Virtual reality simulation to enhance advanced trauma life support trainings - a randomized controlled trial.

BACKGROUND: Advanced Trauma Life Support (ATLS) is the gold standard of initial assessment of trauma patients and therefore a widely used training program for medical professionals. Practical application of the knowledge taught can be challenging for medical students and inexperienced clinicians. Simulation-based training, including virtual reality (VR), has proven to be a valuable adjunct to real-world experiences in trauma education. Previous studies have demonstrated the effectiveness of VR simulations for surgical and technical skills training. However, there is limited evidence on VR simulation training specifically for trauma education, particularly within the ATLS curriculum. The purpose of this pilot study is to evaluate the feasibility, effectiveness, and acceptance of using a fully immersive VR trauma simulation to prepare medical students for the ATLS course. METHODS: This was a prospective randomised controlled pilot study on a convenience sample of advanced medical students (n = 56; intervention group with adjunct training using a commercially available semi-automated trauma VR simulation, n = 28, vs control group, n = 28) taking part in the ATLS course of the Military Physician Officer School. Feasibility was assessed by evaluating factors related to technical factors of the VR training (e.g. rate of interruptions and premature termination). Objective and subjective effectiveness was assessed using confidence ratings at four pre-specified points in the curriculum, validated surveys, clinical scenario scores, multiple choice knowledge tests, and ATLS final clinical scenario and course pass rates. Acceptance was measured using validated instruments to assess variables of media use (Technology acceptance, usability, presence and immersion, workload, and user satisfaction). RESULTS: The feasibility assessment demonstrated that only one premature termination occurred and that all remaining participants in the intervention group correctly stabilised the patient. No significant differences between the two groups in terms of objective effectiveness were observed (p = 0.832 and p = 0.237 for the pretest and final knowledge test, respectively; p = 0.485 for the pass rates for the final clinical scenario on the first attempt; all participants passed the ATLS course). In terms of subjective effectiveness, the authors found significantly improved confidence post-VR intervention (p < .001) in providing emergency care using the ATLS principles. Perceived usefulness in the TEI was stated with a mean of 4 (SD 0.8; range 0-5). Overall acceptance and usability of the VR simulation was rated as positive (System Usability Scale total score mean 79.4 (SD 11.3, range 0-100). CONCLUSIONS: The findings of this prospective pilot study indicate the potential of using VR trauma simulations as a feasible and acceptable supplementary tool for the ATLS training course. Where objective effectiveness regarding test and scenario scores remained unchanged, subjective effectiveness demonstrated improvement. Future research should focus on identifying specific scenarios and domains where VR can outperform or enhance traditional learning methods in trauma simulation.

Supplementary value and diagnostic performance of computed tomography scout view in the detection of thoracolumbar spine injuries.

PURPOSE: Assessing the diagnostic performance and supplementary value of whole-body computed tomography scout view (SV) images in the detection of thoracolumbar spine injuries in early resuscitation phase and identifying frequent image quality confounders. METHODS: In this retrospective database analysis at a tertiary emergency center, three blinded senior experts independently assessed SV to detect thoracolumbar spine injuries. The findings were categorized according to the AO Spine classification system. Confounders impacting SV image quality were identified. The suspected injury level and severity, along with the confidence level, were indicated. Diagnostic performance was estimated using the caret package in R programming language. RESULTS: We assessed images of 199 patients, encompassing 1592 vertebrae (T10-L5), and identified 56 spinal injuries (3.5%). Among the 199 cases, 39 (19.6%) exhibited at least one injury in the thoracolumbar spine, with 12 (6.0%) of them displaying multiple spinal injuries. The pooled sensitivity, specificity, and accuracy were 47%, 99%, and 97%, respectively. All experts correctly identified the most severe injury of AO type C. The most common image confounders were medical equipment (44.6%), hand position (37.6%), and bowel gas (37.5%). CONCLUSION: SV examination holds potential as a valuable supplementary tool for thoracolumbar spinal injury detection when CT reconstructions are not yet available. Our data show high specificity and accuracy but moderate sensitivity. While not sufficient for standalone screening, reviewing SV images expedites spinal screening in mass casualty incidents. Addressing modifiable factors like medical equipment or hand positioning can enhance SV image quality and assessment.

