Why we should view the decision of medical trainees to cheat as the product of a person-by-situation interaction.

BACKGROUND: Cheating during medical training is a delicate subject matter with varying opinions on the prevalence, causes and gravity of cheating during training. PROPOSED FRAMEWORK: In this article, the authors suggest that the decision to cheat is best viewed as the product of a person-by-situation interaction rather than indicating inherent dishonesty and/or extrinsic motivation in those who participate in cheating. This framework can explain why individuals who would typically default to honesty may participate in cheating if there is perceived justification for cheating and where situational variables, such as ease of cheating, rewards for cheating and perceived risk associated with cheating, make the decision to cheat appear rational. DISCUSSION: They discuss why the impression that there is a culture of cheating can provide perceived justification for medical trainees to cheat if they have the opportunity. They then describe how aspects of medical training and assessment may enable or hinder cheating by trainees. Consistent with the person-by-situation interaction framework, they contend that our response to cheating should include interventions directed at both the person who cheated and situational variables that enabled cheating. Recognising that some forms of cheating may be widespread, difficult to detect and contentious (such as the creation and use of exam reconstructs), their proposal for dealing with suspected and pervasive cheating is to identify and target enabling variables such that the decision to cheat becomes less rational. Their hope is that in so doing, we can gradually nudge trainees and the culture of medical training towards honesty.

Personal career decisions during medical training are not complicated, they are complex.

BACKGROUND: For medical training to be deemed successful, in addition to gaining the skills required to make appropriate clinical decisions, trainees must learn how to make good personal decisions. These decisions may affect satisfaction with career choice, work-life balance, and their ability to maintain/improve clinical performance over time-outcomes that can impact future wellness. Here, the authors introduce a decision-making framework with the goal of improving our understanding of personal decisions. METHODS: Stemming from the business world, the Cynefin framework describes five decision-making domains: clear, complicated, complex, chaotic, and confusion, and a key inference of this framework is that decision-making can be improved by first identifying the decision-making domain. Personal decisions are largely complex-so applying linear decision-making strategies is unlikely to help in this domain. RESULTS: The available data suggest that the outcomes of personal decisions are suboptimal, and the authors propose three mechanisms to explain these findings: (1) Complex decision is susceptible to attribute substitution where we subconsciously trade these decisions for easier decisions; (2) predictions are prone to cognitive biases, such as assuming our situation will remain constant (linear projection fallacy), believing that accomplishing a goal will deliver lasting happiness (arrival bias), or overestimating benefits and underestimating costs of future tasks (planning fallacy); and (3) complex decisions have an inherently higher failure rate than complicated decisions because they are the result of an ongoing, dynamic person-by-situation interaction and, as such, have more time to fail and more ways to do so. DISCUSSION: Based upon their view that personal decisions are complex, the authors propose strategies to improve satisfaction with personal decisions, including increasing awareness of biases that may impact personal decisions. Recognising that the outcome of personal decisions can change over time, they also suggest additional interventions to manage these decisions, such as different forms of mentoring.

Trends in Telerehabilitation Utilization in the United States 2020-2021.

OBJECTIVE: To examine telerehabilitation utilization in the United States (US) during the first 2 years of the pandemic. DESIGN: We performed a retrospective analysis of outpatient insurance claims from the IBM MarketScan Commercial Claims and Encounters Database to identify the number and proportion of patients using telerehabilitation from 2020 to 2021. Telerehabilitation was identified based on the presence of specific code modifiers and place of service. SETTING: Retrospective claims analysis. PARTICIPANTS: Individuals living in the United States with employer-sponsored insurance plans using outpatient physical or occupational therapy (PT/OT) (N=2,007,524). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Number and proportion of outpatient PT/OT visits completed via telerehabilitation. RESULTS: We identified 21,026,608 PT/OT visits among 2,007,524 patients. Overall, 49,974 (2.5%) patients received ≥1 telerehabilitation visit during the specified timeframe. We observed trends in utilization over time, with utilization peaking in April 2020 when 10.9% of all PT/OT visits were conducted by telerehabilitation. We also observed geographic trends with lower rates of utilization identified in rural areas. State-by-state utilization rates ranged from 10.4% (California) to 0.3% (Wyoming). CONCLUSION: Telerehabilitation may be underutilized as a means of improving access to PT/OT, especially in rural areas of the country. Further research is needed to examine contributing factors to low observed utilization rates, such as provider and patient perceptions of telerehabilitation.

