Serendipity in oto-rhino-laryngology.

INTRODUCTION: Serendipitous findings are findings that were initially unsought but nevertheless contribute to the development of the discipline. This article reviews eight serendipitous findings in oto-rhino-laryngology important to its advancement. METHOD: The following serendipitous findings are discussed: the accidental discovery of the laryngeal mirror and indirect laryngoscopy by Garcia (1854), the invention of direct oesophagoscopy by Kußmaul (circa 1868), Czermák's (1863) development of diaphanoscopy, the unintentional emergence of bronchography from a clinical error made by Weingartner (1914), adenotomy by Meyer (1869), the discovery of the causes of unbalance related to the vestibular nerve by Flourens (1830), Bárány's (1914) finding that the semi-circular canal reflex is involved in equilibrium, and the relationship between gastroesophageal reflux and middle-ear infections by Poelmans and Feenstra (2002). DISCUSSION: Based on these case studies we conclude that serendipity, defined as the art of making an initially unsought find, does not always appear out of nowhere. Often the researcher is already wrestling with a problem for which the serendipitous finding provides a solution. Sometimes the serendipitous finding enables the application of a known solution to a new problem. And sometimes a serendipitous finding is not recognized as such or considered unimportant. Since observations tend to be theory-loaded, having appropriate background knowledge is a conditio sine qua non to elaborate an unanticipated observation.

Measuring sociocultural engagement of health professions education students: a psychometric study.

BACKGROUND: Sociocultural engagement of students refers to broadening viewpoints and providing awareness of, and respect for, diverse backgrounds and perspectives. However, there are no existing validated instruments in the literature for measuring sociocultural engagement of health professions education (HPE) students. Therefore, the aim of this study is to develop and validate a questionnaire designed to assess sociocultural engagement among HPE students. METHODS: The study included undergraduate HPE students (n = 683) at Gulf Medical University. The initial version of the sociocultural engagement of students' questionnaire (SESQ) was developed after extensive literature review and guided by the Global Learning Qualifications Framework. We then tested the content validity of the questionnaire by using focus group discussion with subject experts (n = 16) and pilot testing with students (n = 20). We distributed the content-validated version of the SESQ (16 items) to undergraduate students in six HPE colleges. To examine the construct validity and construct reliability of the questionnaire, we conducted exploratory factor analysis, followed by confirmatory factor analysis. RESULTS: Confirmatory factor analysis supported the two-factor structure which consists of 13 items with good fitness indices (χ2 = 214.35, df = 61, χ 2/df = 3.51, CFI = 0.98, RMSEA = 0.06, SRMR = 0.025, and AIC = 208.00). The two factors were sociocultural interactions (8 items) and sociocultural adaptation (5 items). The construct reliability of the total questionnaire is 0.97 and the two factors were 0.93 and 0.92 for sociocultural interactions and sociocultural adaptation, respectively. In addition, there were significant weak correlations between both factors of sociocultural engagement scores and student satisfaction with the university experience (r = .19 for each, P = .01). CONCLUSIONS: The sociocultural engagement of students' questionnaire exhibits good evidence of construct validity and reliability. Further studies will be required to test the validity of this questionnaire in other contexts.

Deliberate reflection and clinical reasoning: Founding ideas and empirical findings.

