Pathways, journeys and experiences: Integrating curricular activities related to social accountability within an undergraduate medical curriculum.

BACKGROUND: Health professions education curricula are undergoing reform towards social accountability (SA), defined as an academic institution's obligation to orient its education, service and research to respond to societal needs. However, little is known about how or which educational experiences transform learners and the processes behind such action. For example, those responsible for the development and implementation of undergraduate medical education (UGME) programs can benefit from a deeper understanding of educational approaches that foster the development of competencies related to SA. The purpose of this paper was to learn from the perspectives of the various partners involved in a program's delivery about what curricular aspects related to SA are expressed in a UGME program. METHODS: We undertook a qualitative descriptive study at a francophone Canadian university. Through purposive convenience and snowball sampling, we conducted 16 focus groups (virtual) with the following partners: (a) third- and fourth-year medical students, (b) medical teachers, (c) program administrators (e.g., program leadership), (d) community members (e.g., community organisations) and (e) patient partners. We used inductive thematic analysis to interpret the data. RESULTS: The participants' perspectives organised around four key themes including (a) the definition of a future socially accountable physician, (b) socially accountable educational activities and experiences, (c) characteristics of a socially accountable MD program and (d) suggestions for curriculum improvement and implementation. CONCLUSIONS: We extend scholarship about curricular activities related to SA from the perspectives of those involved in teaching and learning. We highlight the relevance of experiential learning, engagement with community members and patient partners and collaborative approaches to curriculum development. Our study provides a snapshot of what are the sequential pathways in fostering SA among medical students and therefore addresses a gap between knowledge and practice regarding what contributes to the implementation of educational approaches related to SA. We emphasise the need for educational innovation and research to develop and align assessment methods with teaching and learning related to SA.

Exploring medical students' use of principles of self-explanation and structured reflection during clerkship.

Background: While educators observe gaps in clerkship students' clinical reasoning (CR) skills, students report few opportunities to develop them. This study aims at exploring how students who used self-explanation (SE) and structured reflection (SR) for CR learning during preclinical training, applied these learning strategies during clerkship. Methods: We conducted an explanatory sequential mixed-methods study involving medical students. With a questionnaire, we asked students how frequently they adopted behaviours related to SE and SR during clerkship. Next, we conducted a focus group with students to explore why they adopted these behaviours. Results: Fifty-two of 198 students answered the questionnaire and five participated in a focus group. Specific behaviours adopted varied from 50% to 98%. We identified three themes about why students used these strategies: as "just in time" learning strategies; to deepen their understanding and identify gaps in knowledge; to develop a practical approach to diagnosis. A fourth theme related to the balance between learning and assessment and its consequence on adopting SE behaviours. Conclusions: Students having experienced SE and SR regularly in preclinical training tend to transpose these strategies into the clerkship providing them with a practical way to reflect deliberately and capture learning opportunities of the unpredictable clinical context.

Contexte: Alors que les éducateurs observent des lacunes dans les compétences de raisonnement clinique (RC) des étudiants en externat, ces derniers font état de peu d'occasions de les développer. Cette étude vise à explorer comment les étudiants qui ont utilisé l'auto-explication (AE) et la réflexion structurée (RS) pour l'apprentissage du raisonnement clinique pendant la formation préclinique, ont appliqué ces stratégies d'apprentissage pendant l'externat. Méthodes: Nous avons mené une étude séquentielle explicative à méthodes mixtes auprès d'étudiants en médecine. À l'aide d'un questionnaire, nous avons demandé aux étudiants à quelle fréquence ils adoptaient des comportements liés à la AE et à la RS pendant l'externat. Ensuite, nous avons organisé un groupe de discussion avec les étudiants afin d'explorer les raisons pour lesquelles ils ont adopté ces comportements. Résultats: Cinquante-deux étudiants sur 198 ont répondu au questionnaire et cinq ont participé à un groupe de discussion. Les comportements spécifiques adoptés variaient de 50 % à 98 %. Nous avons identifié trois thèmes concernant les raisons pour lesquelles les étudiants ont utilisé ces stratégies : comme stratégies d'apprentissage "juste à temps"; pour approfondir leur compréhension et identifier les lacunes dans les connaissances ; pour développer une approche pratique du diagnostic. Un quatrième thème concernait l'équilibre entre l'apprentissage et l'évaluation et ses conséquences sur l'adoption de comportements liés à l'AE. Conclusions: Les étudiants qui ont fait l'expérience de l'AE et de la RS régulièrement au cours de leur formation préclinique ont tendance à transposer ces stratégies dans l'externat, ce qui leur fournit un moyen pratique de réfléchir délibérément et de saisir les opportunités d'apprentissage dans un contexte clinique imprévisible.

