Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions.

Introduction: Self-regulated learning is a cyclical process of forethought, performance, and self-reflection that has been used as an assessment tool in medical education. No prior studies have evaluated SRL processes for answering multiple-choice questions (MCQs) and most evaluated one or two iterations of a non-MCQ task. SRL assessment during MCQs may elucidate reasons why learners are successful or not on these questions that are encountered repeatedly during medical education. Methods: Internal medicine clerkship students at three institutions participated in a SRL microanalytic protocol that targeted strategic planning, metacognitive monitoring, causal attributions, and adaptive inferences across seven MCQs. Responses were transcribed and coded according to previously published methods for microanalytic protocols. Results: Forty-four students participated. In the forethought phase, students commonly endorsed prioritizing relevant features as their diagnostic strategy (n = 20, 45%) but few mentioned higher-order diagnostic reasoning processes such as integrating clinical information (n = 5, 11%) or comparing/contrasting diagnoses (n = 0, 0%). However, in the performance phase, students' metacognitive processes included high frequencies of integration (n = 38, 86%) and comparing/contrasting (n = 24, 55%). In the self-reflection phase, 93% (n = 41) of students faulted their management reasoning and 84% (n = 37) made negative references to their abilities. Less than 10% (n = 4) of students indicated that they would adapt their diagnostic reasoning process for these questions. Discussion: This study describes in detail student self-regulatory processes during MCQs. We found that students engaged in higher-order diagnostic reasoning processes but were not explicit about it and seldom reflected critically on these processes after selecting an incorrect answer. Self-reflections focused almost exclusively on management reasoning and negative references to abilities which may decrease self-efficacy. Encouraging students to identify and evaluate diagnostic reasoning processes and make attributions to controllable factors may improve performance.

Surveying the Middle Ground: A Thematic Analysis of the Medical School Applications of Standard Performers.

INTRODUCTION: As gatekeepers to the medical profession, admissions committees make important decisions through the analysis of quantitative (e.g. test scores and grade point averages) and qualitative (e.g. letters of recommendation and personal statements) data. One area of the application that deserves additional study is the Work and Activities section, where students describe their extracurricular experiences. Previous research has found different themes that sometimes overlap in the applications of exceptional performing and low performing medical students, but it is unclear if these themes are present in the applications of standard performers. MATERIALS AND METHODS: An exceptional performing medical student is defined as one who was inducted into both the Alpha Omega Alpha Honor Medical Society and the Gold Humanism Honor Society. A low performing medical student is one who was referred to the Student Promotions Committee (SPC) where an administrative action was made. A standard performing medical student is defined as someone who was neither a member of an honor society nor referred to the SPC during medical school. Using a constant comparative method, the applications of standard performers who graduated from the Uniformed Services University between 2017 and 2019 was assessed using exceptional performer themes (success in a practiced activity, altruism, teamwork, entrepreneurship, wisdom, passion, and perseverance) and low performer themes (witnessing teamwork, embellishment of achievement, and description of a future event). The presence of novel themes was also assessed. The absolute number of themes and the diversity of themes were determined. Demographic data were collected (age, gender, number of Medical School Admissions Test [MCAT] attempts, highest MCAT score, and cumulative undergraduate grade point average), and descriptive statistics was performed. RESULTS: A total of 327 standard performers were identified between 2017 and 2019. No novel themes were found after coding 20 applications. All exceptional performer themes were identified in the population of standard performers. The low performing theme of embellishment of achievement was not found. Standard performers had a lower number of total exceptional performer themes and a lower diversity of exceptional performer themes compared to low and exceptional performers, but standard performers also had a lower number and less diversity of low performing themes compared to low performers. CONCLUSIONS: This study suggests that the diversity and frequency of exceptional performing themes in a medical school application may be useful in distinguishing between exceptional performers and other performers, though the small sample size limits quantitative conclusions. Low performing themes may be specific to low performers and thus could be useful to admissions committees. Future studies should include a larger sample size and could assess for predictive validity evidence of these exceptional performing and low performing themes through a blinded protocol.

Why Does This Learner Perform Poorly on Tests? Using Self-Regulated Learning Theory to Diagnose the Problem and Implement Solutions.