CONTEXT: The idea that reflection improves reasoning and learning, since long present in other fields, emerged in the 90s in the medical education literature. Since then, the number of publications on reflection as a means to improve diagnostic learning and clinical problem-solving has increased steeply. Recently, concerns with diagnostic errors have raised further interest in reflection. Several approaches based on reflection have been proposed to reduce clinicians' errors during diagnostic reasoning. What reflection entails varies substantially, and most approaches still require empirical examination. PURPOSE: The present essay aims to help clarify the role of deliberate reflection in diagnostic reasoning. Deliberate reflection is an approach whose effects on diagnostic reasoning and learning have been empirically studied over the past 15 years. The philosophical roots of the approach will be briefly examined, and the theory and practice of deliberate reflection, particularly its effectiveness, will be reviewed. Lessons learned and unresolved issues will be discussed. DISCUSSION: The deliberate reflection approach originated from a conceptualization of the nature of reflection practice in medicine informed by Dewey's and Schön's work. The approach guides physicians through systematically reviewing the grounds of their initial diagnosis and considering alternatives. Experimental evidence has supported the effectiveness of deliberate reflection in increasing physicians' diagnostic performance, particularly in nonstraightforward diagnostic tasks. Deliberate reflection has also proved helpful to improve students' diagnostic learning and to facilitate learning of new information. The mechanisms behind the effects of deliberate reflection remain unclear. Tentative explanations focus on the activation/reorganisation of prior knowledge induced by deliberate reflection. Its usefulness depends therefore on the difficulty of the problem relative to the clinician's knowledge. Further research should examine variations in instructions on how to reflect upon a case, the value of further guidance while learning from deliberate reflection, and its benefits in real practice.

"Studying cognitive reappraisal as an antidote to the effect of negative emotions on medical residents' learning: a randomized experiment".

BACKGROUND: Medical trainees often encounter situations that trigger emotional reactions which may hinder learning. Evidence of this effect on medical trainees is scarce and whether it could be counteracted is unclear. This study investigated the effect of negative emotions on medical residents' learning and whether cognitive reappraisal counteracts it. METHODS: Ninety-nine medical residents participated in a three-phase experiment consisting of: (1) watching a video, either a neutral or an emotion-induction version, the latter either followed by cognitive reappraisal or not (2) learning: all participants studied the same medical text; study-time and cognitive engagement were measured; (3) test: a recall-test measured learning. Data was analysed using Chi-square test and one-way ANOVA. RESULTS: Study time significantly varied between conditions (p = 0.002). The two emotional conditions spent similar time, both significantly less than the neutral condition. The difference in test scores failed to reach significance level (p = 0.053). While the emotional conditions performed similarly, their scores tended to be lower than those of the neutral condition. CONCLUSION: Negative emotions can adversely affect medical residents' learning. The effect of emotions was not counteracted by cognitive reappraisal, which has been successfully employed to regulate emotions in other domains. Further research to examine emotion regulation strategies appropriate for medical education is much needed.

Construct validity of a questionnaire for measuring student engagement in problem-based learning tutorials.

BACKGROUND: Student engagement is student investment of time and energy in academic and non-academic experiences that include learning, teaching, research, governance, and community activities. Although previous studies provided some evidence of measuring student engagement in PBL tutorials, there are no existing quantitative studies in which cognitive, behavioral, and emotional engagement of students in PBL tutorials is measured. Therefore, this study aims to develop and examine the construct validity of a questionnaire for measuring cognitive, behavioral, and emotional engagement of students in PBL tutorials. METHODS: A 15-item questionnaire was developed guided by a previously published conceptual framework of student engagement. Focus group discussion (n = 12) with medical education experts was then conducted and the questionnaire was piloted with medical students. The questionnaire was then distributed to year 2 and 3 medical students (n = 176) in problem-based tutorial groups at the end of an integrated course, where PBL is the main strategy of learning. The validity of the internal structure of the questionnaire was tested by confirmatory factor analysis using structural equation modeling assuming five different models. Predictive validity evidence of the questionnaire was studied by examining the correlations between students' engagement and academic achievement. RESULTS: Confirmatory factor analysis indicates a good fit between the measurement and structural model of an 11-item questionnaire composed of a three-factor structure: behavioral engagement (3 items), emotional engagement (4 items), and cognitive engagement (4 items). Models in which the three latent factors were considered semi-independent provided the best fit. The construct reliabilities of behavioral, cognitive, and emotional factors were 0.82, 0.82, and 0.76, respectively. We failed however to find significant relationships between academic achievement and engagement. CONCLUSIONS: We found a strong evidence to support the construct validity of a three-factor structure of student engagement in PBL tutorial questionnaire. Further studies are required to test the validity of this instrument in other educational settings. The predictive validity is another area needing further scrutiny.

Failure to demonstrate effects of interruptions on diagnostic reasoning: three experiments.

