Starting to Think Like an Expert: An Analysis of Resident Cognitive Processes During Simulation-Based Resuscitation Examinations.

STUDY OBJECTIVE: Simulation is commonly used to teach crisis resource management skills and assess them in emergency medicine residents. However, our understanding of the cognitive processes underlying crisis resource management skills is limited because these processes are difficult to assess and describe. The objective of this study is to uncover and characterize the cognitive processes underlying crisis resource management skills and to describe how these processes vary between residents according to performance in a simulation-based examination. METHODS: Twenty-two of 24 eligible emergency medicine trainees from 1 tertiary academic center completed 1 or 2 resuscitation-based examinations in the simulation laboratory. Resident performance was assessed by a blinded expert using an entrustment-based scoring tool. Participants wore eye-tracking glasses that generated first-person video that was used to augment subsequent interviews led by an emergency medicine faculty member. Interviews were audio recorded and then transcribed. An emergent thematic analysis was completed with a codebook that was developed by 4 research assistants, with subsequent analyses conducted by the lead research assistant with input from emergency medicine faculty. Themes from high- and low-performing residents were subsequently qualitatively compared. RESULTS: Higher-performing residents were better able to anticipate, selectively attend to relevant information, and manage cognitive demands, and took a concurrent (as opposed to linear) approach to managing the simulated patient. CONCLUSION: The results provide new insights into residents' cognitive processes while managing simulated patients in an examination environment and how these processes vary with performance. More work is needed to determine how best to apply these findings to improve crisis resource management education.

Getting Inside the Expert's Head: An Analysis of Physician Cognitive Processes During Trauma Resuscitations.

STUDY OBJECTIVE: Crisis resource management skills are integral to leading the resuscitation of a critically ill patient. Despite their importance, crisis resource management skills (and their associated cognitive processes) have traditionally been difficult to study in the real world. The objective of this study was to derive key cognitive processes underpinning expert performance in resuscitation medicine, using a new eye-tracking-based video capture method during clinical cases. METHODS: During an 18-month period, a sample of 10 trauma resuscitations led by 4 expert trauma team leaders was analyzed. The physician team leaders were outfitted with mobile eye-tracking glasses for each case. After each resuscitation, participants were debriefed with a modified cognitive task analysis, based on a cued-recall protocol, augmented by viewing their own first-person perspective eye-tracking video from the clinical encounter. RESULTS: Eye-tracking technology was successfully applied as a tool to aid in the qualitative analysis of expert performance in a clinical setting. All participants stated that using these methods helped uncover previously unconscious aspects of their cognition. Overall, 5 major themes were derived from the interviews: logistic awareness, managing uncertainty, visual fixation behaviors, selective attendance to information, and anticipatory behaviors. CONCLUSION: The novel approach of cognitive task analysis augmented by eye tracking allowed the derivation of 5 unique cognitive processes underpinning expert performance in leading a resuscitation. An understanding of these cognitive processes has the potential to enhance educational methods and to create new assessment modalities of these previously tacit aspects of expertise in this field.

The challenges of studying visual expertise in medical image diagnosis.

CONTEXT: Visual expertise is the superior visual skill shown when executing domain-specific visual tasks. Understanding visual expertise is important in order to understand how the interpretation of medical images may be best learned and taught. In the context of this article, we focus on the visual skill of medical image diagnosis and, more specifically, on the methodological set-ups routinely used in visual expertise research. METHODS: We offer a critique of commonly used methods and propose three challenges for future research to open up new avenues for studying characteristics of visual expertise in medical image diagnosis. The first challenge addresses theory development. Novel prospects in modelling visual expertise can emerge when we reflect on cognitive and socio-cultural epistemologies in visual expertise research, when we engage in statistical validations of existing theoretical assumptions and when we include social and socio-cultural processes in expertise development. The second challenge addresses the recording and analysis of longitudinal data. If we assume that the development of expertise is a long-term phenomenon, then it follows that future research can engage in advanced statistical modelling of longitudinal expertise data that extends the routine use of cross-sectional material through, for example, animations and dynamic visualisations of developmental data. The third challenge addresses the combination of methods. Alternatives to current practices can integrate qualitative and quantitative approaches in mixed-method designs, embrace relevant yet underused data sources and understand the need for multidisciplinary research teams. CONCLUSION: Embracing alternative epistemological and methodological approaches for studying visual expertise can lead to a more balanced and robust future for understanding superior visual skills in medical image diagnosis as well as other medical fields.

