Methods to Improve Diagnostic Reasoning in Undergraduate Medical Education in the Clinical Setting: a Systematic Review.

BACKGROUND: In recent years, there have been numerous studies exploring different teaching methods for improving diagnostic reasoning in undergraduate medical students. This systematic review examines and summarizes the evidence for the effectiveness of these teaching methods during clinical training. METHODS: PubMed, Embase, Scopus, and ERIC were searched. The inclusion criteria for the review consist of articles describing (1) methods to enhance diagnostic reasoning, (2) in a clinical setting (3) on medical students. Articles describing original research using qualitative, quantitative, or mixed study designs and published within the last 10 years (1 April 2009-2019) were included. Results were screened and evaluated for eligibility. Relevant data were then extracted from the studies that met the inclusion criteria. RESULTS: Sixty-seven full-text articles were first identified. Seventeen articles were included in this review. There were 13 randomized controlled studies and four quasi-experimental studies. Of the randomized controlled studies, six discussed structured reflection, four self-explanation, and three prompts for generating differential diagnoses. Of the remaining four studies, two employed the SNAPPS1 technique for case presentation. Two other studies explored schema-based instruction and using illness scripts. Twelve out of 17 studies reported improvement in clinical reasoning after the intervention. All studies ranked level two on the New World Kirkpatrick model. DISCUSSION: The authors posit a framework to teach diagnostic reasoning in the clinical setting. The framework targets specific deficiencies in the students' reasoning process. There remains a lack of studies comparing the effectiveness of different methods. More comparative studies with standardized assessment and evaluation of long-term effectiveness of these methods are recommended.

Ideal Sequence of Didactic Lectures and Simulation in Teaching Transesophageal Echocardiography Among Anesthesiologists.

OBJECTIVE: Performing a basic perioperative transesophageal echocardiography (TEE) requires 3-dimensional knowledge of cardiac anatomy, psychomotor skills, and image interpretation. Commonly, lectures followed by simulation sequence is used for teaching TEE. Differences may occur among learners when this sequencing of instructional components is altered. The authors investigated the ideal sequence of lectures and simulation in teaching basic perioperative TEE. DESIGN: Prospective randomized comparative study. SETTING: Simulation room in a large academy tertiary care center. PARTICIPANTS: Noncardiac anesthesiologists in Singapore with no prior knowledge of TEE. INTERVENTION: Comparison of acquisition and retention of knowledge and skills between the lecture followed by simulation group (LS) and the simulation followed by lecture (SL) group. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed using multiple-choice questions (MCQs) and skills using a skill test. The primary outcome measured was the MCQ scores (post-course and retest) and the skill test scores (post-course and retest). Of the 43 anesthesiologists who were recruited, 22 were randomized into the LS group and 21 to the SL group. All participants took pre-course and post-course MCQs and post-course skill tests. Post-tests were repeated 1 month after the course to assess retention. There was no significant difference in the post-course MCQ (85.87% v 81.82%) and skill test scores (85.78% v 81.55%) between the SL and LS groups, respectively. The SL group demonstrated significantly better retention of knowledge at 1 month (MCQ score 83.5% v 72.73%; p = 0.003) and skills (skill test score 85.32% v 1.90%; p = 0.016) than the other. CONCLUSION: This study showed that, for retention (at 1 month) of both knowledge and skills, it is preferable to teach practical skills followed by theoretical knowledge to anesthesiologists who are complete novices to TEE.

What factors determine academic achievement in high achieving undergraduate medical students? A qualitative study.

BACKGROUND: Medical students' academic achievement is affected by many factors such as motivational beliefs and emotions. Although students with high intellectual capacity are selected to study medicine, their academic performance varies widely. OBJECTIVES: The aim of this study is to explore the high achieving students' perceptions of factors contributing to academic achievement. MATERIALS AND METHODS: Focus group discussions (FGD) were carried out with 10 male and 9 female high achieving (scores more than 85% in all tests) students, from the second, third, fourth and fifth academic years. During the FGDs, the students were encouraged to reflect on their learning strategies and activities. The discussion was audio-recorded, transcribed and analysed qualitatively. RESULTS: Factors influencing high academic achievement include: attendance to lectures, early revision, prioritization of learning needs, deep learning, learning in small groups, mind mapping, learning in skills lab, learning with patients, learning from mistakes, time management, and family support. Internal motivation and expected examination results are important drivers of high academic performance. Management of non-academic issues like sleep deprivation, homesickness, language barriers, and stress is also important for academic success. CONCLUSION: Addressing these factors, which might be unique for a given student community, in a systematic manner would be helpful to improve students' performance.