Prognostic models in COVID-19 infection that predict severity: a systematic review.

Current evidence on COVID-19 prognostic models is inconsistent and clinical applicability remains controversial. We performed a systematic review to summarize and critically appraise the available studies that have developed, assessed and/or validated prognostic models of COVID-19 predicting health outcomes. We searched six bibliographic databases to identify published articles that investigated univariable and multivariable prognostic models predicting adverse outcomes in adult COVID-19 patients, including intensive care unit (ICU) admission, intubation, high-flow nasal therapy (HFNT), extracorporeal membrane oxygenation (ECMO) and mortality. We identified and assessed 314 eligible articles from more than 40 countries, with 152 of these studies presenting mortality, 66 progression to severe or critical illness, 35 mortality and ICU admission combined, 17 ICU admission only, while the remaining 44 studies reported prediction models for mechanical ventilation (MV) or a combination of multiple outcomes. The sample size of included studies varied from 11 to 7,704,171 participants, with a mean age ranging from 18 to 93 years. There were 353 prognostic models investigated, with area under the curve (AUC) ranging from 0.44 to 0.99. A great proportion of studies (61.5%, 193 out of 314) performed internal or external validation or replication. In 312 (99.4%) studies, prognostic models were reported to be at high risk of bias due to uncertainties and challenges surrounding methodological rigor, sampling, handling of missing data, failure to deal with overfitting and heterogeneous definitions of COVID-19 and severity outcomes. While several clinical prognostic models for COVID-19 have been described in the literature, they are limited in generalizability and/or applicability due to deficiencies in addressing fundamental statistical and methodological concerns. Future large, multi-centric and well-designed prognostic prospective studies are needed to clarify remaining uncertainties.

Stability of Drugs Stored in Helicopters for Use by Emergency Medical Services: A Prospective Observational Study.

STUDY OBJECTIVE: Drugs stored in rescue helicopters may be subject to extreme environmental conditions. The aim of this study was to measure whether drugs stored under the real-life conditions of a Swiss helicopter emergency medical service (HEMS) would retain their potency over the course of 1 year. METHODS: A prospective, longitudinal study measuring the temperature exposure and concentration of drugs stored on 2 rescue helicopters in Switzerland over 1 year. The study drugs included epinephrine, norepinephrine, amiodarone, midazolam, fentanyl, naloxone, rocuronium, etomidate, and ketamine. Temperatures were measured inside the medication storage bags and the crew cabins at 10-minute intervals. Drug stability was measured on a monthly basis over the course of 12 months using high-performance liquid chromatography. The medications were considered stable at a minimum remaining drug concentration of 90% of the label claim. RESULTS: Temperatures ranged from -1.2 °C to 38.1 °C (29.84 °F to 100.58 °F) inside the drug storage bags. Of all the temperature measurements inside the drug storage bags, 37% lay outside the recommended storage conditions. All drugs maintained a concentration above 90% of the label claim. The observation periods for rocuronium and etomidate were shortened to 7 months because of a supply shortage of reference samples. CONCLUSION: Drugs stored under the real-life conditions of Swiss HEMS are subjected to temperatures outside the manufacturer's approved storage requirements. Despite this, all drugs stored under these conditions remained stable throughout our study. Real-life stability testing could be a way to extend drug exchange intervals.

Diagnostic accuracy of a pragmatic, ultrasound-based approach to adult patients with suspected acute appendicitis in the ED.