Measuring physician cognitive load: validity evidence for a physiologic and a psychometric tool.

In general, researchers attempt to quantify cognitive load using physiologic and psychometric measures. Although the construct measured by both of these metrics is thought to represent overall cognitive load, there is a paucity of studies that compares these techniques to one another. The authors compared data obtained from one physiologic tool (pupillometry) to one psychometric tool (Paas scale) to explore whether they actually measured the construct of cognitive load as purported. Thirty-two participants with a range of resuscitation medicine experience and expertise completed resuscitation-medicine based multiple-choice-questions as well as arithmetic questions. Cognitive load, as measured by both tools, was found to be higher for the more difficult questions as well as for questions that were answered incorrectly (p < 0.001). The group with the least medical experience had higher cognitive load than both the intermediate and experienced groups when answering domain-specific questions (p = 0.023 and p = 0.003 respectively for the physiologic tool; p = 0.006 and p < 0.001 respectively for the psychometric tool). There was a strong positive correlation (Spearman's ρ = 0.827, p < 0.001 for arithmetic questions; Spearman's ρ = 0.606, p < 0.001 for medical questions) between the two cognitive load measurement tools. These findings support the validity argument that both physiologic and psychometric metrics measure the construct of cognitive load.

Bifactor exploratory structural equation modeling: A meta-analytic review of model fit.

Multivariate behavioral research often focuses on latent constructs-such as motivation, self-concept, or wellbeing-that cannot be directly observed. Typically, these latent constructs are measured with items in standardized instruments. To test the factorial structure and multidimensionality of latent constructs in educational and psychological research, Morin et al. (2016a) proposed bifactor exploratory structural equation modeling (B-ESEM). This meta-analytic review (158 studies, k = 308, N = 778,624) aimed to estimate the extent to which B-ESEM model fit differs from other model representations, including confirmatory factor analysis (CFA), exploratory structural equation modeling (ESEM), hierarchical CFA, hierarchical ESEM, and bifactor-CFA. The study domains included learning and instruction, motivation and emotion, self and identity, depression and wellbeing, and interpersonal relations. The meta-analyzed fit indices were the χ2 /df ratio, the comparative fit index (CFI), the Tucker-Lewis index (TLI), the root mean square error of approximation (RMSEA), and the standardized root mean squared residual (SRMR). The findings of this meta-analytic review indicate that the B-ESEM model fit is superior to the fit of reference models. Furthermore, the results suggest that model fit is sensitive to sample size, item number, and the number of specific and general factors in a model.

Holistic processing only? The role of the right fusiform face area in radiological expertise.

Radiologists can visually detect abnormalities on radiographs within 2s, a process that resembles holistic visual processing of faces. Interestingly, there is empirical evidence using functional magnetic resonance imaging (fMRI) for the involvement of the right fusiform face area (FFA) in visual-expertise tasks such as radiological image interpretation. The speed by which stimuli (e.g., faces, abnormalities) are recognized is an important characteristic of holistic processing. However, evidence for the involvement of the right FFA in holistic processing in radiology comes mostly from short or artificial tasks in which the quick, 'holistic' mode of diagnostic processing is not contrasted with the slower 'search-to-find' mode. In our fMRI study, we hypothesized that the right FFA responds selectively to the 'holistic' mode of diagnostic processing and less so to the 'search-to-find' mode. Eleven laypeople and 17 radiologists in training diagnosed 66 radiographs in 2s each (holistic mode) and subsequently checked their diagnosis in an extended (10-s) period (search-to-find mode). During data analysis, we first identified individual regions of interest (ROIs) for the right FFA using a localizer task. Then we employed ROI-based ANOVAs and obtained tentative support for the hypothesis that the right FFA shows more activation for radiologists in training versus laypeople, in particular in the holistic mode (i.e., during 2s trials), and less so in the search-to-find mode (i.e., during 10-s trials). No significant correlation was found between diagnostic performance (diagnostic accuracy) and brain-activation level within the right FFA for both, short-presentation and long-presentation diagnostic trials. Our results provide tentative evidence from a diagnostic-reasoning task that the FFA supports the holistic processing of visual stimuli in participants' expertise domain.

