real thing will do: junior medical students' learning from real patients.

OBJECTIVES: This study aimed to explore how medical students experience contacts with real patients and what they learn from them. METHODS: We carried out a post hoc, single-group study in one teaching sector of a 5-year, problem-based, horizontally integrated, outcome-based and community-oriented undergraduate programme, in which students lacked clinical exposure in the pre-clerkship phase. Subjects comprised five cohorts of students on their first clerkships. Data consisted of purposively selected, voluntary, self-report statements regarding real patient learning (RPL). Constant comparative analysis was performed by two independent researchers. RESULTS: Respondents valued patients as an instructional resource that made learning more real. They reported learning through visual pattern recognition as well as through dialogue and physical examination. They more often used social than professional language to describe RPL. They reported affective outcomes including enhanced confidence, motivation, satisfaction and a sense of professional identity. They also reported cognitive outcomes including perspective, context, a temporal dimension, and an appreciation of complexity. Real patient learning helped respondents link theory learned earlier with reality as represented by verbal, visual and auditory experiences. It made learning easier, more meaningful and more focused. It helped respondents acquire complex skills and knowledge. Above all, RPL helped learners to remember subject matter. Most negative responses concerned the difficulty of acquiring appropriate experience, but RPL made a minority of respondents feel uncomfortable and incompetent. CONCLUSIONS: Real patient learning led to a rich variety of learning outcomes, of which at least some medical students showed high metacognitive awareness. Sensitivity from clinical mentors towards the positive and negative outcomes of RPL reported here could support reflective clinical learning.

Scripts and clinical reasoning.

CONTEXT: Each clinical encounter represents an amazing series of psychological events: perceiving the features of the situation; quickly accessing relevant hypotheses; checking for signs and symptoms that confirm or rule out competing hypotheses, and using related knowledge to guide appropriate investigations and treatment. OBJECTIVE: Script theory, issued from cognitive psychology, provides explanations of how these events are mentally processed. This essay is aimed at clinical teachers who are interested in basic sciences of education. It describes the script concept and how it applies in medicine via the concept of the 'illness script'. METHODS: Script theory asserts that, to give meaning to a new situation in our environment, we use goal-directed knowledge structures adapted to perform tasks efficiently. These integrated networks of prior knowledge lead to expectations, as well as to inferences and actions. Expectations and actions embedded in scripts allow subjects to make predictions about features that may or may not be encountered in a situation, to check these features in order to adequately interpret (classify) the situation, and to act appropriately. CONCLUSIONS: Theory raises questions about how illness scripts develop and are refined with clinical experience. It also provides a framework to assist their acquisition.

A comparison of learning strategies, orientations and conceptions of learning of first-year medical students in a traditional and an innovative curriculum.

INTRODUCTION: Students adapt their learning strategies, orientations and conceptions to differences in the learning environment. The new curriculum of the Faculty of Medicine, University of Peradeniya, Sri Lanka, which commenced in 2005, puts greater emphasis on student-centred learning. The aim of this study was to compare the learning strategies, orientations and conceptions measured by means of a validated Sri Lankan version of the Inventory of Learning Styles (ILS) at the end of the first academic year for a traditional curriculum student group and a new curriculum student group. MATERIALS AND METHODS: The Adyayana Rata Prakasha Malawa (ARPM) 130-item Sinhala version of the ILS was administered to students of the traditional curriculum and the new curriculum at the end of their first academic year respectively. Mean scale scores of the 2 groups were compared using independent sample t-test. RESULTS: Students of the new curriculum reported the use of critical processing, concrete processing and memorising and rehearsing strategies significantly more than those in the traditional curriculum group. With respect to learning orientations, personal interest scores were significantly higher for the new curriculum students while reporting of ambiguity was significantly lower among them. CONCLUSION: The results favour the assumption that changes made to the organisation of subject content and instructional and assessment methods have a positive impact on students' use of learning strategies and motivation.

Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning.

OBJECTIVE: To develop a model linking the processes and outcomes of workplace learning. METHODS: We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students. RESULTS: To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning. CONCLUSIONS: The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Student evaluation of the clinical 'curriculum in action'.

AIM: To examine how students' evaluations of the environment, process and outcome of clinical learning interrelated and correlated with assessment results. METHOD: A post hoc study in the 3rd of 5 years in a student-centred, horizontally integrated, objective-based medical curriculum. In the last week of each module, students evaluated what they had learned and how they had learned it using a previously validated, web-based scale. The interrelationships between scale variables and their relationships with summative assessment results were tested using factor analysis, correlation analysis and stepwise multiple regression analysis. RESULTS: Student evaluation yielded 4 summary measures: 2 reflected learning outcomes ('real patient learning' and 'curriculum coverage'), 1 reflected process ('quality of instruction') and 1 reflected environment ('conditions for learning'). They fitted a causal model according to which instruction, conditions for learning and curriculum coverage favoured real patient learning. Real patient learning was rated higher in women than men, and the measures were associated more strongly in women. Performance in end-of-year summative assessments was predicted strongly by mid-year performance but by no other measure. CONCLUSIONS: Students' evaluations of their learning environment and instructional processes correlated with their assessments of 2 outcomes of the curriculum in action: curriculum coverage and real patient learning. There was little shared variance between those measures and students' performance in summative assessments. Given its formative potential, students' evaluation of their curriculum in action could play a useful part in learner-centred clinical education. There is a possibility, which needs further research, that women's evaluations have greater predictive validity than men's. Assessment performance should be regarded not as a solitary gold standard but as just 1 measure of educational outcome.