Implementation of three knowledge-oriented instructional strategies to teach clinical reasoning: Self-explanation, a concept mapping exercise, and deliberate reflection: AMEE Guide No. 150.

The teaching of clinical reasoning is essential in medical education. This guide has been written to provide educators with practical advice on the design, development, and implementation of three knowledge-oriented instructional strategies for the teaching of clinical reasoning to medical students: Self-explanation (SE), a Clinical Reasoning Mapping Exercise (CREsME), and Deliberate Reflection (DR). We first synthesize the theoretical tenets that support the use of these strategies, including knowledge organization, and development of illness scripts. We then provide a detailed description of the key components of each strategy, emphasizing the practical applications of each one by sharing specific examples. We also explore the potential for a combined application of these strategies in a longitudinal and developmental approach to teaching clinical reasoning at the undergraduate level. Finally, we discuss enablers and barriers in the implementation and integration of these teaching strategies while taking into consideration curricular needs, context, and resources. We are aware that many strategies exist and are not arguing that SE, CReSME, and DR are the most effective ones or the only ones to be adopted. Nevertheless, we selected these strategies because of overarching theoretical principles, empirical evidence supporting their use, and our own experience with them. We are hoping to provide practical advice on the implementation of these strategies to practicing educators who aim at developing an integrated approach to the teaching of clinical reasoning to medical students at different stages of their development.

Harnessing a knowledge translation framework to implement an undergraduate medical education intervention: A longitudinal study.

INTRODUCTION: Implementation of evidence-informed educational interventions (EEI) involves applying and adapting theoretical and scientific knowledge to a specific context. Knowledge translation (KT) approaches can both facilitate and structure the process. The purpose of this paper is to describe lessons learned from applying a KT approach to help implement an EEI for clinical reasoning in medical students. METHODS: Using the Knowledge to Action framework, we designed and implemented an EEI intended to support the development of students' clinical reasoning skills in a renewed medical curriculum. Using mixed-methods design, we monitored students' engagement with the EEI longitudinally through a platform log; we conducted focus groups with students and stakeholders, and observed the unfolding of the implementation and its continuation. Data are reported according to six implementation outcomes: Fidelity, Feasibility, Appropriateness, Acceptability, Adoption, and Penetration. RESULTS: Students spent a mean of 24 min on the activity (fidelity outcome) with a high completion rate (between 75% and 95%; feasibility outcome) of the entire activity each time it was done. Focus group data from students and stakeholders suggest that the activity was acceptable, appropriate, feasible, adopted and well-integrated into the curriculum. DISCUSSION: Through the process we observed the importance of having a structuring framework, of working closely and deliberatively with stakeholders and students, of building upon concurrent evaluations in order to adapt iteratively the EEI to the local context and, while taking students' needs into consideration, of upholding the EEI's core educational principles.

Newly approved IV acetaminophen in Canada: Switching from oral to IV acetaminophen. Is IV worth the price difference? A systematic review.

CONTEXT: The use of intravenous acetaminophen leads to meaningful health cost increases for paediatric institutions. Therefore, strict criteria for intravenous acetaminophen administration are needed. OBJECTIVE: To undertake a systematic review of available evidence comparing oral versus intravenous acetaminophen use in children. METHOD: A systematic literature search was conducted on five databases. All prospective interventional studies comparing intravenous to oral acetaminophen in patients <18 years old were included. Data collection and analysis were done according to PRISMA guidelines. RESULTS: Among 6,417 retrieved abstracts, 29 full-text articles were assessed of which 3 were retained. (1) Pharmacokinetic: Oral bioavailability (72% with a high inter-individual variability) was reported in 47 stable patients in a paediatric intensive care unit. (2) Analgesia: In a double-blind randomized controlled trial of 45 children, no difference in analgesia was found between oral and intravenous administration after cleft palate repair. (3) Fever: In an open-label prospective observational study of 200 children, temperature decreased faster after intravenous than oral administration but was similar 4 hours later. CONCLUSIONS: Available data are insufficient to guide clinicians with a rational choice of route of administration. Oral bioavailability should be studied in paediatric populations outside the intensive care unit. Despite the widespread use of intravenous acetaminophen, there is little evidence to suggest that it improves analgesia compared to the oral formulation. Similarly, fever weans faster but whether this translates into any meaningful clinical outcome is unknown. The lack of data plus the significantly higher costs of intravenous acetaminophen should motivate further research.

