Knowledge Attainment and Engagement Among Medical Students: A Comparison of Three Forms of Online Learning.

Objective: This study compared knowledge attainment and student enjoyment and engagement between clinical case vignette, patient-testimony videos and mixed reality (MR) teaching via the Microsoft HoloLens 2, all delivered remotely to third year medical students. The feasibility of conducting MR teaching on a large scale was also assessed. Setting & Participants: Medical students in Year 3 at Imperial College London participated in three online teaching sessions, one in each format. All students were expected to attend these scheduled teaching sessions and to complete the formative assessment. Inclusion of their data used as part of the research trial was optional. Primary and Secondary Outcome Measures: The primary outcome measure was performance on a formative assessment, which served to compare knowledge attainment between three forms of online learning. Moreover, we aimed to explore student engagement with each form of learning via a questionnaire, and also feasibility of applying MR as a teaching tool on a large scale. Comparisons between performances on the formative assessment between the three groups were investigated using a repeated measures two-way ANOVA. Engagement and enjoyment were also analysed in the same manner. Results: A total of 252 students participated in the study. Knowledge attainment of students using MR was comparable with the other two methods. Participants reported higher enjoyment and engagement (p<0.001) for the case vignette method, compared with MR and video-based teaching. There was no difference in enjoyment or engagement ratings between MR and the video-based methods. Conclusion: This study demonstrated that the implementation of MR is an effective, acceptable, and feasible way of teaching clinical medicine to undergraduate students on a large scale. However, case-based tutorials were found to be favoured most by students. Future work could further explore the best uses for MR teaching within the medical curriculum.

Digital Education for Health Professionals: An Evidence Map, Conceptual Framework, and Research Agenda.

BACKGROUND: Health professions education has undergone major changes with the advent and adoption of digital technologies worldwide. OBJECTIVE: This study aims to map the existing evidence and identify gaps and research priorities to enable robust and relevant research in digital health professions education. METHODS: We searched for systematic reviews on the digital education of practicing and student health care professionals. We searched MEDLINE, Embase, Cochrane Library, Educational Research Information Center, CINAHL, and gray literature sources from January 2014 to July 2020. A total of 2 authors independently screened the studies, extracted the data, and synthesized the findings. We outlined the key characteristics of the included reviews, the quality of the evidence they synthesized, and recommendations for future research. We mapped the empirical findings and research recommendations against the newly developed conceptual framework. RESULTS: We identified 77 eligible systematic reviews. All of them included experimental studies and evaluated the effectiveness of digital education interventions in different health care disciplines or different digital education modalities. Most reviews included studies on various digital education modalities (22/77, 29%), virtual reality (19/77, 25%), and online education (10/77, 13%). Most reviews focused on health professions education in general (36/77, 47%), surgery (13/77, 17%), and nursing (11/77, 14%). The reviews mainly assessed participants' skills (51/77, 66%) and knowledge (49/77, 64%) and included data from high-income countries (53/77, 69%). Our novel conceptual framework of digital health professions education comprises 6 key domains (context, infrastructure, education, learners, research, and quality improvement) and 16 subdomains. Finally, we identified 61 unique questions for future research in these reviews; these mapped to framework domains of education (29/61, 47% recommendations), context (17/61, 28% recommendations), infrastructure (9/61, 15% recommendations), learners (3/61, 5% recommendations), and research (3/61, 5% recommendations). CONCLUSIONS: We identified a large number of research questions regarding digital education, which collectively reflect a diverse and comprehensive research agenda. Our conceptual framework will help educators and researchers plan, develop, and study digital education. More evidence from low- and middle-income countries is needed.

Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review.

The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.

Clinical prioritisation questions: A novel assessment tool to encourage tolerance of uncertainty?

Uncertainty is a common and increasingly acknowledged problem in clinical practice. Current single best answer (SBA) style assessments test areas where there is one correct answer, and as the approach to assessment impacts on the approach to learning, these exams may poorly prepare our future doctors to handle uncertainty. We therefore, need to modify our approach to assessment to emphasize reasoning and introduce the possibility of more than one 'correct' answer. We have developed clinical prioritization questions (CPQs), a novel formative assessment tool in which students prioritize possible responses in order of likelihood. This assessment format was piloted with a group of medical students and evaluated in comparison with the more traditional SBA question format in a team-based learning setting. Students reported that they felt ongoing use would help improve their tolerance of uncertainty (p < 0.01). Furthermore, over 80% of students felt that CPQs were more reflective of real-life clinical practice. Group based discussions were significantly longer when answering CPQs (p < 0.01), suggesting they may promote richer discourse. CPQs may have a role in formative assessment to help equip students with the skills to cope with ambiguity and strengthen clinical reasoning and decision-making. Institutions may find them more practical to implement compared with other clinical reasoning assessment tools.

Using prescribing very short answer questions to identify sources of medication errors: a prospective study in two UK medical schools.