Mentorship in medicine is a Complex opportunity.

Mentorship is now recognized as essential to the personal and professional development of physicians. Over the past decade, it has become a common theme in medical education literature, and through this our understanding of mentorship has evolved. Despite this progress, we believe that the prevailing reductionist view of mentorship is oversimplified and may hinder further advances in this space. Instead, we propose that mentorship be viewed through the lens of complexity theory, positioning it as a prototypical complex adaptive system. This shift in perspective will inform our mentorship interventions and evaluations, and can avoid the disappointment that invariably follows when we apply a simple approach to a complex situation.

Exploring the relationship between AM-PAC scores and mobility components in falls and pressure injury risk assessment tools: A pathway to improve nursing clinical efficiency.

BACKGROUND: Nurses routinely perform multiple risk assessments related to patient mobility in the hospital. Use of a single mobility assessment for multiple risk assessment tools could improve clinical documentation efficiency, accuracy and lay the groundwork for automated risk evaluation tools. PURPOSE: We tested how accurately Activity Measure for Post-Acute Care (AM-PAC) mobility scores predicted the mobility components of various fall and pressure injury risk assessment tools. METHOD: AM-PAC scores along with mobility and physical activity components on risk assessments (Braden Scale, Get Up and Go used within the Hendrich II Fall Risk Model®, Johns Hopkins Fall Risk Assessment Tool (JHFRAT) and Morse Fall Scale) were collected on a cohort of hospitalised patients. We predicted scores of risk assessments based on AM-PAC scores by fitting of ordinal logistic regressions between AM-PAC scores and risk assessments. STROBE checklist was used to report the present study. FINDINGS: AM-PAC scores predicted the observed mobility components of Braden, Get Up and Go and JHFRAT with high accuracy (≥85%), but with lower accuracy for the Morse Fall Scale (40%). DISCUSSION: These findings suggest that a single mobility assessment has the potential to be a good solution for the mobility components of several fall and pressure injury risk assessments.

Using Nursing Assessments of Mobility and Activity to Prioritize Patients Most Likely to Need Rehabilitation Services.

OBJECTIVE: To identify nursing assessments of mobility and activity associated with lower-value rehabilitation services. DESIGN: Retrospective cohort analysis of admissions from December 2016 to September 2019 SETTING: Medicine, neurology, and surgery units (n=47) at a tertiary hospital. PARTICIPANTS: We included patients with a length of stay ≥7 days on units that routinely assessed patient function (n=18,065 patients). INTERVENTIONS: Not applicable. MAIN OUTCOME: We examined the utility of nursing assessments of function to identify patients who received lower-value rehabilitation consults, defined as those who received ≤1 therapy visit. MEASURES: Patient function was assessed using 2 Activity Measure for Post-Acute Care (AM-PAC or "6 clicks") inpatient short forms: (1) basic mobility (eg, bed mobility, walking) and (2) daily activity (eg, grooming, toileting). RESULTS: Using an AM-PAC cutoff value of ≥23 correctly identified 92.5% and 98.7% of lower-value physical therapy and occupational therapy visits, respectively. In our cohort, using a cutoff value of ≥23 on the AM-PAC would have eliminated 3482 (36%) of lower-value physical therapy consults and 4076 (34%) of lower-value occupational therapy consults. CONCLUSIONS: Nursing assessment, using AM-PAC scores, can be used to help identify lower-value rehabilitation consults, which can then be reallocated to patients with greater rehabilitation needs. Based on our results, an AM-PAC cutoff value of ≥23 can be used as a guide to help prioritize patients with greater rehabilitation needs.

Safety of peripherally administered 3% hypertonic saline.