Taking Affective Learning in Digital Education One Step Further: Trainees' Affective Characteristics Predicting Multicontextual Pre-training Transfer Intention.

The past decades have shown an accelerated development of technology-enhanced or digital education. Although an important and recognized precondition for study success, still little attention has been paid to examining how an affective learning climate can be fostered in online training programs. Besides gaining insight into the dynamics of affective learning itself it is of vital importance to know what predicts trainees' intention to transfer new knowledge and skills to other contexts. The present study investigated the influence of five affective learner characteristics from the transfer literature (learner readiness, motivation to learn, expected positive outcomes, expected negative outcomes, personal capacity) on trainees' pre-training transfer intention. Participants were 366 adult students enrolled in an online course in information literacy in a distance learning environment. As information literacy is a generic competence, applicable in various contexts, we developed a novel multicontextual transfer perspective and investigated within one single study the influence of the abovementioned variables on pre-training transfer intention for both the students' Study and Work contexts. The hypothesized model has been tested using structural equation modeling. The results showed that motivation to learn, expected positive personal outcomes, and learner readiness were the strongest predictors. Results also indicated the benefits of gaining pre-training insight into the specific characteristics of multiple transfer contexts, especially when education in generic competences is involved. Instructional designers might enhance study success by taking affective transfer elements and multicontextuality into account when designing digital education.

Reconstructing goals for transfer of training in faculty development programs for higher education teachers: A qualitative documentary method approach.

Faculty development programs are often used in universities and higher education institutes to develop the knowledge and skills of their teaching personnel. At the same time, these faculty development programs often remain ineffective because lecturers are not fully using what they learned in their courses, classes, and seminars. The purpose of this case study was to explore the goals higher education teachers had after professional development programs for applying newly trained knowledge and skills. Grounded in 3 × 2 achievement goal model and Ryan and Deci's (2018) goal contents theory, the study addressed the research question: Which types of transfer goals do university teachers have after teacher education? Participants were three lecturers that were selected following the procedures of the maximum variation sampling schema. Adopting a mixed methods approach, data were collected with questionnaires (aimed at profiling the goal orientations of the teachers) and reflective interviews (aimed at reconstructing the goals and goal contents teachers had for transferring the trained skills). Triangulation of the quantitative and qualitative data using the documentary method resulted in a typology of intrinsic, mixed, and extrinsic transfer goals. Directions for future research associated with instrument development and theory building as well as implications for the educational practice in human resource development programs of higher education institutes are discussed.

A new way to look at simulation-based assessment: the relationship between gaze-tracking and exam performance.