BACKGROUND: Diagnostic error is a major source of patient suffering. Researchshows that physicians experience frequent interruptions while being engaged with patients and indicate that diagnostic accuracy may be impaired as a result. Since most studies in the field are observational, there is as yet no evidence suggesting a direct causal link between being interrupted and diagnostic error. Theexperiments reported in this article were intended to assess this hypothesis. METHODS: Three experiments were conducted to test the hypothesis that interruptions hurt diagnostic reasoning and increase time on task. In the first experiment (N = 42), internal medicine residents, while diagnosing vignettes of actual clinical cases were interrupted halfway with a task unrelated to medicine, solving word-spotting puzzles and anagrams. In the second experiment (N = 78), the interruptions were medically relevant ones. In the third experiment (N = 30), we put additional time pressure on the participants. In all these experiments, a control group diagnosed the cases without interruption. Dependent variables were diagnostic accuracy and amount of time spent on the vignettes. RESULTS: In none of the experiments interruptions were demonstrated to influence diagnostic accuracy. In Experiment 1: Mean of interrupted group was 0.88 (SD = 0.37) versus non- interrupted group 0.91 (SD = 0.32). In Experiment 2: Mean of interrupted group was 0.95 (SD = 0.32) versus non-interrupted group 0.94 (SD = 0.38). In Experiment 3: Mean of interrupted group was 0.42 (SD = 0.12) versus non-interrupted group 0.37 (SD = 0.08). Although interrupted residents in all experiments needed more time to complete the diagnostic task, only in Experiment 2, this effect was statistically significant. CONCLUSIONS: These three experiments, taken together, failed to demonstrate negative effects of interruptions on diagnostic reasoning. Perhaps physicians who are interrupted may still have sufficient cognitive resources available to recover from it most of the time.

Specific Disease Knowledge as Predictor of Susceptibility to Availability Bias in Diagnostic Reasoning: a Randomized Controlled Experiment.

BACKGROUND: Bias in reasoning rather than knowledge gaps has been identified as the origin of most diagnostic errors. However, the role of knowledge in counteracting bias is unclear. OBJECTIVE: To examine whether knowledge of discriminating features (findings that discriminate between look-alike diseases) predicts susceptibility to bias. DESIGN: Three-phase randomized experiment. Phase 1 (bias-inducing): Participants were exposed to a set of clinical cases (either hepatitis-IBD or AMI-encephalopathy). Phase 2 (diagnosis): All participants diagnosed the same cases; 4 resembled hepatitis-IBD, 4 AMI-encephalopathy (but all with different diagnoses). Availability bias was expected in the 4 cases similar to those encountered in phase 1. Phase 3 (knowledge evaluation): For each disease, participants decided (max. 2 s) which of 24 findings was associated with the disease. Accuracy of decisions on discriminating features, taken as a measure of knowledge, was expected to predict susceptibility to bias. PARTICIPANTS: Internal medicine residents at Erasmus MC, Netherlands. MAIN MEASURES: The frequency with which higher-knowledge and lower-knowledge physicians gave biased diagnoses based on phase 1 exposure (range 0-4). Time to diagnose was also measured. KEY RESULTS: Sixty-two physicians participated. Higher-knowledge physicians yielded to availability bias less often than lower-knowledge physicians (0.35 vs 0.97; p = 0.001; difference, 0.62 [95% CI, 0.28-0.95]). Whereas lower-knowledge physicians tended to make more of these errors on subjected-to-bias than on not-subjected-to-bias cases (p = 0.06; difference, 0.35 [CI, - 0.02-0.73]), higher-knowledge physicians resisted the bias (p = 0.28). Both groups spent more time to diagnose subjected-to-bias than not-subjected-to-bias cases (p = 0.04), without differences between groups. CONCLUSIONS: Knowledge of features that discriminate between look-alike diseases reduced susceptibility to bias in a simulated setting. Reflecting further may be required to overcome bias, but succeeding depends on having the appropriate knowledge. Future research should examine whether the findings apply to real practice and to more experienced physicians.

