Thresholds of becoming: an exploration of threshold concepts as a means to support professional identity formation in competency-based curricula.

Inherent in every clinical preceptor's role is the ability to understand the learning needs of individual trainees, enabling them to meet their potential. Competency-based medical education frameworks have been developed to this end, but efforts to identify behaviours and activities that define competence are based on mapping knowledge, skills and ability, which can be difficult to integrate into a comprehensive picture of who the trainee is becoming. Professional identity formation, in contrast, prioritizes attention to who trainees are becoming, but provision of detailed guidance to preceptors on how to best support this form of development is challenging. The tension that results limits our ability to optimally support learners as strengths in competency development may mask professional identity development gaps and vice versa. To address this tension, this paper examines how the theory of threshold concepts - troublesome ideas that, once appreciated, fundamentally change how you understand and approach a particular activity - can shine light on professional identity formation and its relationship with developing competence. The recognition and identification of threshold concepts is offered as a means to improve our ability to identify, discuss and support behaviours and actions that impact the learner's capacity to act competently as they develop their identity at various stages of training.

Emergency department visits and hospital admissions for suicidal ideation, self-poisoning and self-harm among adolescents in Canada during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic had profound effects on the mental wellbeing of adolescents. We sought to evaluate pandemic-related changes in health care use for suicidal ideation, self-poisoning and self-harm. METHODS: We obtained data from the Canadian Institute for Health Information on emergency department visits and hospital admissions from April 2015 to March 2022 among adolescents aged 10-18 years in Canada. We calculated the quarterly percentage of emergency department visits and hospital admissions for a composite outcome comprising suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits and hospital admissions. We used interrupted time-series methods to compare changes in levels and trends of these outcomes between the prepandemic (Apr. 1, 2015-Mar. 1, 2020) and pandemic (Apr. 1, 2020-Mar. 31, 2022) periods. RESULTS: The average quarterly percentage of emergency department visits for suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits was 2.30% during the prepandemic period and 3.52% during the pandemic period. The level (0.08%, 95% confidence interval [CI] -0.79% to 0.95%) or trend (0.07% per quarter, 95% CI -0.14% to 0.28%) of this percentage did not change significantly between periods. The average quarterly percentage of hospital admissions for the composite outcome relative to all-cause admissions was 7.18% during the prepandemic period and 8.96% during the pandemic period. This percentage showed no significant change in level (-0.70%, 95% CI -1.90% to 0.50%), but did show a significantly increasing trend (0.36% per quarter; 95% 0.07% to 0.65%) during the pandemic versus prepandemic periods, specifically among females aged 10-14 years (0.76% per quarter, 95% CI 0.22% to 1.30%) and females aged 15-18 years (0.56% per quarter, 95% CI 0.31% to 0.81%). INTERPRETATION: The quarterly change in the percentage of hospital admissions for suicidal ideation, self-poisoning and self-harm increased among adolescent females in Canada during the first 2 years of the COVID-19 pandemic. This underscores the need to promote public health policies that mitigate the impact of the pandemic on adolescent mental health.

Visits to Alberta Emergency Departments for Child Mental Health Concerns During the COVID-19 Pandemic: An Examination of Visit Trends in Relation to School Closures and Reopenings.

OBJECTIVE: We examined emergency department (ED) mental health visit trends by children in relation to periods of school closure and reopening during the COVID-19 pandemic in Alberta, Canada. METHODS: Mental health visits by school-aged children (5 to <18 years) were extracted from the Emergency Department Information System, a province-wide database, from March 11, 2020, to November 30, 2021 (pandemic period; n = 18,997) and March 1, 2019, to March 10, 2020 (1-year, prepandemic comparator period; n = 11,540). We calculated age-specific visit rates and compared rate differences between periods of school closure (March 15-June 30, 2020; November 30, 2020-January 10, 2021; April 22-June 30, 2021) and reopening (September 4-November 29, 2020; January 11-April 21, 2021; September 3-November 30, 2021) to matched prepandemic periods. We used a ratio of relative risk to examine the risk of a visit during closures versus reopenings. RESULTS: The cohort included 11,540 prepandemic visits and 18,997 pandemic visits. Compared with prepandemic periods, ED visit rates increased across all ages during the first (+85.53%; 95% confidence interval [CI], 73.68% to 100.41%) and third (+19.92%; 95% CI, 13.28% to 26.95%) school closures, and decreased during the second closure (-15.37%; 95% CI, -22.22% to -7.92%). During school reopenings, visit rates decreased across all ages during the first reopening (-9.30%; 95% CI, -13.94% to -4.41%) and increased during the third reopening (+13.59%; 95% CI, 8.13% to 19.34%); rates did not change significantly during the second reopening (2.54%; 95% CI, -3.45% to 8.90%). The risk of a visit during school closure versus reopening was only higher for the first closure with 2.06 times the risk (95% CI, 1.88 to 2.25). CONCLUSIONS: Emergency department mental health visit rates were highest during the first school closure of the COVID-19 pandemic, and the risk of a visit during this closure period was twice compared with when schools first reopened.