BACKGROUND: Systematic imaging reduces the rate of missed appendicitis and negative appendectomies in patients with suspected acute appendicitis (AA). Little is known about the utility of ultrasound as a first diagnostic measure in patients with suspected AA. The aim of this retrospective study is to determine whether ultrasound, performed by emergency physicians or radiologists, can be used as first diagnostic measure in suspected cases to rule out AA and to avoid unnecessary CT. METHODS: We performed a retrospective analysis at the ED of the University Hospital Bern, Switzerland, from 2012 to 2014. Our standard protocol is that all adult patients suspected of appendicitis receive an ultrasound as their first imaging test, either by an emergency physician or a radiologist. The test characteristics of conclusive and inconclusive ultrasound exams were compared with a pragmatic gold standard. RESULTS: The study included 508 patients with suspected AA. 308 patients (60.4%) had a conclusive ultrasound. Among these, sensitivity for appendicitis was 89.6% (95% CI 82.1% to 94.3%), specificity 93.8% (89.1% to 96.6%), the positive predictive value was 87.98 (80.84 to 92.71) and the negative predictive value was 94.65 (91.18 to 96.80). The remaining 200 (39.4%) patients had an inconclusive ultrasound exam. 29% (59/200) of these patients ultimately had appendicitis. Less experienced emergency physician sonographers came to a definitive conclusion in 48.1% (95% CI 36.9% to 59.5%), experienced emergency physician sonographers in 76.0% (68.4% to 82.5%) and radiologists in 52.4% (44.5% to 60.2%). CONCLUSION: A conclusive ultrasound of the appendix performed by either emergency physicians or radiologists is a sensitive and specific exam to diagnose or exclude AA in patients with suspected AA. Because of 6% false negative exams, clinical follow-up is mandatory for patients with negative ultrasound. An inconclusive ultrasound warrants further imaging or a follow-up visit, since 29% of patients with inconclusive ultrasound had an AA.

Frequency and predictors of unspecific medical diagnoses in the emergency department: a prospective observational study.

BACKGROUND: Misdiagnosis is a major public health problem, causing increased morbidity and mortality. In the busy setting of an emergency department (ED) patients are diagnosed under difficult circumstances. As a consequence, the ED diagnosis at hospital admittance may often be a descriptive diagnosis, such as "decreased general condition". Our objective was to determine in how far patients with such an unspecific ED diagnosis differ from patients with a specific ED diagnosis and whether they experience a worse outcome. METHODS: We conducted a prospective observational study in Bern university hospital in Switzerland for all adult non-trauma patients admitted to any internal medicine ward from August 15th 2015 to December 7th 2015. Unspecific ED diagnoses were defined through the clinical classification software for ICD-10 by two outcome assessors. As outcome parameters, we assessed in-hospital mortality and length of hospital stay. RESULTS: Six hundred eighty six consecutive patients were included. Unspecific diagnoses were identified in 100 (14.6%) of all consultations. Patients receiving an unspecific diagnosis at ED discharge were significantly more often women (56.0% vs. 43.9%, p = 0.024), presented more often with a non-specific complaint (34% vs. 21%, p = 0.004), were less often demonstrating an abnormal heart rate (5.0% vs. 12.5%, p = 0.03), and less often on antibiotics (32.0% vs. 49.0%, p = 0.002). Apart from these, no studied drug intake, laboratory or clinical data including change in diagnosis was associated significantly with an unspecific diagnosis. Unspecific diagnoses were neither associated with in-hospital mortality in multivariable analysis (OR = 1.74, 95% CI: 0.60-5.04; p = 0.305) adjusted for relevant confounders nor with length of hospital stay (GMR = 0.87, 95% CI: 0.23-3.32; p = 0.840). CONCLUSIONS: Women and patients with non-specific presenting complaints and no abnormal heart rate are at risk of receiving unspecific ED diagnoses that do not allow for targeted treatment, discharge and prognosis. This study did not find an effect of such diagnoses on length of hospital stay nor in-hospital mortality.

