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.

Exploring procedure-based management reasoning: a case of tension pneumothorax.

OBJECTIVES: Management reasoning has not been widely explored but likely requires broader abilities than diagnostic reasoning. An enhanced understanding of management reasoning could improve medical education and patient care. We conducted a novel exploratory study to gain further insights into procedure-based management reasoning. METHODS: Participant physicians managed a simulated patient who acutely decompensates in a team-based, time-pressured, live scenario. Immediately following the scenario, physicians perform a think-aloud protocol by watching video recordings of their performance and narrating their reflections in real-time. Verbatim transcripts of the think-aloud protocol were inductively coded using a constant comparative method and evaluated for themes. RESULTS: We recruited 19 physicians (15 internal medicine, one family medicine, and three general surgery) for this study. Recognizing that diagnostic and management reasoning intertwine, this paper focuses on management reasoning's characteristics. We developed three categories of management reasoning factors with eight subthemes. These are Patient factors: Acuity and Preferences; Physician factors: Recognized Errors, Anxiety, Metacognition, Monitoring, and Threshold to Treat; and one Environment factor: Resources. CONCLUSIONS: Our findings on procedure-based management reasoning are consistent with Situation Awareness and Situated Cognition models and the extant work on management reasoning, demonstrating that management is inherently complex and contextually bound. Unique to this study, all physicians focused on prognosis, indicating that attaining competency in procedural management may require planning and prediction abilities. Physicians also expressed concerns about making mistakes, potentially resulting from the scenario's emphasis on a procedure and our physicians' having less expertise in the treatment of tension pneumothorax.

Combat Readiness, Harm Aversion, and Promotion Eligibility: A Qualitative Study of U.S. Servicemembers Views on Tobacco Use and Control in the Military.

INTRODUCTION: More than half a century after the first Surgeon General's Report on Smoking and Tobacco Use, tobacco use remains the leading cause of preventable disease for the U.S. military. Military tobacco use impairs troop readiness, decreases productivity, reduces servicemember physical performance, and leads to chronic illness in veterans. The Department of Defense (DoD) spends considerable effort to maintain a combat ready force, and tobacco use is contradictory to these efforts. U.S. servicemember tobacco use is estimated to cost the federal government more than $6.5 billion annually. The uniqueness of military culture allows for innovative means of tobacco regulation and prevention. Our study examines the U.S. Navy cultural and servicemember perceptions to inform future tobacco control research and policies. MATERIALS AND METHODS: We developed a behavioral model of tobacco use from existing literature. Using this model as a theoretical framework, our study qualitatively examined tobacco use in the active duty Navy population stationed in Okinawa, Japan. Thirty one-on-one interviews were conducted with active duty servicemembers. Sessions were recorded, transcribed, and analyzed in MAXQDA12. RESULTS: Multiple military-specific themes were identified. Themes: (1) tobacco use is a "right," (2) the military may limit active duty servicemembers' rights, (3) tobacco restrictions are justified if they prevent harm to others, (4) tobacco restrictions are not widely enforced, (5) smoke breaks are viewed as a legitimate reason to rest at work, and (6) the benefit of tobacco is as a stimulant. Novel tobacco cessation techniques suggested by our study include: (1) expand the buddy system to create an artificial support network for tobacco cessation and (2) tie promotion eligibility to tobacco use. CONCLUSIONS: This qualitative study identifies military-specific themes from the tobacco user perspective that help to guide research and policy in reducing tobacco use among military servicemembers. Possible interventions suggested by our findings may include replacing tobacco breaks with fitness breaks to relieve workplace stress and support the culture of fitness, expanding the use of pharmacologic stimulants to replace tobacco when used to maintain alertness, and gathering social support for tobacco cessation from non-healthcare unit members. Further study is needed to elucidate the effectiveness of proposed interventions suggested by our findings, with the ultimate aim of policy changes within the military to optimize health and military readiness, while decreasing long-term health effects and costs of tobacco use.