Exploring mechanisms underlying learning from deliberate reflection: An experimental study.

INTRODUCTION: Previous research suggests that, relative to generating a differential diagnosis, deliberate reflection during practice with clinical cases fosters learning from a subsequently studied scientific text and promotes interest in the subject matter. The present experiment aimed to replicate these findings and to examine whether motivational or cognitive mechanisms, or both, underlie the positive effects of reflection. METHODS: A total of 101 5th-year medical students participated in an experiment containing four phases: Students (a) diagnosed two clinical cases of jaundice-related diseases either through deliberate reflection or differential diagnosis; (b) reported their situational interest and awareness of knowledge gaps; (c) studied a text about jaundice, either under free or restricted time; and (d) recalled the text. Outcome measures were text-recall, situational interest and awareness of knowledge gaps. RESULTS: A main effect of diagnostic approach on recall of the text was found, with the reflection group recalling more studied material than the differential diagnosis group (means: 72.56 vs 58.80; P = .01). No interaction between diagnostic approach and study time (free or restricted) emerged, nor was there a main effect of the latter. Relative to the differential diagnosis group, students who reflected upon the cases scored significantly higher on both situational interest (means: 4.45 vs 3.99, P < .001) and awareness of knowledge gaps (means: 4.13 vs 3.85, P < .01). DISCUSSION: Relative to generating differential diagnoses, reflection upon clinical cases increased learning outcomes on a subsequent study task, an effect that was independent of study time, suggesting that cognitive mechanisms underlie this effect, rather than increases in motivation to study. However, higher scores on situational interest and awareness of knowledge gaps and a tendency towards larger gains when time was free suggest that higher motivation may also contribute to learning from reflection.

Promotion of knowledge transfer and retention in year 2 medical students using an online training exercise.

It was recently shown that novice medical students could be trained to demonstrate the speed-to-diagnosis and diagnostic accuracy typical of System-1-type reasoning. However, the effectiveness of this training can only be fully evaluated when considering the extent to which knowledge transfer and long-term retention occur as a result, the former of which is known to be notoriously difficult to achieve. This study aimed to investigate whether knowledge learned during an online training exercise for chest X-ray diagnosis promoted either knowledge transfer or retention, or both. Second year medical students were presented with, and trained to recognise the features of four chest X-ray conditions. Subsequently, they were shown the four trained-for cases again as well as different representations of the same conditions varying in the number of common elements and asked to provide a diagnosis, to test for near-transfer (four cases) and far-transfer (four cases) of knowledge. They were also shown four completely new conditions to diagnose. Two weeks later they were asked to diagnose the 16 aforementioned cases again to assess for knowledge retention. Dependent variables were diagnostic accuracy and time-to-diagnosis. Thirty-six students volunteered. Trained-for cases were diagnosed most accurately and with most speed (mean score = 3.75/4, mean time = 4.95 s). When assessing knowledge transfer, participants were able to diagnose near-transfer cases more accurately (mean score = 2.08/4, mean time = 15.77 s) than far-transfer cases (mean score = 1.31/4, mean time = 18.80 s), which showed similar results to those conditions previously unseen (mean score = 0.72/4, mean time = 19.46 s). Retention tests showed a similar pattern but accuracy scores were lower overall. This study demonstrates that it is possible to successfully promote knowledge transfer and retention in Year 2 medical students, using an online training exercise involving diagnosis of chest X-rays, and is one of the few studies to provide evidence of actual knowledge transfer.

What happens to misunderstandings of biomedical concepts across a medical curriculum?