BACKGROUND: Administration of 3% sodium chloride through a peripheral venous catheter is associated with risk of infusion-related adverse events (IRAE) due to its high osmolarity. Given this concern and the paucity of data regarding these events, many hospitals have policies that require central line administration of 3% sodium chloride. OBJECTIVE: The objective of this analysis was to evaluate the incidence of IRAE associated with peripheral administration of 3% sodium chloride. METHODS: This analysis included patients who received 3% sodium chloride via a peripheral venous catheter between May 2017 and August 2019. The major endpoint of this analysis was the overall incidence of IRAE, defined as the documentation of infiltration or phlebitis. A multivariable logistic regression was performed to identify potential risk factors (e.g., age, infusion rate, infusion duration, peripheral venous catheter location, and needle gauge) for development of IRAE. RESULTS: A total of 706 administrations in 422 patients were included. Seventy-four (10.5%) administrations were associated with a documented event. Based on the Infusion Nurses grading scale for infiltration or phlebitis, 48% of the events in this analysis were grade 1 in severity. Duration of infusion of 3% sodium chloride was found to be associated with an increased odds of an IRAE (OR per 1 h 1.02, 95% CI 1.01-1.02) in the multivariable analysis. Age, infusion rate, peripheral venous catheter location, and needle gauge were not independently associated with an increased risk of an IRAE. CONCLUSION: These data suggest that IRAE occurred more frequently when 3% sodium chloride was administered over a longer duration and the majority of events were mild with no permanent tissue injury. It may be reasonable to consider peripheral administration of 3% sodium chloride in the acute care setting for a short duration, although additional studies are needed to continue to evaluate its safety.

How much is enough? Proposing achievement thresholds for core EPAs of graduating medical students in Canada.

PURPOSE: The transition towards Competency-Based Medical Education at the Cumming School of Medicine was accelerated by the reduced clinical time caused by the COVID-19 pandemic. The purpose of this study was to define a standard protocol for setting Entrustable Professional Activity (EPA) achievement thresholds and examine their feasibility within the clinical clerkship. METHODS: Achievement thresholds for each of the 12 AFMC EPAs for graduating Canadian medical students were set by using sequential rounds of revision by three consecutive groups of stakeholders and evaluation experts. Structured communication was guided by a modified Delphi technique. The feasibility/consequence models of these EPAs were then assessed by tracking their completion by the graduating class of 2021. RESULTS: The threshold-setting process resulted in set EPA achievement levels ranging from 1 to 8 across the 12 AFMC EPAs. Estimates were stable after the first round for 9 of 12 EPAs. 96.27% of EPAs were successfully completed by clerkship students despite the shortened clinical period. Feasibility was predicted by the slowing rate of EPA accumulation overtime during the clerkship. CONCLUSION: The process described led to consensus on EPA achievement thresholds. Successful completion of the assigned thresholds was feasible within the shortened clerkship.[Box: see text].

The Johns Hopkins Activity and Mobility Promotion Program: A Framework to Increase Activity and Mobility Among Hospitalized Patients.

BACKGROUND: Greater mobility and activity among hospitalized patients has been linked to key outcomes, including decreased length of stay, increased odds of home discharge, and fewer hospital-acquired morbidities. Systematic approaches to increasing patient mobility and activity are needed to improve patient outcomes during and following hospitalization. PROBLEM: While studies have found the Johns Hopkins Activity and Mobility Promotion (JH-AMP) program improves patient mobility and associated outcomes, program details and implementation methods are not published. APPROACH: JH-AMP is a systematic approach that includes 8 steps, described in this article: (1) organizational prioritization; (2) systematic measurement and daily mobility goal; (3) barrier mitigation; (4) local interdisciplinary roles; (5) sustainable education and training; (6) workflow integration; (7) data feedback; and (8) promotion and awareness. CONCLUSIONS: Hospitals and health care systems can use this information to guide implementation of JH-AMP at their institutions.

Effect of Severe Distal Tibia, Ankle, and Mid- to Hindfoot Trauma on Meeting Physical Activity Guidelines 18 Months After Injury.

OBJECTIVE: To examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA. DESIGN: Secondary analysis of observational cohort study. SETTING: A total of 34 United States trauma centers PARTICIPANTS: A total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328). INTERVENTIONS: None. MAIN OUTCOME MEASURES: The Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week. RESULTS: Fewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31). CONCLUSIONS: Patients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.

Construct Validity of Pediatric PROMIS Computerized Adaptive Testing Measures in Children With Adolescent Idiopathic Scoliosis.