Development and validation of a prognostic COVID-19 severity assessment (COSA) score and machine learning models for patient triage at a tertiary hospital.

BACKGROUND: Clinical risk scores and machine learning models based on routine laboratory values could assist in automated early identification of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients at risk for severe clinical outcomes. They can guide patient triage, inform allocation of health care resources, and contribute to the improvement of clinical outcomes. METHODS: In- and out-patients tested positive for SARS-CoV-2 at the Insel Hospital Group Bern, Switzerland, between February 1st and August 31st ('first wave', n = 198) and September 1st through November 16th 2020 ('second wave', n = 459) were used as training and prospective validation cohort, respectively. A clinical risk stratification score and machine learning (ML) models were developed using demographic data, medical history, and laboratory values taken up to 3 days before, or 1 day after, positive testing to predict severe outcomes of hospitalization (a composite endpoint of admission to intensive care, or death from any cause). Test accuracy was assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: Sex, C-reactive protein, sodium, hemoglobin, glomerular filtration rate, glucose, and leucocytes around the time of first positive testing (- 3 to + 1 days) were the most predictive parameters. AUROC of the risk stratification score on training data (AUROC = 0.94, positive predictive value (PPV) = 0.97, negative predictive value (NPV) = 0.80) were comparable to the prospective validation cohort (AUROC = 0.85, PPV = 0.91, NPV = 0.81). The most successful ML algorithm with respect to AUROC was support vector machines (median = 0.96, interquartile range = 0.85-0.99, PPV = 0.90, NPV = 0.58). CONCLUSION: With a small set of easily obtainable parameters, both the clinical risk stratification score and the ML models were predictive for severe outcomes at our tertiary hospital center, and performed well in prospective validation.

Differential diagnosis checklists reduce diagnostic error differentially: A randomised experiment.

INTRODUCTION: Wrong and missed diagnoses contribute substantially to medical error. Can a prompt to generate alternative diagnoses (prompt) or a differential diagnosis checklist (DDXC) increase diagnostic accuracy? How do these interventions affect the diagnostic process and self-monitoring? METHODS: Advanced medical students (N = 90) were randomly assigned to one of four conditions to complete six computer-based patient cases: group 1 (prompt) was instructed to write down all diagnoses they considered while acquiring diagnostic test results and to finally rank them. Groups 2 and 3 received the same instruction plus a list of 17 differential diagnoses for the chief complaint of the patient. For half of the cases, the DDXC contained the correct diagnosis (DDXC+), and for the other half, it did not (DDXC-; counterbalanced). Group 4 (control) was only instructed to indicate their final diagnosis. Mixed-effects models were used to analyse results. RESULTS: Students using a DDXC that contained the correct diagnosis had better diagnostic accuracy, mean (standard deviation), 0.75 (0.44), compared to controls without a checklist, 0.49 (0.50), P < 0.001, but those using a DDXC that did not contain the correct diagnosis did slightly worse, 0.43 (0.50), P = 0.602. The number and relevance of diagnostic tests acquired were not affected by condition, nor was self-monitoring. However, participants spent more time on a case in the DDXC-, 4:20 min (2:36), P ≤ 0.001, and DDXC+ condition, 3:52 min (2:09), than in the control condition, 2:59 min (1:44), P ≤ 0.001. DISCUSSION: Being provided a list of possible diagnoses improves diagnostic accuracy compared with a prompt to create a differential diagnosis list, if the provided list contains the correct diagnosis. However, being provided a diagnosis list without the correct diagnosis did not improve and might have slightly reduced diagnostic accuracy. Interventions neither affected information gathering nor self-monitoring.

Do different response formats affect how test takers approach a clinical reasoning task? An experimental study on antecedents of diagnostic accuracy using a constructed response and a selected response format.