Research on the extent and nature of commonly misunderstood fundamental biomedical concepts across a medical curriculum is scarce. These misunderstandings could point toward robust misconceptions. We examined first whether common misunderstandings persist throughout a medical curriculum, followed by a fine-grained analysis to identify their nature. We designed and administered a 2-tier test to 987 medical students across our curriculum, with 8 questions covering the respiratory and cardiovascular systems, cell division, and homeostatic processes. Proportions of incorrect responses were computed. Four questions where misunderstandings persisted were further qualitatively analyzed. A one-way ANOVA showed the proportion of incorrect responses decreased significantly by students' academic year [F(6, 986) = 96.05, P < 0.001]. While novices and end-of -first-year students showed similar proportion of incorrect responses (P > 0.05), incorrect responses decreased significantly between first years and second years (P < 0.001). Thereafter, the proportion of incorrect responses remained stable from second to final year (P > 0.05), with ∼35% of incorrect responses. Five questions showed no decrease of incorrect responses between second and final years, with two questions where final year students performed marginally better than novices. A Chi-square analysis, with Bonferroni post hoc test, showed certain misunderstandings appeared frequently across the curriculum. The qualitative analysis of the open-ended questions yielded 15 categories of common misunderstandings of fundamental biomedical concepts in all years of training. If educators become aware of commonly misunderstood biomedical concepts, preventative measures could be taken to prevent robust misconceptions.

How cognitive psychology changed the face of medical education research.

In this article, the contributions of cognitive psychology to research and development of medical education are assessed. The cognitive psychology of learning consists of activation of prior knowledge while processing new information and elaboration on the resulting new knowledge to facilitate storing in long-term memory. This process is limited by the size of working memory. Six interventions based on cognitive theory that facilitate learning and expertise development are discussed: (1) Fostering self-explanation, (2) elaborative discussion, and (3) distributed practice; (4) help with decreasing cognitive load, (5) promoting retrieval practice, and (6) supporting interleaving practice. These interventions contribute in different measure to various instructional methods in use in medical education: problem-based learning, team-based learning, worked examples, mixed practice, serial-cue presentation, and deliberate reflection. The article concludes that systematic research into the applicability of these ideas to the practice of medical education presently is limited and should be intensified.

Effects of deliberate reflection on students' engagement in learning and learning outcomes.

CONTEXT: Reflection in practice is assumed to enhance interest in knowing more about a topic, increasing engagement in learning and learning outcomes. However, this claim lacks empirical evidence, particularly in medical education. The authors investigated the effects of deliberate reflection upon clinical cases on medical students' engagement in a learning activity and learning outcomes. METHODS: A three-task (diagnostic task; learning activity; test) experiment was conducted in August 2017. Seventy-two fourth-year students from UNIFENAS-BH Medical School, Brazil, diagnosed two clinical cases with jaundice as the chief complaint, either by following a deliberate reflection procedure or making differential diagnosis. Subsequently, all participants received the same study material on the diagnosis of jaundice. Finally, they took a recall test on the study material. Outcome measurements were study time and test scores. RESULTS: There was a significant effect of experimental condition on students' engagement in the learning activity and on learning outcomes. Students who deliberately reflected upon the cases invested more time in studying the material than those who made a differential diagnosis (respectively, mean = 254.97, standard deviation = 115.45 versus mean = 194.96, standard deviation = 111.68; p = 0.02; d = 0.53). Deliberate reflection was also related to higher scores in the test relative to differential diagnosis (respectively, mean = 22.08, standard deviation = 14.94 versus mean = 15.75, standard deviation = 9.24; p = 0.03; d = 0.51). Medium effect sizes (Cohen's d) were observed in both measurements. CONCLUSIONS: Relative to making differential diagnosis, deliberate reflection while diagnosing cases fostered medical students' engagement in learning and increased learning outcomes. Teachers can employ this relatively easy procedure, possibly both with simulated and real scenarios, to motivate their students and help them expand their knowledge, an important requirement for their professional development.

Evidence supporting dual-process theory of medical diagnosis: a functional near-infrared spectroscopy study.