A layered analysis of self-explanation and structured reflection to support clinical reasoning in medical students.

Self-explanation and structured reflection have been studied independently with results suggesting that both learning interventions can effectively support medical students' clinical reasoning development. Given this evidence, medical schools may want/begin to implement these interventions in their curricula. Implementing educational interventions requires educators to maintain the core philosophy and principles of the interventions intact while adjusting implementation techniques to the specificities of individual learning contexts. Educational scholars have yet to explicitly articulate the philosophy, principles and techniques of self-explanation and structured reflection. Without such descriptions, educators risk failing to realize self-explanation's and structured reflection's effect to support students' clinical reasoning skill development in their implementations. Relying on the layered analysis approach, we articulate the philosophy, principles and techniques of self-explanation and structured reflection. This description is framed within the context of an actual implementation to illustrate the philosophies underpinning self-explanation and structured reflection, the principles that realize those philosophies, and the techniques that can be used to enact those principles. Building on the similarities between self-explanation and structured reflection, while also harnessing their differences, we identify why and how these interventions can be combined in a single implementation, while preserving their philosophies and principles. The layered analysis of self-explanation and structured reflection offers essential insights into the underpinnings of these interventions. They are articulated in this manuscript in hopes that other scholars will continue to refine these descriptions thereby facilitating effective use of self-explanation and structured reflection for clinical reasoning development.

Comparison of Assessment by a Virtual Patient and by Clinician-Educators of Medical Students' History-Taking Skills: Exploratory Descriptive Study.

BACKGROUND: A virtual patient (VP) can be a useful tool to foster the development of medical history-taking skills without the inherent constraints of the bedside setting. Although VPs hold the promise of contributing to the development of students' skills, documenting and assessing skills acquired through a VP is a challenge. OBJECTIVE: We propose a framework for the automated assessment of medical history taking within a VP software and then test this framework by comparing VP scores with the judgment of 10 clinician-educators (CEs). METHODS: We built upon 4 domains of medical history taking to be assessed (breadth, depth, logical sequence, and interviewing technique), adapting these to be implemented into a specific VP environment. A total of 10 CEs watched the screen recordings of 3 students to assess their performance first globally and then for each of the 4 domains. RESULTS: The scores provided by the VPs were slightly higher but comparable with those given by the CEs for global performance and for depth, logical sequence, and interviewing technique. For breadth, the VP scores were higher for 2 of the 3 students compared with the CE scores. CONCLUSIONS: Findings suggest that the VP assessment gives results akin to those that would be generated by CEs. Developing a model for what constitutes good history-taking performance in specific contexts may provide insights into how CEs generally think about assessment.

Expectations, observations, and the cognitive processes that bind them: expert assessment of examinee performance.

Performance-based assessment (PBA) is a valued assessment approach in medical education, be it in a clerkship, residency, or practice context. Raters are intrinsic to PBA and the increased use of PBA has lead to an increased interest in rater cognition. Although several researchers have tackled factors that may influence the variability in rater judgment, the critical examination of rater observation of performance and the translation of that data into judgements are being investigated. The purpose of this study was to qualitatively investigate the cognitive processes of raters, and to create a framework that conceptualizes those processes when raters assess a complex performance. We conducted semi-structured interviews with 11 faculty members (nominated as excellent assessors) from a Department of Medicine to investigate how raters observe, interpret, and translate performance into judgments. The transcribed verbal protocols were analyzed using Constructivist Grounded Theory in order to develop a theoretical model of raters' assessment processes. Several themes emerged from the data and were grouped according to three macro-level themes describing how the raters balance two sources of data [(1) external sources of information and (2) internal/personal sources of information] by relying on specific cognitive processes to assess an examinee performance. The results from our study demonstrate that assessment is a difficult cognitive task that involves nuance using specific cognitive processes to weigh external and internal data against each other. Our data clearly draws attention to the constant struggle between objectivity and subjectivity that is observed in assessment as illustrated by the importance given to nuancing the examinee's observed performance.

Self-explanation in learning clinical reasoning: the added value of examples and prompts.