OBJECTIVE: A key task of the team leader in a medical emergency is effective information gathering. Studying information gathering patterns is readily accomplished with the use of gaze-tracking glasses. This technology was used to generate hypotheses about the relationship between performance scores and expert-hypothesized visual areas of interest in residents across scenarios in simulated medical resuscitation examinations. METHODS: Emergency medicine residents wore gaze-tracking glasses during two simulation-based examinations (n=29 and 13 respectively). Blinded experts assessed video-recorded performances using a simulation performance assessment tool that has validity evidence in this context. The relationships between gaze patterns and performance scores were analyzed and potential hypotheses generated. Four scenarios were assessed in this study: diabetic ketoacidosis, bradycardia secondary to beta-blocker overdose, ruptured abdominal aortic aneurysm and metabolic acidosis caused by antifreeze ingestion. RESULTS: Specific gaze patterns were correlated with objective performance. High performers were more likely to fixate on task-relevant stimuli and appropriately ignore task-irrelevant stimuli compared with lower performers. For example, shorter latency to fixation on the vital signs in a case of diabetic ketoacidosis was positively correlated with performance (r=0.70, p<0.05). Conversely, total time spent fixating on lab values in a case of ruptured abdominal aortic aneurysm was negatively correlated with performance (r= −0.50, p<0.05). CONCLUSIONS: There are differences between the visual patterns of high and low-performing residents. These findings may allow for better characterization of expertise development in resuscitation medicine and provide a framework for future study of visual behaviours in resuscitation cases.

The Neural Implementation of Surgical Expertise Within the Mirror-Neuron System: An fMRI Study.

Motor expertise is an important aspect of high-level performance in professional tasks such as surgery. While recently it has been shown that brain activation as measured by functional magnetic resonance imaging (fMRI) within the mirror-neuron system (MNS) is modulated by expertise in sports and music, little is known about the neural underpinnings of professional, e.g., surgical expertise. Here, we investigated whether and (if so) how surgical expertise is implemented in the MNS in medical professionals across three levels of surgical qualification. In order to answer the more specific research question, namely, if the neural implementation of motor expertise develops in a linear or non-linear fashion, the study compares not only brain activation within the MNS related to action observation of novices and experts, but also intermediates. Ten novices (medical students), ten intermediates (residents in orthopedic surgery) and ten experts (orthopedic surgeons) watched 60 video clips (5 s each) of daily-life activities and surgical procedures each while their brain activation was measured using a 3-T fMRI scanner. An established localization procedure was followed to functionally define the MNS for each participant individually. A 2 (video type: daily-life activities, surgical procedures) × 3 (expertise level: novice, intermediate, expert) ANOVA yielded a non-significant interaction. Furthermore, separate analyses of the precentral and parietal part of the MNS also yielded non-significant interactions. However, post hoc comparisons showed that intermediates displayed marginally significantly lower brain activation in response to surgery-related videos within the MNS than novices. No other significant differences were found. We did not find evidence for the hypothesis that the brain-activation level in the MNS evoked by observing surgical videos reflects the level of surgical expertise in the professional task of (orthopedic) surgery. However, the results suggest a potential non-linear relationship between expertise level and MNS-activation level.

Traditional microscopy instruction versus process-oriented virtual microscopy instruction: a naturalistic experiment with control group.

BACKGROUND: Virtual microscopy is being introduced in medical education as an approach for learning how to interpret information in microscopic specimens. It is, however, far from evident how to incorporate its use into existing teaching practice. The aim of the study was to explore the consequences of introducing virtual microscopy tasks into an undergraduate pathology course in an attempt to render the instruction more process-oriented. The research questions were: 1) How is virtual microscopy perceived by students? 2) Does work on virtual microscopy tasks contribute to improvement in performance in microscopic pathology in comparison with attending assistant-led demonstrations only? METHOD: During a one-week period, an experimental group completed three sets of virtual microscopy homework assignments in addition to attending demonstrations. A control group attended the demonstrations only. Performance in microscopic pathology was measured by a pre-test and a post-test. Student perceptions of regular instruction and virtual microscopy were collected one month later by administering the Inventory of Intrinsic Motivation and open-ended questions. RESULTS: The students voiced an appreciation for virtual microscopy for the purposes of the course and for self-study. As for learning gains, the results indicated that learning was speeded up in a subgroup of students consisting of conscientious high achievers. CONCLUSIONS: The enriched instruction model may be suited as such for elective courses following the basic course. However, the instructional model needs further development to be suited for basic courses.