PURPOSE: The objective of this study was to determine the extent to which the dual-process theory of medical diagnosis enjoys neuroscientific support. To that end, the study explored whether neurological correlates of system-2 thinking could be located in the brain. It was hypothesised that system-2 thinking could be observed as the activation of the prefrontal cortex. METHOD: An experimental paradigm was applied that consisted of a learning and a test phase. During the learning phase, 22 medical students were trained in diagnosing chest X-rays. Four of these eight cases were presented repeatedly, to develop a high level of expertise for these cases. During the test phase, all eight cases were presented and the participants' prefrontal cortex was scanned using functional near-infrared spectroscopy. Response time and diagnostic accuracy were recorded as behavioural indicators. RESULTS: The results revealed that participants' diagnostic accuracy in the test phase was significantly higher for the trained cases as compared with the untrained cases (F[1, 21] = 138.80, p < 0.001, η2  = 0.87). Also, their response time was significantly shorter for these cases (F[1, 21] = 18.12, p < 0.001, η2  = 0.46). Finally, the results revealed that only for the untrained cases, could a significant activation of the anterolateral prefrontal cortex be observed (F[1, 21] = 21.00, p < 0.01, η2  = 0.34). CONCLUSION: The fact that only untrained cases triggered higher levels of blood oxygenation in the prefrontal cortex is an indication that system-2 thinking is a cognitive process distinct from system 1. Implications of these findings for the validity of the dual-process theory are discussed.

Fostering novice students' diagnostic ability: the value of guiding deliberate reflection.

BACKGROUND: Deliberate reflection when practising the diagnosis of clinical cases has been shown to develop medical students' diagnostic competence. Adding guidance by cueing reflection or providing modelling of reflection increased the benefits of reflection for advanced (Years 5-6) students. The present study investigated whether we could replicate and extend these findings by comparing the effects of free, cued and modelled reflection on novice students' diagnostic competence. METHODS: A total of 80 third-year medical students participated in a two-phase experiment. In the learning phase, students diagnosed nine clinical cases under one of three conditions: free reflection; cued reflection, and modelled reflection. Two weeks later, all students diagnosed four new examples of the diseases studied in the learning phase and four cases of non-studied related diseases ('adjacent diseases'). The main outcome measurements were diagnostic accuracy scores (range 0-1) on studied and adjacent diseases. RESULTS: For studied diseases, there was a significant effect of experimental condition on diagnostic accuracy (p < 0.02), with the cued-reflection group (mean = 0.58, standard deviation [SD] = 0.23) performing significantly better than the free-reflection group (mean = 0.41, SD = 0.20; p < 0.02). The cued-reflection and modelled-reflection groups (mean = 0.54, SD = 0.22) did not differ in diagnostic accuracy (p > 0.05), nor did the modelled-reflection group perform better than the free-reflection group (p > 0.05). For adjacent diseases, the three groups scored extremely low, without significant differences in performance (p > 0.05). Cued reflection and free reflection were rated as requiring similar effort (p > 0.05) and both were more demanding than studying examples of reflection (both p < 0.001) in the learning phase. CONCLUSIONS: Simply cueing novice students' reflection to focus it on relevant diseases was sufficient to increase diagnostic performance relative to reflection without any guidance. Cued reflection and studying examples of reflection appear to be equally useful approaches for teaching clinical diagnosis to novice students. Students found studying examples of reflection required less effort but cued reflection will certainly demand much less investment from teachers.

Effects of graded versus ungraded individual readiness assurance scores in team-based learning: a quasi-experimental study.

Pre-class preparation is a crucial component of team-based learning (TBL). Lack of preparation hinders both individual learning and team performance during TBL. The purpose of the present study was to explore how the grading of the individual readiness assurance test (iRAT) can affect pre-class preparation, iRAT performance and performance in the end-of-year examination. Using a quasi-experimental design, Year 1 and 2 students' download frequency for their pre-class materials, performance on iRAT and examination were examined under two conditions; (1) under which the iRAT was graded and (2) under which the iRAT was ungraded. Medical students (N = 220) from three cohorts were included in the study. Differences between both conditions were tested by means of six separate ANCOVAs, using medical school entry test scores as the covariate to account for potential cohort effects. Results revealed that students were downloading more pre-class materials prior to their TBL sessions, and were performed significantly better on iRAT when their performance was graded, even after controlling for cohort effects. Analysis of covariance demonstrated that performance on iRAT also appeared to affect performance on their examination scores. The results of the study suggest that grading has a positive effect on students' iRAT scores. Implications for TBL are discussed.