BACKGROUND: The use of patient-reported outcome measures, especially Patient-Reported Outcomes Measurement Information System (PROMIS) measures, has increased in recent years. Given this growth, it is imperative to ensure that the measures being used are validated for the intended population(s)/disease(s). Our objective was to assess the construct validity of 8 PROMIS computer adaptive testing (CAT) measures among children with adolescent idiopathic scoliosis (AIS). METHODS: We prospectively enrolled 200 children (aged 10 to 17 y) with AIS, who completed 8 PROMIS CATs (Anxiety, Depressive Symptoms, Mobility, Pain Behavior, Pain Interference, Peer Relationships, Physical Activity, Physical Stress Experiences) and the Scoliosis Research Society-22r questionnaire (SRS-22r) electronically. Treatment categories were observation, bracing, indicated for surgery, or postoperative from posterior spinal fusion. Construct validity was evaluated using known group analysis and convergent and discriminant validity analyses. Analysis of variance was used to identify differences in PROMIS T -scores by treatment category (known groups). The Spearman rank correlation coefficient ( rs ) was calculated between corresponding PROMIS and SRS-22r domains (convergent) and between unrelated PROMIS domains (discriminant). Floor/ceiling effects were calculated. RESULTS: Among treatment categories, significant differences were found in PROMIS Mobility, Pain Behavior, Pain Interference, and Physical Stress Experiences and in all SRS-22r domains ( P <0.05) except Mental Health ( P =0.15). SRS-22r Pain was strongly correlated with PROMIS Pain Interference ( rs =-0.72) and Pain Behavior ( rs =-0.71) and moderately correlated with Physical Stress Experiences ( rs =-0.57). SRS-22r Mental Health was strongly correlated with PROMIS Depressive Symptoms ( rs =-0.72) and moderately correlated with Anxiety ( rs =-0.62). SRS-22r Function was moderately correlated with PROMIS Mobility ( rs =0.64) and weakly correlated with Physical Activity ( rs =0.34). SRS-22r Self-Image was weakly correlated with PROMIS Peer Relationships ( rs =0.33). All unrelated PROMIS CATs were weakly correlated (| rs |<0.40). PROMIS Anxiety, Mobility, Pain Behavior, and Pain Interference and SRS-22r Function, Pain, and Satisfaction displayed ceiling effects. CONCLUSIONS: Evidence supports the construct validity of 6 PROMIS CATs in evaluating AIS patients. Ceiling effects should be considered when using specific PROMIS CATs. LEVEL OF EVIDENCE: Level II, prognostic.

Time to Completion of Pediatric PROMIS Computerized Adaptive Testing Measures and the SRS-22r in an Adolescent Idiopathic Scoliosis Population.

BACKGROUND: Patient-reported outcome measures are useful tools to quantify patients' pre-treatment and post-treatment symptoms. Historically used "legacy measures", such as the Scoliosis Research Society-22 revised questionnaire (SRS-22r), are often disease-specific and can be time-intensive. Recently developed Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive testing (CAT) measures may reduce administrative burdens and permit more efficient outcome collection within clinic workflows. In an era of medicine where payments are becoming tied to outcomes, we sought to assess the time to completion (TTC) of 8 pediatric PROMIS CAT measures and the SRS-22r in adolescents with idiopathic scoliosis. MATERIALS AND METHODS: Patients presenting to a large, urban tertiary referral hospital were prospectively enrolled into the study. Subjects were first-time survey respondents in various phases and types of treatment for adolescent idiopathic scoliosis. In total, 200 patients ranging from 10 to 17 years old completed 8 Pediatric PROMIS CATs and the SRS-22r. PROMIS CATs administered include Physical Activity, Mobility, Anxiety, Depressive symptoms, Peer Relationships, Physical Stress Experiences, Pain Behavior and Pain Interference. TTC was calculated using start and stop timestamps in the REDCap software. RESULTS: The mean (±SD) TTC for each PROMIS CAT was 1.1 (±0.9) minutes with physical activity, mobility, anxiety, depressive symptoms, peer relationships, physical stress experiences, pain behavior, and pain interference taking 1.2, 1.4, 1.0, 0.9, 1.2, 1.0, 1.0, and 1.2 minutes on average to complete, respectively. Mean TTC for the SRS-22r was 5.2 (±3.0) minutes. CONCLUSIONS: In this pediatric orthopaedic cohort, completion of 8 PROMIS CATs demonstrated minimal test-taker burden and time required for completion. These findings support rapid and easily integrable PROMIS CATs in clinical practice to aid in increased delivery of efficient, patient-centered care. LEVEL OF EVIDENCE: III, cross-sectional study.