The use of response formats in assessments of medical knowledge and clinical reasoning continues to be the focus of both research and debate. In this article, we report on an experimental study in which we address the question of how much list-type selected response formats and short-essay type constructed response formats are related to differences in how test takers approach clinical reasoning tasks. The design of this study was informed by a framework developed within cognitive psychology which stresses the importance of the interplay between two components of reasoning-self-monitoring and response inhibition-while solving a task or case. The results presented support the argument that different response formats are related to different processing behavior. Importantly, the pattern of how different factors are related to a correct response in both situations seem to be well in line with contemporary accounts of reasoning. Consequently, we argue that when designing assessments of clinical reasoning, it is crucial to tap into the different facets of this complex and important medical process.

Challenges of students and residents of human medicine in the first four months of the fight against the Covid-19 pandemic - Implications for future waves and scenarios.

INTRODUCTION: In the fight against the Covid-19 pandemic, medical students and residents are expected to adapt and contribute in a healthcare environment characterized by ever-changing measures and policies. The aim of this narrative review is to provide a summary of the literature that addresses the challenges of students and residents of human medicine in the first 4 months of the fight against the Covid-19 pandemic in order to identify gaps and find implications for improvement within the current situation and for potential future scenarios. METHODS: We performed a systematic literature search and content analysis (CA) of articles available in English language that address the challenges of students and residents of human medicine in the first 4 months of the fight against the Covid-19 pandemic. RESULTS: We retrieved 82 articles from a wide range of journals, professional backgrounds and countries. CA identified five recurring subgroup topics: "faculty preparation", «uncertainties and mental health¼, «clinical knowledge¼, «rights and obligations¼ and «(self-) support and supply¼. Within these subgroups the main concerns of (re-)deployment, interruption of training and career, safety issues, transmission of disease, and restricted social interaction were identified as potential stressors that hold a risk for fatigue, loss of morale and burnout. DISCUSSION: Students and residents are willing and able to participate in the fight against Covid-19 when provided with appropriate deployment, legal guidance, safety measures, clinical knowledge, thorough supervision, social integration and mental health support. Preceding interviews to decide on reasonable voluntary deployment, the use of new technology and frequent feedback communication with faculties, educators and policymakers can further help with a successful and sustainable integration of students and residents in the fight against the pandemic. CONCLUSION: It is critical that faculties, educators and policymakers have a thorough understanding of the needs and concerns of medical trainees during pandemic times. Leaders should facilitate close communication with students and residents, value their intrinsic creativeness and regularly evaluate their needs in regards to deployment, knowledge aspects, safety measures, legal concerns and overall well-being.

Man or machine? Impact of tutor-guided versus simulator-guided short-time bronchoscopy training on students learning outcomes.

BACKGROUND: Simulation based medical education is efficient for the acquisition of flexible bronchoscopy navigational skills and the knowledge of the tracheobronchial anatomy. However, bronchoscopy simulator training is not routinely integrated into pneumologic fellowship programs or undergraduate medical education for time and/or cost reasons. Our study compares the effect of self-guided bronchoscopy simulator training versus tutor guided training on the acquisition of navigational skills and knowledge of the bronchial anatomy. METHODS: Third-year undergraduate medical students were randomized to either a tutor- or simulator guided bronchoscopy simulator training focusing on the acquisition of navigational skills and the knowledge of the tracheobronchial anatomy. Every student performed a baseline bronchoscopy followed by a structured bronchoscopy simulator training and finally an assessment bronchoscopy at the end of the training program. Groups were compared by means of a repeated measurement ANOVA and effect sizes calculated as Cohens' d. RESULTS: Fifty-four eligible students participated in the study. Knowledge of the tracheobronchial anatomy significantly increased from pre- to post training (all p < 0.001; all d > 2), navigational skills significantly decreased (all p < 0.005; all d < 1). There were no significant differences between groups. Instruction by the simulator as well as by the tutor was rated as helpful by the students. Twenty-two (84.6%) of the participants of the simulator guided group would have appreciated an additional instruction by a tutor. CONCLUSION: Short-time simulator guided bronchoscopy training improves knowledge of the tracheobronchial anatomy in novice bronchoscopists as much as tutor guided training, but navigational skills seem to worsen in both groups. Further studies assessing transfer to clinical practice are needed to find the optimal teaching method for basic flexible bronchoscopy.