A randomized trial comparing cadaveric dissection and examination of prosections as applied surgical anatomy teaching pedagogies.

Anatomy is an important component in the vertical integration of basic science and clinical practice. Two common pedagogies are cadaveric dissection and examination of prosected specimens. Comparative studies mostly evaluate their immediate effectiveness. A randomized controlled trial design was employed to compare both the immediate and long-term effectiveness of dissection and prosection. Eighty third-year medical students undergoing their surgical rotation from the Yong Loo Lin School of Medicine were randomized into two groups: dissection and prosection. Each participated in a one-day hands-on course following a similar outline that demonstrated surgical anatomy in the context of its clinical relevance. A pre-course test was conducted to establish baseline knowledge. A post-course test was conducted immediately after and at a one-year interval to evaluate learner outcome and knowledge retention. A post-course survey was conducted to assess participant perception. Thirty-nine and thirty-eight participants for the dissection and prosection groups, respectively, were included for analysis. There was no significant difference between mean pre-course test scores between the dissection and prosection groups [12.6 (3.47) vs. 12.7 (3.16), P > 0.05]. Both the mean immediate [27.9 (4.30) vs. 24.9 (4.25), P < 0.05] and 1 year [23.9 (4.15) vs. 19.9 (4.05), P < 0.05] post-course test scores were significantly higher in the dissection group. However, when adjusted for course duration [dissection group took longer than prosection group (mean 411 vs. 265 min)], these findings were negated. There is no conclusive evidence of either pedagogy being superior in teaching surgical anatomy. Based on learner surveys, dissection provides a greater learner experience.

Stress and its effects on medical students: a cross-sectional study at a college of medicine in Saudi Arabia.

Medical education is perceived as being stressful, and a high level of stress may have a negative effect on cognitive functioning and learning of students in a medical school. This cross-sectional study was conducted to determine the prevalence of stress among medical students and to observe an association between the levels of stress and their academic performance, including the sources of their stress. All the medical students from year one to year five levels from the College of Medicine, King Saud University, were enrolled in the study. The study was conducted using Kessler10 psychological distress (K10) inventory, which measures the level of stress according to none, mild, moderate, and severe categories. The prevalence of stress was measured and compared with the five study variables, such as gender, academic year, academic grades, regularity to course attendance, and perceived physical problems. The response rate among the study subjects was 87% (n=892). The total prevalence of stress was 63%, and the prevalence of severe stress was 25%. The prevalence of stress was higher (p<0.5) among females (75.7%) than among males (57%) (odds ratio=2.3, chi2=27.2, p<0.0001). The stress significantly decreased as the year of study increased, except for the final year. The study variables, including being female (p<0.0001), year of study (p<0.001), and presence of perceived physical problems (p<0.0001), were found as independent significant risk factors for the outcome variables of stress. Students' grade point average (academic score) or regularity to attend classes was not significantly associated with the stress level. The prevalence of stress was higher during the initial three years of study and among the female students. Physical problems are associated with high stress levels. Preventive mental health services, therefore, could be made an integral part of routine clinical services for medical students, especially in the initial academic years, to prevent such occurrence.

Examiner perceptions of a portfolio assessment process.

BACKGROUND: The portfolio assessment process is important for assessing learner achievement. AIMS: To study examiner perceptions of Dundee Medical School's portfolio assessment process, in years 4 and 5 of the 5-year curriculum, in relation to: outcomes as a framework for the portfolio assessment process; portfolio content; portfolio assessment process; end points of the portfolio assessment process; appropriateness of the two part final exam format and examiner training. METHODS: A questionnaire containing statements and open questions was used to obtain examiner feedback. Responses to each statement were compared over 3 years: 1999, 2000 and 2003. RESULTS: Response rates were 100%, 88% and 61% in 1999, 2002 and 2003, respectively. Examiners were positive about the ability of institutionally set learning outcomes (Dundee 12 exit learning outcomes) to provide a framework for the portfolio assessment process. They found difficulties, however, with the volume of portfolio content and the time allocated to assess it. Agreeing a grade for each learning outcome for the candidate with their co-examiner did not present difficulties. The comprehensive, holistic picture of the candidate provided by the portfolio assessment process was perceived to be one of its strengths. Examiners were supportive of the final examination format, and were satisfied with their briefing about the process. CONCLUSIONS: The 12 exit learning outcomes of Dundee curriculum provide an appropriate framework for the portfolio assessment process, but the content of the portfolio requires fine-tuning particularly with regard to quantity. Time allocated to examiners for the portfolio assessment process needs to be balanced against practicability. The holistic picture of the candidate provided by the process was one of its strengths.