Review: Patient engagement in child, adolescent, and youth mental health care research - a scoping review.

BACKGROUND: Youth and children's lived experiences are rarely considered in studies seeking to improve or evaluate their mental health care. We conducted a scoping review to identify approaches to child, adolescent, and youth engagement in mental health studies as well as study-reported barriers, constraints, and facilitators to engagement. METHOD: We systematically searched six electronic databases for literature. We included studies of mental health care service design, development, or evaluation that involved engagement of children, adolescents, and/or youth with mental disorders or who intentionally self-harm. Studies could be of any design as long as patient engagement was used at any point during its design and/or conduct. Engagement could include co-designing health services/interventions and/or participating as a co-researcher. We assessed the reporting of patient engagement using the Guidance for Reporting Involvement of Patients and the Public 2 Long-Form (GRIPP2-LF) checklist and used the Experience Based Co-design (EBCD) framework to guide data extraction and analysis. RESULTS: Sixteen articles were included in the review. Most studies used engagement to develop or adapt a mental health service (75%) and utilized a participatory or co-design approach (69%). Participants were namely adolescents and youth (aged 10-24 years) with some studies including young adults (up to 29 years old). Most studies followed less than 50% of the EBCD framework, and the commonly reported study barriers were related to aspects addressed in EBCD: time restrictions, recruitment, and generalizability. Frequently reported study facilitators included study methodology, youth engagement, and having a diverse participant sample. CONCLUSIONS: Findings from this review suggest that the EBCD framework is not commonly used to guide patient engagement in studies of mental health care services. Future initiatives should consider following the framework to ensure meaningful evaluation and improvements to youth and children's mental health care services.

Utility of MyHEARTSMAP in Youth Presenting to the Emergency Department with Mental Health Concerns.

OBJECTIVES: To evaluate the utility of a digital psychological self-assessment tool, MyHEARTSMAP (scores on 10 sections: home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources), in youth presenting to the pediatric emergency department (ED) with a mental health concern. STUDY DESIGN: We conducted a prospective cohort study in 2 tertiary care pediatric EDs from December 2017 to October 2019. Youth 10-17 years old triaged for a mental health concern were screened and enrolled to complete MyHEARTSMAP on a mobile device. A clinician blinded to the MyHEARTSMAP assessment conducted their own assessment which was used as the reference standard. Utility was quantified as the sensitivity and specificity of MyHEARTSMAP in detecting psychiatric, social, youth health, and functional concerns. RESULTS: Among 379 eligible youth, 351 were approached and 233 (66.4%) families were enrolled. Sensitivity for youth MyHEARTSMAP self-assessments ranged from 87.4% in the youth health domain to 99.5% in the psychiatric domain for identifying any concern, and 33.3% in the social domain to 74.6% in the psychiatric domain for severe concerns. Specificity ranged from 66.7% in the psychiatric domain to 98.2% in the youth health domain for no or only mild concerns. CONCLUSIONS: Youth and guardian MyHEARTSMAP assessments are sensitive for detecting psychosocial concerns requiring follow-up beyond pediatric ED evaluation. Specificity for no or only mild concerns was high in the nonpsychiatric domains.

"What is the actual goal of the pathway?": examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework.

BACKGROUND: Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion. METHODS: Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation. RESULTS: The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2-4 predominant topics that can be condensed into six overarching themes regarding clinicians' views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes. CONCLUSION: Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

The impact of humanoid robot presence in the paediatric emergency department waiting room: A prospective cohort study.