Online forward triage during the COVID-19 outbreak.

Health systems face major challenges during the COVID-19 pandemic with new information and challenges emerging daily and frequently changing guidelines. Online forward triage tools (OFTTs) provide useful information, direct patients and free physician resources.We implemented an OFTT targeted at the current pandemic, adapted the content and goals and assessed its effects. The OFTT was implemented on 2 March 2020 and modified regularly based on the revised testing criteria issued by the Swiss Federal Office of Public Health. After testing criteria liberalised, a chatbot tool was set up on 9 April 2020 to assess urgency of testing, referral to available testing sites and need for emergency care.In the first 40 days of the OFTT, there were more than 17 300 visitors and 69.8% indicated they would have contacted the healthcare system if the online test had not been available. During the initial week of operation, using the conservative testing strategy, 9.1% of visitors received recommendations to be tested, which increased to 36.0% of visitors after a change in testing criteria on 9 March 2020. Overall, since the implementation of the tool, 26.27% of all users of the site have been directed to obtain testing. The Chatbot tool has had approximately 50 consults/day.Setting up an OFTT should be considered as part of local strategies to cope with the COVID-19 pandemic. It may ease the burden on the healthcare system, reassure patients and inform authorities. To account for the dynamic development of the pandemic, frequent adaptation of the tool is of great importance. Further research on clinical outcomes of OFTT is urgently needed.

A dangerously underrated entity? Non-specific complaints at emergency department presentation are associated with utilisation of less diagnostic resources.

BACKGROUND: Patients presenting with non-specific complaints (NSC), such as generalised weakness, or feeling unwell, constitute about 20% of emergency care consultations. In contrast to patients presenting with specific symptoms, these patients experience more hospitalisations, longer stays in hospital and even higher mortality. However, little is known about the actual resources spent on patients with NSC in the emergency department (ED). METHODS: We have conducted a retrospective analysis from January 1st, 2013 until December 31st, 2017 in a Swiss tertiary care ED to assess the impact of NSC on the utilisation of diagnostic resources in adult patients with highlyurgent or urgent medical complaints. RESULTS: We randomly selected 1500 medical consultations from our electronic health record database: The majority of patients (n = 1310, 87.3%) presented with a specific complaint; n = 190 (12.7%) with a NSC. Univariate analysis showed no significant difference in the utilisation of total diagnostic resources in the ED [specific complaints: 844 (577-1313) vs. NSC: 778 (551-1183) tax points, p = 0.092, median (interquartile range)]. A backward selection logistic regression model was adjusted for the identified covariates (age, diabetes, cerebrovascular and liver disease, malignancy, past myocardial infarction, antihypertensive, antithrombotic or antidiabetic medication, night or weekend admission and triage category). This identified a significant association of NSC with lower utilisation of ED diagnostic resources [geometric mean ratio (GMR) 0.91, 95% CI: 0.84-0.99, p = 0.042]. CONCLUSIONS: Non-specific complaints (NSC) are a frequent reason for emergency medicine consultations and are associated with lower utilisation of diagnostic resources during ED diagnostic testing than with specific complaints.

Anemia and iron metabolism in COVID-19: a systematic review and meta-analysis.