An interprofessional examination of the Johns Hopkins Mobility Goal Calculator among hospitalized postsurgical patients.

Individualized mobility goals created using a goal calculator have been shown to increase patient mobility on medical nursing units, but have not been studied among postoperative populations. This study aimed to examine the feasibility of an automated mobility goal calculator on a postoperative nursing unit. To examine this, we used the goal calculator to create goals for patients (N = 128) following surgery and mobilized each patient with either a nurse or physical therapist. Each patient's highest level of mobility was recorded and providers completed surveys on the appropriateness of calculated goals. Overall, 94% of patients achieved calculated goals. Patients with more pain achieved goals significantly less often than those with less pain. Those with higher mobility achieved their goals similarly with either provider. Providers reported 47% of goals were appropriate, with goals being set too low as the primary reason for goals being inappropriate. We conclude that the automated goal calculator can be used on postoperative nursing units to set realistic goals for patients after surgery.

Safety of Intravenous Olanzapine Administration at a Tertiary Academic Medical Center.

BACKGROUND: Although approved by the Food and Drug Administration for intramuscular administration only, analyses have described the administration of intravenous push (IVP) olanzapine, particularly for acute agitation. The safety and efficacy of IVP olanzapine has mostly been limited to emergency department patients. OBJECTIVE: To evaluate the safety of IVP olanzapine administration in the inpatient setting. METHODS: This single-center, retrospective analysis was conducted between July 1, 2018, and December 31, 2019, at Brigham and Women's Hospital in Boston, Massachusetts. Adult patients who received at least 1 dose of IVP olanzapine were included in the analysis. Safety endpoints analyzed included the following adverse drug events (ADEs): hypotension, bradycardia, cardiac arrhythmias, extrapyramidal adverse effects, and respiratory depressive events. Data on IV site reactions, including phlebitis and infiltration, were also collected. RESULTS: A total of 1,247 IVP administrations of olanzapine were identified across 252 patients. Two or more doses were received by 159 patients (63.1%). Most administrations (66%) took place in intensive care units, with 33% administered on general medicine wards. Overall, 104 administrations (8.3%) were associated with at least 1 ADE. Hypotension and bradycardia occurred in 62 (5.2%) and 16 (1.3%) administrations, respectively. Phlebitis occurred with 8 administrations (1.4%). All other adverse events were rare (<1%). CONCLUSION AND RELEVANCE: Hypotension, the most commonly noted ADE, occurred more frequently than in previous studies. IVP olanzapine appears to be a safe route of administration in hospitalized patients, including those receiving multiple doses. Further studies are required to evaluate the effect of IV olanzapine on hemodynamics.

Safety of Intravenous Push Lacosamide Compared With Intravenous Piggyback at a Tertiary Academic Medical Center.

BACKGROUND: There are limited data regarding the incidence of adverse events associated with administering lacosamide by intravenous push (IVP) compared with IV piggyback (IVPB). OBJECTIVE: The objective of this analysis was to compare the safety profile, including cardiovascular effects, sedative effects, and IV site reactions of IVP and IVPB lacosamide administration. METHODS: A retrospective pre/post cohort analysis comparing patients who received lacosamide via IVP and IVPB was conducted. Safety end points included hypotension, bradycardia, medication-related sedation, and IV site reactions. The relationship between patient characteristics and the incidence of safety end points was analyzed using the Student t-test and χ2 test as appropriate. RESULTS: Bradycardia occurred after 0.19% of IVP administrations and 1.09% of IVPB administrations assessed (P = 0.07). Hypotension was observed in 3.16% of IVP administrations compared to 1.59% in the IVPB cohort (P = 0.12). Post lacosamide-related sedation was noted in 11.32% and 11.68% of the IVP and IVPB cohorts, respectively (P = 0.87). Infusion site reaction rates of 1.80% and 0.84% were documented in the IVP and IVPB cohorts, respectively (P = 0.33). Of note, only 1 adverse event required clinical intervention. One 200-mg dose in the IVP cohort required a fluid bolus postadministration. CONCLUSION AND RELEVANCE: IVP lacosamide was associated with a similar incidence of cardiovascular, neurological, and infusion site-related adverse events compared with IVPB, in which nearly every adverse event was deemed clinically insignificant. Lacosamide administered via IVP may be considered a safe alternative method of administration in the acute care setting.