BACKGROUND: The waiting room represents families' first point of contact with the emergency department (ED). We wished to study if a humanoid robot technology presence in the waiting room would improve satisfaction and decrease anxiety for caregivers in the paediatric ED. METHODS: This observational cohort study was conducted from September to December 2018 at a Canadian paediatric ED. All caregivers and children >11 years in the ED waiting room were eligible. We compared a robotic intervention (RI) to standard of care (SOC) education in the waiting room. The RI was a 5-minute psychoeducational program describing the ED process and flow. Specific days were designated for RI or SOC. An anonymous survey was administered twice, at the same times, on both SOC and RI days. The primary outcomes were (a) caregiver satisfaction with waiting room experience using a 5-point Likert scale; and (b) caregiver-reported anxiety in the waiting room, as measured by the State Trait Anxiety Inventory - State Scale. RESULTS: Six hundred and thirty-three caregivers participated, with a median age of 37 years (IQR 32 to 42); 80 children participated, with a median age of 15 years (IQR 13 to 16). Caregivers reported greater overall satisfaction in the RI cohort (174/200, 87.0%) compared to the SOC cohort (144/229, 62.9%; P<0.0001). Caregivers also reported lower anxiety in the RI cohort (39.38±11.38) compared to the SOC cohort (42.04±11.99; P=0.009). CONCLUSIONS: A humanoid robot-based psycho educational intervention in the paediatric ED waiting room has a positive impact on caregiver satisfaction and anxiety.

Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department.

OBJECTIVES: To evaluate the utility of universal psychosocial screening in the emergency department (ED) using MyHEARTSMAP, a digital self-assessment and management guiding tool. STUDY DESIGN: We conducted a cohort study of youth 10-17 years of age with nonmental health related presentations at 2 pediatric EDs. On randomly selected shifts (December 2017-February 2019), participants completed their psychosocial self-assessments using MyHEARTSMAP on a mobile device, then underwent a standardized clinical mental health assessment (criterion standard). We reported the sensitivity and specificity of respondents' self-assessment, against a clinician's standard emergency psychosocial assessment, and the frequency of psychosocial issues and recommended mental health resources identified by screening. RESULTS: We approached 1432 eligible youth, among which 795 youth consented to participate (55.5%). Youth and guardians' sensitivity at self-identifying psychiatric concerns was 92.7% (95% CI 89.1, 95.4%) and 93.1% (95% CI 89.5, 95.8%), respectively. In cases where clinicians had determined to be no psychiatric issues, 98.5% (95% CI 96.7, 99.4%) of youth and 98.9% (95% CI 97.3, 99.7%) of guardians identified the youth as having no or only mild issues. Screening identified 36.4% of youth as having issues in at least 1 psychosocial domain which warranted further follow-up. CONCLUSIONS: Psychosocial screening in EDs using MyHEARTSMAP can reliably be conducted using the MyHEARTSMAP self-assessment tool and over one-third of screened youth identified issues which can be directed to further care.

A sensitive and cost-effective high-performance liquid chromatography/tandem mass spectrometry (multiple reaction monitoring) method for the clinical measurement of serum hepcidin.

RATIONALE: Hepcidin is a peptide hormone that plays a central role in regulating iron metabolism. It is a potential biomarker for the diagnosis, monitoring and treatment of iron metabolism disorders. Serum hepcidin level can differ by 3 orders of magnitude depending on the patient's condition. Existing liquid chromatography/mass spectrometry (LC/MS) assays lack clinical sensitivity or require costly sample preparation steps. A simple, sensitive, robust and cost-effective assay for serum hepcidin quantitation in routine clinical laboratories is needed. METHODS: A high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS) method was developed to quantify hepcidin in human serum using chemically synthesized hepcidin as a standard and stable-isotope-labeled hepcidin as the internal standard. The method was validated according to CLSI-C62A guidelines. Calibrators were prepared with hepcidin-free serum. Clinical samples were separately processed and compared using solid-phase extraction (SPE) and acetonitrile (ACN) protein precipitation. RESULTS: The calibration curve was validated over the range of 0.1-100 nmol/L with R2  >0.99. Both the SPE and the ACN precipitation methods had excellent and comparable reproducibility. The intra-day and inter-day coefficients of variation (CVs) were <3% and <6%. There was 89% and 88% hepcidin recovery by SPE and ACN preparation. Measurement of secondary reference material using non-traceable calibrators yielded up to 30% positive bias, comparable with values obtained by an external comparator. Hepcidin was stable in serum at ambient temperature and at 4°C. The relative errors (REs) were ≤1.2% and ≤4.4%, respectively. The freeze-thaw (-70°C) stability after 3 cycles showed a relative error (RE) of ≤1.8%. The impact on hepcidin recovery due to hemolysis (4+), lipemia (4+) and Icterus (4+) was <3%. CONCLUSIONS: We have developed and validated a simple, sensitive, robust and cost-effective HPLC/MS/MS method for the quantitation of serum hepcidin. The method uses ACN protein precipitation for sample preparation and reversed-phase normal-flow HPLC. Sample preparation is inexpensive; it can be automated with a liquid handling system to allow high-throughput application.