Iron metabolism and anemia may play an important role in multiple organ dysfunction syndrome in Coronavirus disease 2019 (COVID-19). We conducted a systematic review and meta-analysis to evaluate biomarkers of anemia and iron metabolism (hemoglobin, ferritin, transferrin, soluble transferrin receptor, hepcidin, haptoglobin, unsaturated iron-binding capacity, erythropoietin, free erythrocyte protoporphyrine, and erythrocyte indices) in patients diagnosed with COVID-19, and explored their prognostic value. Six bibliographic databases were searched up to August 3rd 2020. We included 189 unique studies, with data from 57,563 COVID-19 patients. Pooled mean hemoglobin and ferritin levels in COVID-19 patients across all ages were 129.7 g/L (95% Confidence Interval (CI), 128.51; 130.88) and 777.33 ng/mL (95% CI, 701.33; 852.77), respectively. Hemoglobin levels were lower with older age, higher percentage of subjects with diabetes, hypertension and overall comorbidities, and admitted to intensive care. Ferritin level increased with older age, increasing proportion of hypertensive study participants, and increasing proportion of mortality. Compared to moderate cases, severe COVID-19 cases had lower hemoglobin [weighted mean difference (WMD), - 4.08 g/L (95% CI - 5.12; - 3.05)] and red blood cell count [WMD, - 0.16 × 1012 /L (95% CI - 0.31; - 0.014)], and higher ferritin [WMD, - 473.25 ng/mL (95% CI 382.52; 563.98)] and red cell distribution width [WMD, 1.82% (95% CI 0.10; 3.55)]. A significant difference in mean ferritin levels of 606.37 ng/mL (95% CI 461.86; 750.88) was found between survivors and non-survivors, but not in hemoglobin levels. Future studies should explore the impact of iron metabolism and anemia in the pathophysiology, prognosis, and treatment of COVID-19.

Self-monitoring accuracy does not increase throughout undergraduate medical education.

CONTEXT: Accurate self-assessment of one's performace on a moment-by-moment basis (ie, accurate self-monitoring) is vital for the self-regulation of practising physicians and indeed for the effective regulation of self-directed learning during medical education. However, little is currently known about the functioning of self-monitoring and its co-development with medical knowledge across medical education. This study is the first to simultaneously investigate a number of relevant aspects and measures that have so far been studied separately: different measures of self-monitoring for a broad area of medical knowledge across 10 different performance levels. METHODS: This study assessed the self-monitoring accuracy of medical students (n = 3145) across 10 semesters. Data collected during the administration of the formative Berlin Progress Test Medicine (PTM) were analysed. The PTM comprises 200 multiple-choice questions covering all major medical disciplines and organ systems. A self-report indicator (ie, confidence) and two behavioural indicators of self-monitoring accuracy (ie, response time and the likelihood of changing an initial answer to a correct rather than an incorrect item) were examined for their development over semesters. RESULTS: Analyses of more than 390 000 observations (of approximately 250 students per semester) showed that confidence was higher for correctly than for incorrectly answered items and that 86% of items answered with high confidence were indeed correct. Response time and the likelihood of the initial answer being changed were higher when the initial answer was incorrect than when it was correct. Contrary to expectations, no differences in self-monitoring accuracy were observed across semesters. CONCLUSIONS: Convergent evidence from different measures of self-monitoring suggests that medical students self-monitor their knowledge on a question-by-question basis well, although not perfectly, and to the same degree as has been found in studies outside medicine. Despite large differences in performance, no variations in self-monitoring across semesters (with the exception of the first semester) were observed.

An observational study of self-monitoring in ad hoc health care teams.