PROBLEM: Learners who underperform on standardized tests are common throughout all levels of medical education and require considerable faculty time and effort to remediate. Current methods for remediating test-taking difficulties are typically not grounded in educational theory or supported by high-quality evidence. APPROACH: A test-taking assessment was developed based on self-regulated learning (SRL) microanalytic assessment and training and used during academic year 2012-2013. This method assesses the SRL subprocesses of strategic planning, self-monitoring, causal attributions, and adaptive inferences during the educational task of answering test questions. The method was designed for one-on-one use by teacher and learner, and for learner self-assessment and practice. OUTCOMES: At one academic institution, this method was used to categorize learners into struggling test-taker subtypes which correspond to deficiencies in the SRL subprocesses outlined above. A learning plan based on the SRL deficiency was developed for each struggling test-taker subtype. In a small number of internal medicine residents with low in-training examination scores, use of this method yielded improvements in 2013 in-training examination score that doubled the expected improvement based on historical averages. NEXT STEPS: This method is a novel application of SRL theory to a commonly encountered problem in medical education: the learner who performs poorly on tests. Large-scale, multicenter studies of medical learners at a variety of training levels and program types are needed to determine the effectiveness and generalizability of this intervention.

Physical Effects of Anabolic-androgenic Steroids in Healthy Exercising Adults: A Systematic Review and Meta-analysis.

Many athletes use anabolic-androgenic steroids (AAS) for physical enhancement but the magnitude of these gains and associated adverse effects has not been rigorously quantified. MEDLINE, EMBASE, Cochrane, SPORTDiscus, and PsycINFO were searched to identify randomized placebo-controlled trials of AAS in healthy exercising adults that reported one of the following outcomes: muscular strength, body composition, cardiovascular endurance, or power. Two authors appraised abstracts to identify studies for full-text retrieval; these were reviewed in duplicate to identify included studies. Study quality was assessed using the Cochrane method. Data were extracted in duplicate and pooled using the DerSimonian and Laird random effects model and to calculate the ratio of mean outcome improvement where possible. Pooled standardized mean difference (SMD) in muscle strength between AAS and placebo was 0.27 (95% confidence interval, 0.07-0.47; I = 12.7%; 21 studies). Change in strength was 52% greater in the AAS group compared to placebo. The SMD for change in lean mass between AAS and placebo was 0.62 (95% confidence interval, 0.35-0.89; I = 26%; 14 studies). Due to missing data, fat mass, cardiovascular endurance, power, and adverse effects were summarized qualitatively. Only 13 of 25 studies reported adverse effects including increased low density lipoprotein (LDL), decreased high density lipoprotein (HDL), irritability, and acne. In healthy exercising adults, AAS use is associated with a small absolute increase in muscle strength and moderate increase in lean mass. However, the transparency and completeness of adverse effect reporting varied, most studies were of short duration, and doses studied may not reflect actual use by athletes.

Perspective of the Graduating Medical Student: The Ideal Curriculum for the Fourth Year of Undergraduate Medical Education.

OBJECTIVE: To explore medical students' perspective regarding the fourth year of medical school and common educational activities thereof. METHODS: The authors surveyed students graduating in 2012 with a military service obligation about the importance of common fourth-year activities, the proportion of the fourth year devoted to these activities, and important considerations for the fourth-year curriculum. The authors calculated mean importance scores for educational activities and mean proportions of the fourth year that should be devoted to certain activities. Two reviewers independently coded free-text answers to identify and calculate frequencies for common themes. RESULTS: The response rate was 40% (376/942). Participants rated activities related to improving clinical skills and securing the residency of their choice as more than activities such as learning business skills, conducting research, and studying basic sciences. Participants indicated that electives and direct patient care should comprise the majority of the fourth year and frequently mentioned improving specialty-specific clinical skills, pursuing personal medical interests, and taking time to relax as important fourth-year themes. CONCLUSIONS: Students value activities related to securing and succeeding in their chosen residency and the opportunity to pursue electives and take vacation. Faculty should consider the student perspective when reforming curricula.

Dietary factors and luteal phase deficiency in healthy eumenorrheic women.