Safety of intravenous push thiamine administration at a tertiary academic medical center.

OBJECTIVES: Intravenous (IV) thiamine, administered using both diluted solution for infusion and undiluted solution for IV push, is used to correct low levels of thiamine. Although thiamine has a good safety profile, its IV administration is associated with rare cases of anaphylaxis. The objective of this analysis was to evaluate the incidence of anaphylaxis and IV site reactions associated with IV push thiamine. DESIGN: A single-center, retrospective chart review was performed using electronic health records. SETTING AND PARTICIPANTS: All adult patients who received undiluted IV push thiamine between June 1, 2015, and July 31, 2017, were included. Patient demographics, IV access site, allergy history, and antihistaminic medication use before thiamine administration were collected. OUTCOME MEASURES: Anaphylaxis was assessed while infiltration and phlebitis were evaluated using a standardized institutional grading system. All documented adverse events were adjudicated with the Naranjo Nomogram for adverse drug reaction assessment. RESULTS: A total of 8606 administrations in 2595 patients were evaluated; 5560 doses were administered peripherally, 1643 doses were administered centrally, and the line of administration was not documented for the remaining doses. Administrations included 7605 doses of 100 mg, 433 of 200 mg, 549 of 250 mg, and 19 of 500 mg. No anaphylactic or anaphylactoid reactions were observed. A total of 26 injection site reactions (0.30%) were noted in 19 patients (phlebitis, 12 events and infiltration, 14 events). Assessment with the Naranjo Nomogram classified 18 reactions to have a possible likelihood and 8 reactions to have a probable likelihood of being caused by IV push thiamine administration. CONCLUSION: Administration of IV push thiamine was not associated with any anaphylactic event and had a low incidence of IV site reactions. IV push thiamine in doses up to 250 mg appeared to be safe. There may be an indication for its safe administration with doses up to 500 mg, although more research is needed.

Temporal pattern of emotions and cognitive load during simulation training and debriefing.

BACKGROUND: In the simulated clinical environment, there is a perceived benefit to the emotional activation experienced by learners; however, potential harm of excessive and/or negative emotions has also been hypothesized. An improved understanding of the emotional experiences of learners during each phase of the simulation session will inform instructional design. METHODS: In this observational study, we asked 174 first-year medical students about their emotional state upon arrival to the simulation lab (t1). They were then trained on a standard simulation scenario, after which they rated their emotional state and perceived cognitive load (t2). After debriefing, we then asked them to again rate their emotions and cognitive load (t3). RESULTS: Students reported that their experience of tranquility (a positive and low-arousal state) dropped from pre-scenario (t1) to post-scenario (t2), and returned to baseline levels after debriefing (t3), from 0.69 (0.87) to 0.14 (0.78) to 0.62 (0.78). Post scenario cognitive load was rated to be moderately high at 6.62 (1.12) and scores increased after debriefing to 6.90 (1.05) d = 0.26, p < 0.001. Cognitive load was associated with the simultaneous measures of emotions at both t2 and t3. CONCLUSIONS: Participant emotions are significantly altered through the experience of medical simulation and emotions are associated with subjective ratings of cognitive load.

How can we reduce bias during an academic assessment reappraisal?

Aims: To describe potential sources of bias during an academic assessment reappraisal and ways to mitigate these. Methods: We describe why the typical scenario of an academic assessment reappraisal - where committee members are asked to weigh contrasting accounts of past events that they did not witness, and to rate elusive constructs, such as "fairness" - is prone to multiple types of bias, including attribute substitution, default bias, confirmation bias, and impact bias. We also discuss how increased awareness of sources of bias and of debiasing strategies can improve the validity of decision making. Results: Strategies that can reduce bias in reappraisal include clearly articulating and focusing on the reappraisal question (did bias cause a wrong decision to be made?), educating those involved in the reappraisal of the types of bias that frequently occur in teaching and assessment (including biases that they themselves may introduce to the reappraisal), and ensuring that those involved in the reappraisal contribute equally to making decisions and recommendation. Conclusions: All academic assessments of students, particularly those that involve subjective ratings of performance, are prone to bias, which threatens the integrity of the assessment process. Given the high stakes of academic assessments, we feel that each medical school should have a process for assessment reappraisal that reduces, rather than compounds, the likelihood of wrong assessment decisions.