The Wright table of the cardiac cycle: a stand-alone supplement to the Wiggers diagram.

The Wright table is introduced as a novel tool for teaching and learning the cardiac cycle. It supplements the nearly 100-yr-old Wiggers diagram, which is information rich but difficult for many students to learn. The Wright table offers a compact presentation of information, viewable both in terms of how 1) each compartment's pressures and flows change over time; and 2) the heart works as a pump, first filling and then emptying the ventricles, thereby moving blood from low-pressure venous to high-pressure arterial compartments. This new four-by-four display of interrelated aspects of cardiac cycle events offers a more integrated view of the phases of ventricular filling and emptying than can be easily observed in the Wiggers diagram. It also shows how ECG-related waves of depolarization and repolarization drive the events of each subsequent phase. The Wright table is a stand-alone teaching aid; however, it is designed such that weaknesses of the Wiggers diagram are complemented by strengths of the Wright table, and vice versa. Results of an anonymous student survey support the utility of the Wright table in medical education. Three modifications of the Wright table, each modeling specific cardiac conditions (i.e., paradoxical split S2 in left bundle branch block, mild aortic stenosis, and moderate aortic stenosis), are included to illustrate how the Wright table might be used in clinical training and research. In summary, the Wright table of the cardiac cycle provides new perspectives for visualization of the cardiac cycle in health and disease.

Thinking theta and alpha: Mechanisms of intuitive and analytical reasoning.

Humans have a unique ability to engage in different modes of thinking. Intuitive thinking (coined System 1, see Kahneman, 2011) is fast, automatic, and effortless whereas analytical thinking (coined System 2) is slow, contemplative, and effortful. We extend seminal pupillometry research examining these modes of thinking by using electroencephalography (EEG) to decipher their respective underlying neural mechanisms. We demonstrate that System 1 thinking is characterized by an increase in parietal alpha EEG power reflecting autonomic access to long-term memory and a release of attentional resources whereas System 2 thinking is characterized by an increase in frontal theta EEG power indicative of the engagement of cognitive control and working memory processes. Consider our results in terms of an example - a child may need cognitive control and working memory when contemplating a mathematics problem yet an adult can drive a car with little to no attention by drawing on easily accessed memories. Importantly, the unravelling of intuitive and analytical thinking mechanisms and their neural signatures will provide insight as to how different modes of thinking drive our everyday lives.

Predictors of rural family medicine practice in Canada.

OBJECTIVE: To examine the attributes of Canadian medical students at matriculation that predicted later practice in a rural location, with the goal of enhancing evidence-based approaches to increasing the numbers of rural family physicians. DESIGN: Demographic, attitudinal, and career choice data were collected from medical students at matriculation. Students were followed prospectively, and these data were linked to postresidency practice location. SETTING: Eight Canadian medical schools. PARTICIPANTS: Study participants were 15 classes of medical students entering medical school between 2002 and 2004. MAIN OUTCOME MEASURES: Backward stepwise logistic regression analysis was used to identify the entry characteristics that predicted postresidency practice as a rural family physician. RESULTS: Data from 1542 students were analyzed. A strong association was found between career interest in rural family medicine at entry into medical school and postresidency rural practice as a family physician. Logistic regression analysis that did not include entry career interest found older age, being in a relationship, having completed school in a rural community, having a societal orientation, and expressing a desire for a varied scope of practice to be predictive of practising in a rural location. When entry career interest in a rural setting was included in the multivariate model, only this variable and older age predicted postresidency rural family practice. CONCLUSION: This study identified a number of demographic and attitudinal variables at medical school entry that predict postresidency practice in a rural setting. These results suggest multiple potential areas where the pipeline to rural family practice can be further supported in order to address the shortage of rural family physicians.

