Does providing the correct diagnosis as feedback after self-explanation improve medical students diagnostic performance?

BACKGROUND: Self-explanation without feedback has been shown to improve medical students' diagnostic reasoning. While feedback is generally seen as beneficial for learning, available evidence of the value of its combination with self-explanation is conflicting. This study investigated the effect on medical students' diagnostic performance of adding immediate or delayed content-feedback to self-explanation while solving cases. METHODS: Ninety-four 3rd-year students from a Canadian medical school were randomly assigned to three experimental conditions (immediate-feedback, delayed-feedback, control). In the learning phase, all students solved four clinical cases by giving i) the most likely diagnosis, ii) two main arguments supporting this diagnosis, and iii) two plausible alternative diagnoses, while using self-explanation. The immediate-feedback group was given the correct diagnosis after each case; delayed-feedback group received the correct diagnoses only after the four cases; control group received no feedback. One week later, all students solved four near-transfer (i.e., same final diagnosis as the learning cases but different scenarios) and four far-transfer cases (i.e., different final diagnosis from the learning cases and different scenarios) by answering the same three questions. Students' diagnostic accuracy (score for the response to the first question only) and diagnostic performance (combined score of responses to the three questions) scores were assessed in each phase. Four one-way ANOVAs were performed on each of the two scores for near and far-transfer cases. RESULTS: There was a significant effect of experimental condition on diagnostic accuracy on near-transfer cases (p < .05). The immediate-feedback and delayed-feedback groups performed equally well, both better than control (respectively, mean = 90.73, standard deviation =10.69; mean = 89.92, standard deviation = 13.85; mean = 82.03, standard deviation = 17.66). The experimental conditions did not significantly differ on far-transfer cases. CONCLUSIONS: Providing feedback to students in the form of the correct diagnosis after using self-explanation with clinical cases is potentially beneficial to improve their diagnostic accuracy but this effect is limited to similar cases. Further studies should explore how more elaborated feedback combined with self-explanation may impact students' diagnostic performance on different cases.

Reduced tumor necrosis factor alpha production in lipopolysaccharide-treated whole blood from patients in the intensive care unit.

OBJECTIVE: To determine the cytokine response to lipopolysaccharide in patients in the intensive care unit. PATIENTS: Patients in a mixed medical/surgical intensive care unit with fever and a de novo clinical dysfunction of at least one organ system. METHODS: Whole blood from patients and from laboratory controls was stimulated with 8 ng/mL of lipopolysaccharide (Escherichia coli 0111:B4) at 37 degrees C, and tumor necrosis factor alpha (TNF-alpha) was measured using enzyme linked immunosorbent assay at 4, 8, and 24 hours. The same subjects' purified monocytes were cultured with 8 ng/mL of lipopolysaccharide in the presence of autologous or pooled control plasma or cocultured with purified autologous polymorphonuclear leukocytes at a polymorphonuclear leukocyte-monocyte ratio of 10:1, and TNF-alpha was measured at 24 hours using the enzyme linked immunosorbent assay. RESULTS: We detected high (n = 5) and low (n = 5) TNF-alpha responders in whole blood producing a mean (+/- SEM) of 27.2 +/- 6.3 pg/mL per 1000 monocytes vs 0.0 +/- 2.4 pg/mL per 1000 monocytes, respectively (controls, 58.0 +/- 13.0 pg/mL per 1000 monocytes). The kinetics of TNF-alpha production in both groups were comparable. Purified monocytes from both groups of patients cultured with lipopolysaccharide alone produced equivalent TNF-alpha values (42.4 +/- 10.5 vs 40.8 +/- 12.5 pg/mL per 1000 monocytes). Assayable TNF-alpha was not different with autologous vs control serum but was markedly diminished by the presence of polymorphonuclear leukocytes in patients as well as in controls; the two groups of patients did not differ in this polymorphonuclear leukocyte effect. CONCLUSION: Lipopolysaccharide stimulation of monocytes in the whole blood results in marked variation of TNF-alpha production. This phenomenon may account for the variable septic response to infection in patients in the intensive care unit.

A donor-derived asialo-GM1+ cell induces depression of B-cell genesis during systemic graft-versus-host disease.

The nature of the effector cell(s) responsible for the depression of B-cell genesis in the bone marrow of mice undergoing systemic graft-versus-host disease (GVHD) has been examined. Donor C57BL/6 (B6) mice were treated in vivo with either a single injection of anti-asialo GM1 antibody (anti-ASGM1) to eliminate naturally occurring (endogenous) ASGM1+ cells or B6xAF1 (B6AF1) lymphoid cells followed by anti-ASGM1 to eliminate both endogenous and "induced" ASGM1+ cells. Lymphoid cells from donor mice after the elimination of endogenous ASGM1+ cells produced severe GVHD and concomitant depression of B-cell genesis when injected into B6AF1 recipients. In contrast, cells from donors depleted of both the endogenous and inducible ASGM1+ populations did not cause GVHD or depletion of B lineage cells in B6AF1 recipients but did depress B-cell genesis in B6C3F1 mice. The "induced" ASGM1+ cells were Thy 1+, but their elimination did not significantly alter either overall T-cell function or specific cytotoxic T-cell (CTL) reactivity against the sensitizing (B6AF1) strain. The results suggest that the effector cell responsible for the depression of B-cell genesis during systemic GVHD can be induced to express ASGM1, is strain-specific and Thy 1+; but is not a conventional CTL.

A physician-centred intervention to shorten hospital stay: a pilot study.

BACKGROUND: Studies of length of stay (LOS) in hospital usually focus on physician-independent factors. In this study, the authors identified physician-dependent factors and tested an intervention aimed at them to determine its effect on LOS. METHODS: A prospective comparison of LOS on 2 general medical wards in a tertiary care teaching hospital before and after the intervention. The pre-intervention (control) period and the intervention period were each 4 weeks. The intervention consisted of a checklist for planning management and discharge. RESULTS: Overall, the mean LOS was shorter during the intervention period than during the control period, but the difference was not statistically significant (12.0 and 14.4 days respectively, p = 0.13). The difference was significant on ward A (11.0 v. 14.7 days respectively, p = 0.02) but not on ward B (13.0 and 14.0 days respectively, p = 0.90). INTERPRETATION: An intervention at the level of the admitting physician may help to shorten LOS on a general medical ward.