Do poor patients suffer from inaccurate diagnoses more than well-to-do patients? A randomized control trial.

BACKGROUND: Poor patients have greater morbidity and die up to 10 years earlier than patients who have higher socio-economic status. These findings are often attributed to differences in life-style between groups. The present study aimed at investigating the extent to which physicians contribute to the effect by providing relative poorer care, resulting in relative neglect in terms of time spent with a poor patient and more inaccurate diagnoses. METHODS: A randomised experiment with 45 internal medicine residents. Doctors diagnosed 12 written clinical vignettes that were exactly the same except for the description of the patients' socio-economic status. Each participant diagnosed four of the vignettes in a poor-patient version, four in a rich-patient version, and four in a version that did not contain socio-economic markers, in a balanced within-subjects incomplete block design. Main measurements were: diagnostic accuracy scores and time spent on diagnosis. RESULTS: Mean diagnostic accuracy scores (range 0-1) did not significantly differ among the conditions of the experiment (for poor patients: 0.48; for rich patients: 0.52; for patients without socio-economic markers: 0.54; p > 0.05). While confronted with patients not presenting with socio-economic background information, the participants spent significantly less time-to-diagnosis ((for poor patients: 168 s; for rich patients: 176 s; for patients without socio-economic markers: 151 s; p < 0.01), however due to the fact that the former vignettes were shorter. CONCLUSION: There is no reason to believe that physicians are prejudiced against poor patients and therefore treat them differently from rich patients or patients without discernible socio-economic background.

Factors underlying suboptimal diagnostic performance in physicians under time pressure.

CONTEXT: Time pressure has been implicated in the suboptimal diagnostic performance of doctors and in increases in diagnostic errors. However, the reasons underlying these effects are not clear. The aim of this study was to investigate the influence of time pressure on physicians' diagnostic accuracy and to explore the mediating effects of perceived stress (emotional pathway) and number of plausible diagnostic hypotheses (cognitive pathway) on the proposed relationship. METHODS: We conducted a randomised controlled experiment. A total of 75 senior internal medicine residents completed eight written clinical cases under conditions with (n = 40) or without (n = 35) time pressure. They were then asked to: (i) rate the overall stress experienced, and (ii) write down any alternative hypotheses they had thought of when diagnosing the cases. In a post hoc analysis, a mediation path analysis was performed to test the causal relationships between time pressure, perceived stress and number of alternative diagnoses. RESULTS: Participants who were under time pressure spent less time diagnosing the cases (85.54 seconds versus 181.81 seconds; p< 0.001) and had a lower mean diagnostic accuracy score (0.44 versus 0.53; p = 0.01). In addition, they reported more stress (5.80 versus 4.69; p = 0.01) and generated fewer plausible tentative hypotheses (0.37 versus 0.51; p = 0.01). Two path coefficients were found to be statistically significant; the first path coefficient referred to the relationship between time pressure and perceived stress (standardised ß = 0.25, p = 0.029), and the second negative path coefficient referred to the relationship between time pressure and number of plausible alternative hypotheses (standardised ß = -0.32, p< 0.01). CONCLUSIONS: Time pressure adversely influences physicians' diagnostic accuracy by increasing their stress response and reducing the number of plausible hypotheses as mediators.

Effect of reflection on medical students' situational interest: an experimental study.