Hemispheric activation differences in novice and expert clinicians during clinical decision making.

Clinical decision making requires knowledge, experience and analytical/non-analytical types of decision processes. As clinicians progress from novice to expert, research indicates decision-making becomes less reliant on foundational biomedical knowledge and more on previous experience. In this study, we investigated how knowledge and experience were reflected in terms of differences in neural areas of activation. Novice and expert clinicians diagnosed simple or complex (easy, hard) cases while functional magnetic resonance imaging (fMRI) data were collected. Our results highlight key differences in the neural areas activated in novices and experts during the clinical decision-making process. fMRI data were collected from ten second year medical students (novices) and ten practicing gastroenterologists (experts) while they diagnosed sixteen (eight easy and eight hard) clinical cases via multiple-choice questions. Behavioral data were collected for diagnostic accuracy (correct/incorrect diagnosis) and time taken to assign a clinical diagnosis. Two analyses were performed with the fMRI data. First, data from easy and hard cases were compared within respective groups (easy > hard, hard > easy). Second, neural differences between novices and experts (novice > expert, expert > novice) were assessed. Experts correctly diagnosed more cases than novices and made their diagnoses faster than novices on both easy and hard cases (all p's < 0.05). Time taken to diagnose hard cases took significantly longer for both novices and experts. While similar neural areas were activated in both novices and experts during the decision making process, we identified significant hemispheric activation differences between novice and expert clinicians when diagnosing hard clinical cases. Specifically, novice clinicians had greater activations in the left anterior temporal cortex and left ventral lateral prefrontal cortex whereas expert clinicians had greater activations in the right dorsal lateral, right ventral lateral, and right parietal cortex. Hemispheric differences in activation were not observed between novices and experts while diagnosing easy clinical cases. While clinical decision-making engaged the prefrontal cortex (PFC) in both novices and experts, interestingly we observed expertise related differences in the regions and hemispheres of PFC activation between these groups for hard clinical cases. Specifically, in novices we observed activations in left hemisphere neural regions associated with factual rule-based knowledge, whereas in experts we observed right hemisphere activation in neural regions associated with experiential knowledge. Importantly, at the neural level, our data highlight differences in so called type 2 clinical decision-making processes related to prior knowledge and experience.

Working memory, reasoning, and expertise in medicine-insights into their relationship using functional neuroimaging.

Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical reasoning and WM while participants read clinical cases with functional magnetic resonance imaging (fMRI). More specifically, we examined the impact of clinical case difficulty (easy, hard) and clinician level of expertise (2nd year medical students, senior gastroenterologists) on neural activity within regions of cortex associated with WM (i.e., the prefrontal cortex) during the reasoning process. fMRI was used to scan ten second-year medical students and ten practicing gastroenterologists while they reasoned through sixteen clinical cases [eight straight forward (easy) and eight complex (hard)] during a single 1-h scanning session. Within-group analyses contrasted the easy and hard cases which were then subsequently utilized for a between-group analysis to examine effects of expertise (novice > expert, expert > novice). Reading clinical cases evoked multiple neural activations in occipital, prefrontal, parietal, and temporal cortical regions in both groups. Importantly, increased activation in the prefrontal cortex in novices for both easy and hard clinical cases suggests novices utilize WM more so than experts during clinical reasoning. We found that clinician level of expertise elicited differential activation of regions of the human prefrontal cortex associated with WM during clinical reasoning. This suggests there is an important relationship between clinical reasoning and human WM. As such, we suggest future models of clinical reasoning take into account that the use of WM is not consistent throughout all clinical reasoning tasks, and that memory structure may be utilized differently based on level of expertise.

How do medical students form impressions of the effectiveness of classroom teachers?