CONTEXT: Recent studies suggest that self-explanation (SE) while diagnosing cases fosters the development of clinical reasoning in medical students; however, the conditions that optimise the impact of SE remain unknown. The example-based learning framework justifies an exploration of students' use of their own SEs combined with the study of examples. This study aimed to assess the impact on medical students' diagnostic performance of: (i) combining students' SEs with their listening to examples of residents' SEs, and (ii) the addition of prompts (specific questions) while working with examples. METHODS: This study consisted of a training phase and an assessment phase conducted 1 week later. In the training phase, 54 Year 3 medical students were randomly assigned to one of three groups. In all groups, students first solved four clinical cases using SE. Subsequently, Group 1 listened to examples of residents' SEs with prompts; Group 2 listened to examples of residents' SEs without prompts, and the control group solved word puzzles. Then, all students again solved the same four cases. One week later, all students solved four similar and four different cases. Students' diagnostic performance and diagnostic accuracy scores were assessed for each case at each time-point. RESULTS: Although all groups' diagnostic accuracy scores on similar cases improved significantly between the training and the assessment phase, Group 1 showed a significantly higher diagnostic performance score after 1 week than the control group (p = 0.037). On different cases, Group 1 obtained significantly higher diagnostic accuracy (p = 0.011) and diagnostic performance (p < 0.001) scores than the control group and a significantly higher diagnostic performance score than Group 2 (p = 0.018). CONCLUSIONS: Self-explanation seems to be an effective technique to help medical students learn clinical reasoning. Its impact is increased significantly by combining it with examples of residents' SEs and prompts. Although students' exposure to examples of clinical reasoning is important, their 'active processing' of these examples appears to be critical to their learning from them.

Does medical students' diagnostic performance improve by observing examples of self-explanation provided by peers or experts?

Educational strategies that promote the development of clinical reasoning in students remain scarce. Generating self-explanations (SE) engages students in active learning and has shown to be an effective technique to improve clinical reasoning in clerks. Example-based learning has been shown to support the development of accurate knowledge representations. The purpose of this study was to investigate the effect of combining student's SE and observation of peer's or expert's SE examples on diagnostic performance. Fifty-three third-year medical students were assigned to a peer SE example, an expert SE example or control (no example) group. All participants solved a set of the same four clinical cases (training cases), 1-after SE, 2-after listening to a peer or expert SE example or after a control task, and 3-1 week later. They solved a new set of four different cases (transfer cases) also 1 week later. For training cases, students improved significantly their diagnostic performance overtime but the main effect of group was not significant suggesting that students' SE mainly drives the observed effect. On transfer cases, there was no difference between the three groups (p > .05). Educational implications are discussed and further studies on different types of examples and additional strategies to help students actively process examples are proposed.

The role of the assessor: exploring the clinical supervisor's skill set.

BACKGROUND: Clinical supervisors have several different responsibilities. Although their responsibilities as an assessor are important, little is known about what skill set should be acquired for this role and how to foster their development. Documenting assessor skills to study their acquisition and development is critical. METHODS: A web survey based on the principles of Appreciative Inquiry was distributed to faculty members and residents from a Department of Medicine at a Canadian University. Participants were asked to list five and then to identify five (from a list of 10) characteristics or skills demonstrated by clinical supervisors recognised for their excellent assessment skills. RESULTS: Seventeen per cent of faculty members and 23 per cent of residents completed the survey. Fairness is perceived as a key characteristic of an excellent assessor. Faculty members consider that appropriate medical knowledge and skills are important. Residents expressed the importance of appropriate feedback. Both groups indicated the importance of direct observation as a basis for assessment. DISCUSSION: This study offers preliminary insights into the characteristics of excellent assessors. Given the importance of assessment in the daily activities of clinical supervisors, research efforts should strive to better characterise this role in the hopes of increasing the quality and accuracy of assessment.

Students' self-explanations while solving unfamiliar cases: the role of biomedical knowledge.

OBJECTIVE: General guidelines for teaching clinical reasoning have received much attention, despite a paucity of instructional approaches with demonstrated effectiveness. As suggested in a recent experimental study, self-explanation while solving clinical cases may be an effective strategy to foster reasoning in clinical clerks dealing with less familiar cases. However, the mechanisms that mediate this benefit have not been specifically investigated. The aim of this study was to explore the types of knowledge used by students when solving familiar and less familiar clinical cases with self-explanation. METHODS: In a previous study, 36 third-year medical students diagnosed familiar and less familiar clinical cases either by engaging in self-explanation or not. Based on an analysis of previously collected data, the present study compared the content of self-explanation protocols generated by seven randomly selected students while solving four familiar and four less familiar cases. In total, 56 verbal protocols (28 familiar and 28 less familiar) were segmented and coded using the following categories: paraphrases, biomedical inferences, clinical inferences, monitoring statements and errors. RESULTS: Students provided more self-explanation segments from less familiar cases (M = 275.29) than from familiar cases (M = 248.71, p = 0.046). They provided significantly more paraphrases (p = 0.001) and made more errors (p = 0.008). A significant interaction was found between familiarity and the type of inferences (biomedical versus clinical, p = 0.016). When self-explaining less familiar cases, students provided significantly more biomedical inferences than familiar cases. CONCLUSIONS: Lack of familiarity with a case seems to stimulate medical students to engage in more extensive thinking during self-explanation. Less familiar cases seem to activate students' biomedical knowledge, which in turn helps them to create new links between biomedical and clinical knowledge, and eventually construct a more coherent mental representation of diseases. This may clarify the previously found positive effect that self-explanation has on the diagnosis of unfamiliar cases.