The cognitive validity of the Script Concordance Test: a processing time study.

BACKGROUND: According to the theory on which the Script Concordance Test (SCT) is based, scripts contain expectations on features that are associated with each illness and about the range of values that are typical, atypical, or incompatible. PURPOSE: To document the construct validity of the SCT, we investigated the theory prediction that once a script is activated, new incoming information (e.g., additional clinical features) is processed faster if it is typical for that script than if it is atypical. If it is incompatible, processing time falls in between. METHODS: We presented 2 groups of participants (30 fourth-year medical students and 30 full-time geriatricians) with 64 clinical vignettes (divided over 5 types of prevalent clinical presentations in geriatrics), each accompanied by a diagnostic hypothesis aimed to instantiate an appropriate script. Next, we presented a new finding, which could be typical, atypical, or incompatible given the hypothesis. Participants had to decide as quickly and accurately as possible whether the new finding increased, decreased, of did not affect the likelihood of the diagnostic hypothesis. We administered the test on a computer. The dependent variable was processing time. We analyzed data with a repeated measure 2 x 3 analysis of variance. RESULTS: Typical information was processed faster than atypical and incompatible information (M = 10.6 sec vs. 19.2 sec and 16.4 sec, respectively; p lt; .001 for both). Incompatible information was processed faster than atypical information (16.4 sec vs. 19.2; p < .001). There was no significant difference between the groups of geriatricians and students. CONCLUSION: It is possible to predict what kind of information will be processed faster depending of the typicality and compatibility of clinical data for given hypotheses. Results support SCT construct validity.

Students' opinions about their preparation for clinical practice.

INTRODUCTION: There are data that suggest that medical students do not feel sufficiently prepared for clinical practice in the clerkships. The transition from pre-clinical to clinical training causes problems. OBJECTIVES: To seek quantitative verification of qualitative findings from an earlier focus group study on problems medical students encounter when entering the clinical phase of undergraduate training. METHODS: At the start of the clinical phase, all Year 4 students at Maastricht Medical School were surveyed on the transition from pre-clinical to clinical training and its effects on workload, knowledge, skills and learning. RESULTS: The response rate was 67%. Students were uncertain as to how to behave and act, mainly because they did not know what was expected of them. They experienced a drastic increase in workload and a lack of time for studying. They considered themselves to be moderately prepared with regard to knowledge and they regarded their physical examination skills as satisfactory. Students reported having difficulty applying theoretical knowledge in clinical practice and perceived shortcomings in basic science knowledge. In addition, they felt compelled to change their learning strategies. DISCUSSION: The results of this study confirm the findings of the focus group study. The students experienced problems related to professional socialisation and workload and deficiencies in knowledge and the organisation of knowledge. A good starting point for improvement may involve exploring students' suggestions of an extensive introduction into the clerkships, a more gradual transition with regard to workload and closer integration of pre-clinical and clinical education.

How can medical students learn in a self-directed way in the clinical environment? Design-based research.

AIM: This study aimed to establish whether and under what conditions medical students can learn in a self-directed manner in the clinical environment. METHOD: A web-based learning management system brought 66 placement students, in a problem-based learning (PBL) medical curriculum, into closer touch with their clinical learning objectives and ways of achieving them. Free response comments from 16 of them during the 7 weeks they used it, transcripts of group discussions before and after the period of use, and responses from all 66 students to a questionnaire were analysed qualitatively. RESULTS: Students were rarely fully autonomous or subservient. They valued affective and pedagogic support, and relied on teachers to manage their learning environment. With support, they were motivated and able to choose how and when to meet their learning needs. The new system was a useful adjunct. CONCLUSIONS: Self-direction, interpreted literally, was a method of learning that students defaulted to when support and guidance were lacking. They found "supported participation" more valuable. Learning in the clinical environment was a social process with as many differences from, as similarities to, PBL.

General competencies of problem-based learning (PBL) and non-PBL graduates.

INTRODUCTION: Junior doctors have reported shortcomings in their general competencies, such as organisational skills and teamwork. We explored graduates' perceptions of how well their training had prepared them for medical practice and in general competencies in particular. We compared the opinions of graduates from problem-based learning (PBL) and non-PBL schools, because PBL is supposed to enhance general competencies. METHOD: We analysed the responses of 1159 graduates from 1 PBL and 4 non-PBL schools to a questionnaire survey administered 18 months after graduation. RESULTS: Compared with their non-PBL colleagues, the PBL graduates gave higher ratings for the connection between school and work, their medical training and preparation for practice. According to the graduates, the most frequently used competencies with sufficient coverage during medical training were expert knowledge, profession-specific skills and communication skills. The majority of the PBL graduates, but less than half of the non-PBL graduates, indicated that communication skills had been covered sufficiently. All the graduates called for more curriculum attention on working with computers, planning and organisation, and leadership skills. More PBL graduates than non-PBL graduates indicated that they had learned profession-specific methods, communication skills and teamwork in medical school. DISCUSSION: Overall, the graduates appeared to be satisfied with their knowledge and skills. The results suggest that the PBL school provided better preparation with respect to several of the competencies. However, both PBL and non-PBL graduates identified deficits in their general competencies, such as working with computers and planning and organising work. These competencies should feature more prominently in undergraduate medical education.