CONTEXT: Teaching effectiveness ratings (TERs) are used to provide feedback to teachers on their performance and to guide decisions on academic promotion. However, exactly how raters make decisions on teaching effectiveness is unclear. OBJECTIVES: The objectives of this study were to identify variables that medical students appraise when rating the effectiveness of a classroom teacher, and to explore whether the relationships among these variables and TERs are modified by the physical attractiveness of the teacher. METHODS: We asked 48 Year 1 medical students to listen to 2-minute audio clips of 10 teachers and to describe their impressions of these teachers and rate their teaching effectiveness. During each clip, we displayed either an attractive or an unattractive photograph of an unrelated third party. We used qualitative analysis followed by factor analysis to identify the principal components of teaching effectiveness, and multiple linear regression to study the associations among these components, type of photograph displayed, and TER. RESULTS: We identified two principal components of teaching effectiveness: charisma and intellect. There was no association between rating of intellect and TER. Rating of charisma and the display of an attractive photograph were both positively associated with TER and a significant interaction between these two variables was apparent (p < 0.001). The regression coefficient for the association between charisma and TER was 0.26 (95% confidence interval [CI] 0.10-0.41) when an attractive picture was displayed and 0.83 (95% CI 0.66-1.00) when an unattractive picture was displayed (p < 0.001). CONCLUSIONS: When medical students rate classroom teachers, they consider the degree to which the teacher is charismatic, although the relationship between this attribute and TER appears to be modified by the perceived physical attractiveness of the teacher. Further studies are needed to identify other variables that may influence subjective ratings of teaching effectiveness and to evaluate alternative strategies for rating teaching effectiveness.

Filling in the gaps of clerkship with a comprehensive clinical skills curriculum.

Although the clinical clerkship model is based upon sound pedagogy, including theories of social learning and situated learning, studies evaluating clinical performance of residents suggests that this model may not fully meet the learning needs of students. Here our objective was to design a curriculum to bridge the learning gaps of the existing clerkship model and then evaluate the impact of this on performance on clerkship summative evaluations. We followed Kern's framework to design our curriculum and then compared performance on the clerkship objective structured clinical examination (OSCE), all summative clerkship multiple choice question (MCQ) examinations, and the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 before and after the introduction of our curriculum. In the 2 years following the introduction of our clinical skills curriculum the mean score on the clerkship OSCE was significantly higher than in the 2 years prior to our curriculum [67.12 (5.3) vs. 62.44 (4.93), p < 0.001, d = 0.91]. With the exception of the surgical clerkship MCQ, performance on all clerkship summative MCQ examinations and MCCQE Part 1 was significantly higher following the introduction of our curriculum. In this study we found a significant improvement in the performance on clerks on summative evaluations of knowledge and clinical skills following the introduction of our clinical skills curriculum. Given the unpredictable nature of clinical rotations, the clerkship will always be a risk of failing to deliver the intended curriculum-so medical schools should continue to explore and evaluate ways of changing the delivery of clerkship training to improve learning outcomes.

Estimation of post-test probabilities by residents: Bayesian reasoning versus heuristics?

Although the process of diagnosing invariably begins with a heuristic, we encourage our learners to support their diagnoses by analytical cognitive processes, such as Bayesian reasoning, in an attempt to mitigate the effects of heuristics on diagnosing. There are, however, limited data on the use ± impact of Bayesian reasoning on the accuracy of disease probability estimates. In this study our objective was to explore whether Internal Medicine residents use a Bayesian process to estimate disease probabilities by comparing their disease probability estimates to literature-derived Bayesian post-test probabilities. We gave 35 Internal Medicine residents four clinical vignettes in the form of a referral letter and asked them to estimate the post-test probability of the target condition in each case. We then compared these to literature-derived probabilities. For each vignette the estimated probability was significantly different from the literature-derived probability. For the two cases with low literature-derived probability our participants significantly overestimated the probability of these target conditions being the correct diagnosis, whereas for the two cases with high literature-derived probability the estimated probability was significantly lower than the calculated value. Our results suggest that residents generate inaccurate post-test probability estimates. Possible explanations for this include ineffective application of Bayesian reasoning, attribute substitution whereby a complex cognitive task is replaced by an easier one (e.g., a heuristic), or systematic rater bias, such as central tendency bias. Further studies are needed to identify the reasons for inaccuracy of disease probability estimates and to explore ways of improving accuracy.