Optometrists' clinical reasoning made explicit: a qualitative study.

PURPOSE: Because the clinical reasoning processes engaged in by practicing optometrists have not previous been investigated, until now, there has been no way of knowing whether models of clinical reasoning from other health professions can be transposed to optometry. The purpose of this study has therefore been twofold: making explicit the clinical reasoning processes of optometrists at both the "competent" and "expert" levels and comparing these processes to highlight the characteristics of clinical reasoning expertise. METHODS: Four competent-level optometrists and four expert-level optometrists participated in this qualitative study. Each optometrist performed a complete optometric examination on a preselected patient. Each of these examinations was recorded on a DVD video and followed by a feedback session, also captured on a DVD video. The feedback session was conducted using techniques inspired by a form of interview called the "explicitation interview," aiming to describe optometrists' mental actions and the time sequence of these actions throughout the examination. RESULTS: The results indicate that optometrists' clinical reasoning is patient centered and includes both analytical and nonanalytical modes of reasoning. When compared with a competent-level optometrist, an expert-level optometrist is more patient centered, formulates an earlier mental representation of the patient's clinical situation (including diagnosis formulation), plans examinations more thoroughly, is able to analyze and reflect during cognitively demanding tasks, and draws up his or her care management plan throughout the entire examination. CONCLUSIONS: The verbalization of optometrists' clinical reasoning processes represents a first step toward a better understanding of this competency. The impact of this research on optometric education is discussed. The results open doors to further research in the field, for example, toward defining the stages of clinical reasoning development among optometry students and professionals.

The influence of medical students' self-explanations on diagnostic performance.

CONTEXT: Skill in clinical reasoning is a highly valued attribute of doctors, but instructional approaches to foster medical students' clinical reasoning skills remain scarce. Self-explanation is an instructional procedure, the positive effects of which on learning have been demonstrated in a variety of domains, but which remain largely unexplored in medical education. OBJECTIVES: The purpose of this study was to investigate the effects of self-explanation on students' learning of clinical reasoning during clerkships and to examine whether these effects are affected by topic familiarity. METHODS: An experimental study with a training phase and an assessment phase was conducted with 36 Year 3 medical students, randomly assigned to one of two groups. In the training phase, students solved 12 clinical cases (four cases on a less familiar topic; four on a more familiar topic; four on filler topics), either generating self-explanations (n = 18) or not (n = 18). The self-explanations were generated after minimal instructions and no feedback was provided to students. One week later, in the assessment phase, students were requested to diagnose 12 different, more difficult cases, similarly distributed among the same more familiar topic, less familiar topic and filler topics, and their diagnostic performance was assessed. RESULTS: In the training phase the performance of the two groups did not differ. However, in the assessment phase 1 week later, a significant interaction was found between self-explanation and case topic familiarity (F(1,34) = 6.18, p < 0.05). Students in the self-explanation condition, compared with those in the control condition, demonstrated better diagnostic performance on subsequent clinical cases, but this effect emerged only for cases concerning the less familiar topic. CONCLUSIONS: The present study shows the beneficial influence of generating self-explanations when dealing with less familiar clinical contexts. Generating self-explanations without feedback resulted in better diagnostic performance than in the control group at 1 week after the intervention.

Incipient neuroleptic malignant syndrome with quetiapine/paroxetine combination treatment: atypical presentation and early, successful rechallenge with olanzapine.

A 26-year-old caucasian male developed incipient neuroleptic malignant syndrome (NMS) during the course of paranoid schizophrenia with catatonic signs at admission, while on quetiapine/paroxetine combination treatment. The clinical presentation was "atypical", but increased creatine kinase levels and positive myoglobinemia were highly suggestive of the diagnosis. Of note, the patient was successfully rechallenged with olanzapine. The implications of the drug regimen and of the catatonic presentation are discussed.