STUDY QUESTION: Are prospectively assessed dietary factors, including overall diet quality, macronutrients and micronutrients, associated with luteal phase deficiency (LPD) in healthy reproductive aged women with regular menstrual cycles? SUMMARY ANSWER: Mediterranean Diet Score (MDS), fiber and isoflavone intake were positively associated with LPD while selenium was negatively associated with LPD after adjusting for age, percentage body fat and total energy intake. WHAT IS KNOWN ALREADY: LPD may increase the risk of infertility and early miscarriage. Prior research has shown positive associations between LPD and low energy availability, either through high dietary restraint alone or in conjunction with high energy expenditure via exercise, but few studies with adequate sample sizes have been conducted investigating dietary factors and LPD among healthy, eumenorrheic women. STUDY DESIGN, SIZE, DURATION: The BioCycle Study (2005-2007) prospectively enrolled 259 women from Western New York state, USA, and followed them for one (n = 9) or two (n = 250) menstrual cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women aged 18-44 years, with self-reported BMI between 18 and 35 kg/m(2) and cycle lengths between 21 and 35 days, were included in the study. Participants completed baseline questionnaires, four 24-h dietary recalls per cycle and daily diaries capturing vigorous exercise, perceived stress and sleep; they also provided up to eight fasting serum samples during clinic visits timed to specific phases of the menstrual cycle using a fertility monitor. Cycles were included for this analysis if the peak serum luteal progesterone was >1 ng/ml and a urine or serum LH surge was detected. Associations between prospectively assessed diet quality, macronutrients and micronutrients and LPD (defined as luteal duration <10 days) were evaluated using generalized linear models adjusting for age, percentage body fat and total energy intake. MAIN RESULTS AND THE ROLE OF CHANCE: LPD occurred in 41 (8.9%) of the 463 cycles from 246 women in the final analysis. After adjusting for age, percentage body fat and total energy intake, LPD was positively associated with MDS, adjusted odds ratio (aOR): 1.70 (95% confidence interval [CI]: 1.17, 2.48), P = 0.01. In separate macro- and micronutrient adjusted models, increased fiber and isoflavone intake showed modest positive associations with LPD: fiber (per g), aOR: 1.10 (95% CI: 0.99, 1.23), P = 0.07; and isoflavones (per 10 mg), aOR: 1.38 (95% CI: 0.99, 1.92), P = 0.06. In contrast, selenium (per 10 mcg) was inversely associated with LPD, aOR: 0.80 (95% CI: 0.65, 0.97), P = 0.03. Additional adjustments for relevant lifestyle factors including vigorous exercise, perceived stress and sleep did not appreciably alter estimates. LIMITATIONS, REASONS FOR CAUTION: The number of LPD cycles was limited, and thus these findings are exploratory. We relied on participant self-report of their medical history to apply exclusion criteria; it is possible that we admitted to the study women with a gynecologic or medical disease who were unaware of their diagnosis. WIDER IMPLICATIONS OF THE FINDINGS: Our study suggests that diet quality may be associated with LPD among healthy eumenorrheic women. As LPD may contribute to infertility and early miscarriage, further research is warranted to elucidate how dietary factors, such as MDS, may influence LPD. The inverse association we found with selenium is supported by previous research and deserves further investigation to determine whether this finding has pathophysiologic and therapeutic implications. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. No competing interests declared.

Poly(ionic liquid) superabsorbent for polar organic solvents.

A simple, polymerized ionic liquid (poly(IL)) based on methylimidazolium cations tethered to a polystyrene backbone exhibits superabsorbent behavior toward polar organic solvents, most notably propylene carbonate (PC) and dimethyl sulfoxide (DMSO), wherein the poly(IL) was observed to swell more than 390 and 200 times (w/w) its original mass, yet absorbs negligible quantities of water, hexanes, and other solvents, many of which were miscible with the IL monomer. Although solubility parameters and dielectric constants are typically used to rationalize such behaviors, we find that poly(IL)-solvent compatibility is most clearly correlated to solvent dipole moment. Poly(IL) superabsorbency is not reliant upon the addition of a cross-linking agent.