Co-designing discharge communication interventions for mental health visits to the pediatric emergency department: a mixed-methods study.

BACKGROUND: Discharge communication is essential to convey information regarding the care provided and follow-up plans after a visit to a hospital emergency department (ED), but it can be lacking for visits for pediatric mental health crises. Our objective was to co-design and conduct usability testing of new discharge communication interventions to improve pediatric mental health discharge communication. METHODS: The study was conducted in two phases using experience-based co-design (EBCD). In phase 1 (Sep 2021 to Jan 2022), five meetings were conducted with a team of six parents and two clinicians to co-design new ED discharge communication interventions for pediatric mental health care. Thematic analysis was used to identify patterns in team discussions and participant feedback related to discharge communication improvement and the Capability, Opportunity, Motivation, Behavior (COM-B) model was used to identify strategies to support the delivery of the new interventions. After meeting five, team members completed the Public and Patient Engagement Evaluation Tool (PPEET) to evaluate the co-design experience. In phase 2 (Apr to Jul 2022), intervention usability and satisfaction were evaluated by a new group of parents, youth aged 16-24 years, ED physicians, and nurses (n = 2 of each). Thematic analysis was used to identify usability issues and a validated 5-point Likert survey was used to evaluate user satisfaction. Evaluation results were used by the co-design team to finalize the interventions and delivery strategies. RESULTS: Two discharge communication interventions were created: a brochure for families and clinicians to use during the ED visit, and a text-messaging system for families after the visit. There was high satisfaction with engagement in phase 1 (overall mean PPEET score, 4.5/5). In phase 2, user satisfaction was high (mean clinician score, 4.4/5; mean caregiver/youth score, 4.1/5) with both interventions. Usability feedback included in the final intervention versions included instructions on intervention use and ensuring the text-messaging system activates within 12-24 h of discharge. CONCLUSIONS: The interventions produced by this co-design initiative have the potential to address gaps in current discharge practices. Future testing is required to evaluate the impact on patients, caregivers, and health care system use after the ED visit.

Discharge communication is an important component of an emergency department (ED) visit for a mental health crisis as most children who visit the ED for mental health care are discharged home. To date, patients and their caregivers have not been involved in developing discharge communication interventions for this type of care. Our aim was to involve patients and caregivers to improve the communication provided to children and their caregivers during ED visits for mental health crises. We established a design team made up of six parents and two clinicians to design two new discharge communication interventions: a brochure for families and clinicians to use together during the ED visit, and a text-messaging system to support families after the visit. We tested how useable these interventions were with four other ED health care providers, two parents, and two youth. These participants reported high user satisfaction with the brochure, and usability feedback was used by the design team to improve the final versions of the two interventions. At the end of the project, the design team reported high satisfaction with their engagement experiences with the project. The interventions created by the team have the potential to address knowns gaps in current discharge practices, but future testing is required to evaluate the impact of these interventions on patients, caregivers, and health care system use after the ED visit.

Prevalence of pain-related presentations in Canadian pediatric emergency departments.

OBJECTIVE: Pain is a common reason for attendance to the emergency department; however, pediatric specific data on the prevalence, location, and etiology of painful presentations are limited in the literature. Therefore, the objective of this study was to determine the prevalence of pain-related presentations to pediatric emergency departments during the triage process and characterize the anatomical locations and organ systems most affected by pain in a modern cohort. METHODS: A two-center health record review of triage documentation was conducted at Canadian pediatric emergency departments. All children (< 18 years) were eligible for inclusion. Data were extracted from administrative sources with one week of consecutive patients included every 3 months over a one-year timeframe. Regression analyses were completed to identify variables associated with painful presentations and analgesia provision during the triage process. RESULTS: A total of 7208 emergency department presentations were included. Median [IQR] child age was 5.2 [1.9, 11.8] years and 53.2% were male. 58.8% of children were found to have pain as a component of their triage presentation. Of those with pain (n = 4237), 24.1% had a pain score documented and 13.8% had analgesia provided at triage. Location of pain (n = 4523) was predominantly in the head (38.0%), extremities (27.8%), and abdomen (22.8%). Primary organ systems most affected (n = 4237) included the musculoskeletal (31.1%), gastrointestinal (18.3%), and cutaneous (including lacerations) (14.4%) systems. CONCLUSIONS: In this study, pain was identified in almost 60% of all pediatric emergency department presentations at the time of triage. Suboptimal documentation of pain scores and provision of analgesia at triage were found for children with pain. These results support early assessment and implementation of pain management strategies at triage. Results can also focus further research efforts to the management of the most commonly presenting types of pediatric pain.