Student perceptions of a portfolio assessment process.

OBJECTIVES: The objectives of this study were to identify and analyse students' attitudes to the portfolio assessment process over time. METHODS: A questionnaire containing statements and open questions was used to obtain feedback from students at the University of Dundee Medical School, Scotland. The responses to each statement were compared over 4 years (1999, 2000, 2002 and 2003). RESULTS: Response rates were 83% in 1999, 70% in 2000, 89% in 2002 and 88% in 2003. A major finding is that students perceived that portfolio building heightened their understanding of the exit learning outcomes and enabled reflection on their work. Student reactions to the portfolio process were initially negative, although they appreciated that senior staff took time to become familiar with their work through reviewing their portfolios. Student attitudes became more positive over the 4 years as the process evolved. Although portfolio assessment was recognised as supporting student learning, portfolio building was perceived to interfere with clinical learning as a result of the excessive amounts of paper evidence required. CONCLUSIONS: Paperwork should be kept within manageable limits. A student induction process that highlights the importance of providing evidence for achieving all learning outcomes, not just theoretical knowledge and skills, may be helpful in allaying student concern over portfolio building and assessment and support preparation for lifelong learning and reflective clinical practice.

The long case and its modifications: a literature review.

CONTEXT: This review provides a summary of the published literature on the suitability of the long case and its modifications for high-stakes assessment. METHODS: Databases related to medicine were searched for articles published from 2000 to 2008, using the keywords 'long case', 'clinical examinations' and 'clinical assessment'. Reference lists of review articles were hand-searched. Articles related to the objective structured clinical examination were eliminated. Research-based articles with hard data were given more emphasis in this review than those based on opinion. RESULTS: Eighteen articles were identified. The main disadvantage of the long case is its inability to sample the curriculum widely, resulting in low reliability. The main advantage of the long case is its ability to assess the candidate's overall (holistic) approach to the patient. Modifications to the long case attempt to: structure the format and the marking scheme; increase the number of examiners; observe the candidate's behaviour, and increase the number of cases. CONCLUSIONS: The long case is a traditional clinical examination format for the assessment of clinical competence and assessment at this level is important. The starting point for the majority of recent research on the long case has been an acceptance of its low reliability and modifications to the format have been proposed. Further evidence of the efficacy of these modifications is required, however, before they can be recommended for summative assessment. If further research is to be undertaken on the long case, it should focus on finding practicable ways of sampling the curriculum widely to increase reliability while maintaining the holistic approach towards the patient, which represents the attraction of the long case.

The Objective Structured Clinical Examination (OSCE) as a determinant of veterinary clinical skills.

The Objective Structured Clinical Examination (OSCE) has become an excellent tool to evaluate many elements of a student's clinical skills, especially including communication with the patient (human medicine) or client (veterinary medicine); eliciting clinical information from these conversations; some aspects of the physical examination; and many areas of clinical evaluation and assessment. One key factor is that the examination can be structured to compare different students' abilities.

Selection for postgraduate training.

BACKGROUND: Selection for an educational programme requires meticulous planning and the adoption of sound educational principles to decide on how and what should be assessed. This article provides a step-wise guide for developing a selection process for postgraduate specialty training, based on the best practice in the literature. METHOD: The literature on selecting applicants for educational programmes was reviewed to categorise the selection methods according to their purpose, and their relative strengths and weaknesses. A step-wise guide that encapsulated the best practice for designing a selection process for postgraduate specialty training was then developed. RESULTS: The steps of developing a selection process for postgraduate specialty training are: determining the competencies required for the training programme; selecting the competencies that can be assessed at selection; identifying content for selection; blueprinting; choice of selection tests; development of test material; piloting; and implementation and evaluation of the selection process. There are robust tests to assess applicants' knowledge at the lower two levels of Miller's pyramid. Scenario-based testing holds promise for assessing at 'shows-how' level. Assessing at 'does' level during selection is difficult, but not impossible. DISCUSSION: There is no one test that can be used to select an applicant for a postgraduate training programme. Rather a battery of tests that assesses all the competencies, sampled according to a blueprint, should be used. The eight-step guide proposed in this article provides an educationally sound and defensible procedure to develop a selection process.