OBJECTIVE: To assess the utility and ability of the novel prescribing very short answer (VSA) question format to identify the sources of undergraduate prescribing errors when compared with the conventional single best answer (SBA) question format and assess the acceptability of machine marking prescribing VSAs. DESIGN: A prospective study involving analysis of data generated from a pilot two-part prescribing assessment. SETTING: Two UK medical schools. PARTICIPANTS: 364 final year medical students took part. Participation was voluntary. There were no other inclusion or exclusion criteria. OUTCOMES: (1) Time taken to mark and verify VSA questions (acceptability), (2) differences between VSA and SBA scores, (3) performance in VSA and (4) SBA format across different subject areas and types of prescribing error made in the VSA format. RESULTS: 18 200 prescribing VSA questions were marked and verified in 91 min. The median percentage score for the VSA test was significantly lower than the SBA test (28% vs 64%, p<0.0001). Significantly more prescribing errors were detected in the VSA format than the SBA format across all domains, notably in prescribing insulin (96.4% vs 50.3%, p<0.0001), fluids (95.6% vs 55%, p<0.0001) and analgesia (85.7% vs 51%, p<0.0001). Of the incorrect VSA responses, 33.1% were due to the medication prescribed, 6.0% due to the dose, 1.4% due to the route and 4.8% due to the frequency. CONCLUSIONS: Prescribing VSA questions represent an efficient tool for providing detailed insight into the sources of significant prescribing errors, which are not identified by SBA questions. This makes the prescribing VSA a valuable formative assessment tool to enhance students' skills in safe prescribing and to potentially reduce prescribing errors.

Development of a web-based tool for undergraduate engagement in medical research; the ProjectPal experience.

BACKGROUND: We report the development and evaluation of a web-based tool designed to facilitate student extra-curricular engagement in medical research through project matching students with academic supervisors. UK based university students were surveyed to explore their perceptions of undergraduate research, barriers and facilitators to current engagement. Following this, an online web-based intervention ( www.ProjectPal.org ) was developed to support access of students to research projects and supervisors. A pilot intervention was undertaken across a London-based university in January 2013 to February 2016. In March 2016, anonymised data were extracted from the prospective data log for analysis of website engagement and usage. Supervisors were surveyed to evaluate the website and student outputs. RESULTS: Fifty-one students responded to the electronic survey. Twenty-four (47%) reported frustration at a perceived lack of opportunities to carry out extra-curricular academic projects. Major barriers to engaging in undergraduate research reported were difficulties in identifying suitable supervisors (33/51; 65%) and time pressures (36/51; 71%) associated with this. Students reported being opportunistic in their engagement with undergraduate research. Following implementation of the website, 438 students signed up to ProjectPal and the website was accessed 1357 times. Access increased on a yearly basis. Overall, 70 projects were advertised by 35 supervisors. There were 86 applications made by students for these projects. By February 2016, the 70 projects had generated 5 peer-review publications with a further 7 manuscripts under peer-review, 14 national presentations, and 1 national prize. CONCLUSION: The use of an online platform to promote undergraduate engagement with extra-curricular research appears to facilitate extra-curricular engagement with research. Further work to understand the impact compared to normal opportunistic practices in enhancing student engagement is now underway.

Effect of maternal heart disease on fetal growth.

OBJECTIVE: To estimate the effect of maternal heart disease on fetal growth and neonatal outcomes. METHODS: A retrospective cohort study of all women with congenital and acquired heart disease admitted at Chelsea and Westminster Hospital between 1994 and 2010 was performed. The women who delivered immediately before and immediately after each index pregnancy were used as controls. Data were obtained from medical and obstetric notes. Birth weight percentiles were calculated using a customized birth weight percentile program, and neonatal complications (preterm birth, perinatal mortality, and recurrence of congenital heart disease) were noted. RESULTS: Median birth weight percentile was significantly lower in the heart disease group (31) compared with the control group (49;P.001 Mann-Whitney U test [corrected].The rate of neonatal complications was significantly higher in the heart disease group (34% compared with 15%). Preterm birth occurred in 42 (13%) pregnancies, of which 67% were iatrogenic. Eighty-one (25%) newborns in the heart disease group were small for gestational age, and there were four stillbirths and four neonatal deaths (perinatal mortality rate 20 per 1,000). CONCLUSION: This cohort study suggests a significant reduction in fetal growth rates associated with maternal heart disease, which is also associated with preterm delivery and reduced birth weight. The presence of maternal cyanosis and a reduced cardiac output are the most significant predictors. LEVEL OF EVIDENCE: II.

Pregnancy in women with a systemic right ventricle after surgically and congenitally corrected transposition of the great arteries.