CONTEXT: Reflection has been considered crucial to learning. Engaging in reflection while solving problems is expected to foster identification of knowledge gaps and interest in learning more about them, the latter being a major motivational force in learning. Although theoretically sound, this assumption still lacks empirical evidence. This experiment investigated whether reflection while diagnosing clinical cases of different levels of difficulty influences medical students' awareness of knowledge gaps and situational interest. METHODS: Forty-two fourth-year students from a Brazilian medical school were randomly allocated to diagnose six clinical cases (three difficult; three easy), either by following a structured reflection procedure (reflection group) or by giving alternative diagnoses (control group). Subsequently, for each case, all students rated their situational interest and awareness of knowledge gaps. RESULTS: Situational interest was significantly higher in the reflection group than in the control group (mean = 4.10, standard deviation = 0.50 versus mean = 3.65, standard deviation = 0.48, respectively; p = 0.003; range, 1-5). The effect size was large (d = 0.92). Awareness of knowledge gaps was higher in the reflection group than in the control group, but the difference was not significant. Case difficulty influenced both situational interest, which was significantly higher on easy than on difficult cases (mean = 3.96, standard deviation = 0.56 versus mean = 3.80, standard deviation = 0.55, respectively; p = 0.004), and awareness of knowledge gaps, with higher scores observed on difficult compared with easy cases (mean = 3.99, standard deviation = 0.46 versus mean = 3.66, standard deviation = 0.53, respectively; p < .001). No interaction between experimental condition and case difficulty emerged. CONCLUSION: Relative to providing alternative diagnoses while solving cases, structured reflection increased medical students' interest and may therefore be a useful tool for teachers concerned with enhancing students' motivation for learning. Surprisingly, easy cases promoted higher situational interest despite the higher awareness of knowledge gaps on difficult cases. This suggests the potential for case difficulty to inhibit students' interest in learning, a possibility that demands further investigation.

How cognitive engagement fluctuates during a team-based learning session and how it predicts academic achievement.

The objective of the paper is to report findings of two studies that attempted to find answers to the following questions: (1) What are the levels of cognitive engagement in TBL? (2) Are there differences between students who were more exposed to TBL than students who were less exposed to TBL? (3) To which extent does cognitive engagement fluctuate as a function of the different activities involved in TBL? And (4) How do cognitive engagement scores collected over time correlate with each other and with academic achievement? The studies were conducted with Year-1 and -2 medical students enrolled in a TBL curriculum (N = 175, 62 female). In both studies, six measurements of cognitive engagement were taken during the distinct TBL activities (preparation phase, individual/team readiness assurance test, burning questions, and application exercises). Data were analysed by means of one-way repeated-measures ANOVAs and path modelling. The results of the repeated-measures ANOVA revealed that cognitive engagement systematically fluctuated as a function of the distinct TBL activities. In addition, Year-1 students reported significantly higher levels of cognitive engagement compared to Year-2 students. Finally, cognitive engagement was a significant predictor of performance (ß = .35). The studies presented in this paper are a first attempt to relate the different activities undertaken in TBL with the extent to which they arouse cognitive engagement with the task at hand. Implications of these findings for TBL are discussed.

The effect of self-explanation of pathophysiological mechanisms of diseases on medical students' diagnostic performance.

Self-explanation while diagnosing clinical cases fosters medical students' diagnostic performance. In previous studies on self-explanation, students were free to self-explain any aspect of the case, and mostly clinical knowledge was used. Elaboration on knowledge of pathophysiological mechanisms of diseases has been largely unexplored in studies of strategies for teaching clinical reasoning. The purpose of this two-phase experiment was to investigate the effect of self-explanation of pathophysiology during practice with clinical cases on students' diagnostic performance. In the training phase, 39 4th-year medical students were randomly assigned to solve 6 criterion cases (3 of jaundice; 3 of chest pain), either self-explaining the pathophysiological mechanisms of the findings (n = 20) or without self-explaining (n = 19). One-week later, in the assessment phase, all students solved 6 new cases of the same syndromes. A repeated-measures analysis of variance on the mean diagnostic accuracy scores showed no significant main effects of study phase (p = 0.34) and experimental condition (p = 0.10) and no interaction effect (p = 0.42). A post hoc analysis found a significant interaction (p = 0.022) between study phase and syndrome type. Despite equal familiarity with jaundice and chest pain, the performance of the self-explanation group (but not of the non-self-explanation group) on jaundice cases significantly improved between training and assessment phases (p = 0.035) whereas no differences between phases emerged on chest pain cases. Self-explanation of pathophysiology did not improve students' diagnostic performance for all diseases. Apparently, the positive effect of this form of self-explanation on performance depends on the studied diseases sharing similar pathophysiological mechanisms, such as in the jaundice cases.