BACKGROUND: Working in ad hoc teams in a health care environment is frequent but a challenging and complex undertaking. One way for teams to refine their teamwork could be through post-resuscitation reflection and debriefing. However, this would require that teams have insight into the quality of their teamwork. This study investigates (1) the accuracy of the self-monitoring of ad hoc resuscitation teams and their leaders relative to external observations of their teamwork and (2) the relationship of team self-monitoring and external observations to objective performance measures. METHODS: We conducted a quantitative observational study of real-world ad hoc interprofessional teams responding to a simulated cardiac arrest in an emergency room. Teams consisting of residents, consultants, and nurses were confronted with an unexpected, simulated, standardized cardiac arrest situation. Their teamwork was videotaped to allow for subsequent external evaluation on the team emergency assessment measure (TEAM) checklist. In addition, objective performance measures such as time to defibrillation were collected. All participants completed a demographic questionnaire prior to the simulation and a questionnaire tapping their perceptions of teamwork directly after it. RESULTS: 22 teams consisting of 115 health care professionals showed highly variable performance. All performance measures intercorrelated significantly, with the exception of team leaders' evaluations of teamwork, which were not related to any other measures. Neither team size nor cumulative experience were correlated with any measures, but teams led by younger leaders performed better than those led by older ones. CONCLUSION: Team members seem to have better insight into their team's teamwork than team leaders. As a practical consequence, the decision to debrief and the debriefing itself after a resuscitation should be informed by team members, not just leaders.

What determines diagnostic resource consumption in emergency medicine: patients, physicians or context?

OBJECTIVES: A major cause for concern about increasing ED visits is that ED care is expensive. Recent research suggests that ED resource consumption is affected by patients' health status, varies between physicians and is context dependent. The aim of this study is to determine the relative proportion of characteristics of the patient, the physician and the context that contribute to ED resource consumption. METHODS: Data on patients, physicians and the context were obtained in a prospective observational cohort study of patients hospitalised to an internal medicine ward through the ED of the University Hospital Bern, Switzerland, between August and December 2015. Diagnostic resource consumption in the ED was modelled through a multilevel mixed effects linear regression. RESULTS: In total, 473 eligible patients seen by one of 38 physicians were included in the study. Diagnostic resource consumption heavily depends on physicians' ratings of case difficulty (p<0.001, z-standardised regression coefficient: 147.5, 95% CI 87.3 to 207.7) and-less surprising-on patients' acuity (p<0.001, 126.0, 95% CI 65.5 to 186.6). Neither the physician per se, nor their experience, the patients' chronic health status or the context seems to have a measurable impact (all p>0.05). CONCLUSIONS: Diagnostic resource consumption in the ED is heavily affected by physicians' situational confidence. Whether we should aim at altering physician confidence ultimately depends on its calibration with accuracy.

Accuracy of self-monitoring: does experience, ability or case difficulty matter?

CONTEXT: The ability to self-monitor one's performance in clinical settings is a critical determinant of safe and effective practice. Various studies have shown this form of self-regulation to be more trustworthy than aggregate judgements (i.e. self-assessments) of one's capacity in a given domain. However, little is known regarding what cues inform learners' self-monitoring, which limits an informed exploration of interventions that might facilitate improvements in self-monitoring capacity. The purpose of this study is to understand the influence of characteristics of the individual (e.g. ability) and characteristics of the problem (e.g. case difficulty) on the accuracy of self-monitoring by medical students. METHODS: In a cross-sectional study, 283 medical students from 5 years of study completed a computer-based clinical reasoning exercise. Confidence ratings were collected after completing each of six cases and the accuracy of self-monitoring was considered to be a function of confidence when the eventual answer was correct relative to when the eventual answer was incorrect. The magnitude of that difference was then explored as a function of year of seniority, gender, case difficulty and overall aptitude. RESULTS: Students demonstrated accurate self-monitoring by virtue of giving higher confidence ratings (57.3%) and taking a shorter time to work through cases (25.6 seconds) when their answers were correct relative to when they were wrong (41.8% and 52.0 seconds, respectively; p< 0.001 and d > 0.5 in both instances). Self-monitoring indices were related to student seniority and case difficulty, but not to overall ability or student gender. CONCLUSIONS: This study suggests that the accuracy of self-monitoring is context specific, being heavily influenced by the struggles students experience with a particular case rather than reflecting a generic ability to know when one is right or wrong. That said, the apparent capacity to self-monitor increases developmentally because increasing experience provides a greater likelihood of success with presented problems.