OBJECTIVE: To determine maternal and neonatal outcomes in women with a systemic right ventricle (RV). STUDY DESIGN: A retrospective (historical) cohort study of maternal and neonatal outcomes at a tertiary referral academic obstetric unit (Chelsea and Westminster Hospital, London). RESULTS: Nineteen pregnancies in 14 women with a systemic RV were compared with 76 controls. There were no maternal deaths. In the study group cardiac complications occurred in six (32%) pregnancies. Obstetric complications occurred in four (21%) case pregnancies, not significantly higher than in the control group. The rate of neonatal complication was significantly higher in the study population with neonatal complications in 12 (63%) case pregnancies compared with 13 (17%) control pregnancies. The median birthweight centile was 9 in the study population, significantly lower than the control population. CONCLUSIONS: Our cohort study demonstrates high maternal and neonatal morbidity and low birthweight in the presence of a systemic RV. Cardiac complications were more common in women with RV dysfunction and arrhythmias prior to pregnancy. Preconception counselling and tertiary care during pregnancy for these patients is highly advisable.

Effect of pregnancy on clinical status and ventricular function in women with heart disease.

BACKGROUND: Pregnant women with heart disease (HD) are at an increased risk for maternal and neonatal adverse events. However, the effect of pregnancy on clinical status and ventricular function in women with HD has not been examined in a controlled study. METHODS AND RESULTS: Ninety-three women with HD were studied longitudinally. Of these, fifty-three underwent clinical and echocardiographic evaluation before and 1.5+/-1.1 years after pregnancy (pregnancy group), whereas forty served as controls matched for age (28.6+/-4.6 versus 28.5+/-6.6, p=0.88), diagnosis, and length of follow-up (2.9+/-1.4 versus 2.6+/-1.1, p=0.23). NYHA functional class remained unchanged in both groups during follow-up. End diastolic and end systolic dimensions and shortening fraction of the morphologic left ventricle also remained unchanged. Furthermore, systemic and subpulmonary ventricular function remained unchanged in the pregnancy and control groups on semiquantitative analysis. Pregnancy, however, was associated with a persisting increase in subpulmonary ventricular size in patients with tetralogy of Fallot (ToF) which was not present in tetralogy controls. Furthermore, diagnosis of ToF was the only predictor of an increase in subpulmonary ventricular size after pregnancy on univariate logistic regression analysis (OR 8.8[95% CI 1.9-41.1], p=0.006). CONCLUSIONS: In this longitudinal controlled study amongst women with HD no deleterious midterm effects of pregnancy on clinical status and right and left ventricular function were found. However, pregnancy was associated with a persisting increase in subpulmonary ventricular size, attributable to patients with repaired ToF. This may have prognostic implications and merits further investigation.

Controversies in pregnancy and congenital heart disease.

As increasing numbers of children with congenital heart disorders reach adulthood, the family physician, cardiologist, and obstetrician will increasingly be called upon to give advice regarding the safety of pregnancy. This need has been further highlighted by the recognition that maternal mortality associated with cardiac disease is rising. Unfortunately, this field of practice remains relatively "evidence-sparse" with many management decisions being guided by anecdote and "best guess" common sense. Not surprisingly, this results in many fundamental controversies over the optimal care these patients should receive. This article highlights, through the use of case histories, some of these contentious areas, reflecting the different manifestations of congenital maternal cardiac disease and highlighting the limitations of our knowledge.

Informed consent: can a patient ever be fully informed?

PURPOSE OF REVIEW: The National Health Service Litigation Authority has issued a warning about the process of asking a patient for their consent prior to a medical procedure. This warning was issued in the light of the case of Chester v. Afshar. For the first time in English law the courts have appeared to state that failure to give a patient adequate information about a procedure is negligent per se. This article briefly examines the history of consent since the famous case of Bolam and reviews the recent legal commentary on the case of Chester. It will also consider a proposed solution to the question 'What is adequate information?' RECENT FINDINGS: The medicolegal literature traces the change in the legal test used to determine whether a patient has been adequately informed. It charts the evolution of a 'prudent patient' test and suggests ways in which medical practitioners might adequately fulfil their duty to inform patients properly. SUMMARY: Since the case of Chester v. Afshar it has become harder for a doctor to escape a charge of negligence if they have given inadequate information at the time of asking a patient for their consent to undergo a medical procedure. It is in everyone's interests - doctor and patient - to make the process of consent transparent and to an agreed national standard.

Cardiac disease in pregnancy.

Congenital heart disease in pregnancy is increasingly common because of the advances in surgery and medical therapy which have taken place over the last 30 years, which means that more affected women are surviving into the reproductive age. Antenatal counselling needs to be tailored to the specific lesion, with pulmonary hypertension and cyanotic disease presenting a risk of maternal mortality of up to 50%. The use of anticoagulants in women with artificial valves presents a particular challenge, heparin being safer for the baby and warfarin for the mother. Peripartum cardiomyopathy and Marfan's syndrome may be less dangerous than once thought. The risk of congenital heart disease in the fetus is increased, from twice to 20-fold, depending on the nature of the mother's lesion. Care throughout pregnancy and in the puerperium should be multidisciplinary and include cardiologists, obstetricians and midwives with experience of such cases, preferably in a tertiary centre.