RéSUMé: OBJECTIF: La douleur est un motif courant de présence à l'urgence, mais les données pédiatriques spécifiques sur la prévalence, l'emplacement et l'étiologie des présentations douloureuses sont limitées dans la littérature. Par conséquent, l'objectif de cette étude était de déterminer la prévalence des présentations liées à la douleur aux services d'urgence pédiatriques au cours du processus de triage et de caractériser les emplacements anatomiques et les systèmes d'organes les plus touchés par la douleur dans une cohorte moderne. MéTHODES: Un examen des dossiers médicaux de deux centres des documents de triage a été effectué aux services d'urgence pédiatriques du Canada. Tous les enfants (< 18 ans) étaient admissibles à l'inclusion. Les données ont été extraites de sources administratives avec une semaine de patients consécutifs inclus tous les 3 mois sur une période d'un an. Des analyses de régression ont été effectuées pour identifier les variables associées aux présentations douloureuses et à l'analgésie pendant le processus de triage. RéSULTATS: Un total de 7208 présentations à l'urgence ont été incluses. L'âge médian [IQR] des enfants était de 5,2 [1,9, 11,8] ans et 53,2 % étaient des hommes. 58,8 % des enfants présentaient de la douleur dans leur présentation de triage. Parmi les personnes souffrant de douleur (n = 4237), 24,1 % avaient un score de douleur documenté et 13,8 % avaient reçu une analgésie au triage. L'emplacement de la douleur (n = 4523) était principalement dans la tête (38,0 %), les extrémités (27,8 %) et l'abdomen (22,8 %). Les systèmes d'organes primaires les plus touchés (n = 4237) comprenaient les systèmes musculosquelettiques (31,1 %), gastro-intestinaux (18,3 %) et cutanés (y compris les lacérations) (14,4 %). CONCLUSIONS: Dans cette étude, la douleur a été identifiée dans près de 60 % de toutes les présentations aux urgences pédiatriques au moment du triage. La documentation sous-optimale des scores de douleur et la fourniture d'analgésie au triage ont été trouvées pour les enfants souffrant de douleur. Ces résultats appuient l'évaluation précoce et la mise en œuvre de stratégies de gestion de la douleur au triage. Les résultats peuvent également concentrer davantage les efforts de recherche sur la gestion des types de douleur pédiatrique les plus courants.

Diagnostic performance 1 h after simulation training predicts learning.

Although simulation training improves post-training performance, it is unclear how well performance soon after simulation training predicts longer term outcomes (i.e., learning). Here our objective was to assess the predictive value of performance 1 h post-training of performance 6 weeks later. We trained 84 first year medical students a simulated case of chest pain due to aortic stenosis. They then received training on a case of acute onset dyspnea due to pulmonary embolism, after which we evaluated diagnostic performance on their trained murmur followed by novel murmur. We repeated the evaluation of diagnostic performance on the same murmurs 6 weeks later. One hour post-training 88.1 % of students identified the training murmur, compared to 60.7 % for the novel murmur. Six weeks after training the corresponding results were 89.3 and 65.5 %, respectively (p < 0.0001 for both time periods). The probability of students diagnosing their training murmur 6 weeks post-training if they diagnosed this after 1 h (positive predictive value) was 0.89 [0.87, 0.93], and the probability of misdiagnosing their trained murmur 6 weeks post-training if they misdiagnosed this after 1 h (negative predictive value) was 0.10 [0.01, 0.40]. The corresponding positive and negative predictive values for the novel murmur were 0.69 [0.55, 0.80] and 0.39 [0.24, 0.57], respectively. Students who successfully diagnosed a cardiac murmur 1 h after simulation training were very likely to recognize the same murmur 6 weeks later, suggesting that we can use performance 1 h post-training as a learning outcome.