An Exploration of Pediatricians' Professional Identities: A Q-Methodology Study.

Professional identities may influence a wide range of attitudes, ethical standards, professional commitments and patient safety. This study aimed to explore the important elements that comprise pediatricians' professional identities. A Q-methodology was used to identify the similarities and differences in professional identity. Forty pediatricians were recruited from two tertiary referral hospitals in Taiwan. A list of statements was developed by five attending physicians and three residents. R software was used to analyze the Q-sorts to load the viewpoints and formulate the viewpoint arrays. Additional qualitative data-one-to-one personal interviews-were analyzed. Twenty-eight of forty pediatricians, 11 males and 17 females, with an average age of 39.9 (27-62) years, were associated with four viewpoints. We labeled the four viewpoints identified for professional identity as (1) professional recognition, (2) patient communication, (3) empathy and (4) insight. The professional recognition viewpoint comprised of youngest participants-28-36 years-with the majority as residents (77.8%), while the empathy viewpoint comprised the oldest participants-38-62 years-with all as attending physicians. All participants in the empathy and insight viewpoints were married. This study found professional identity to be a multifaceted concept for pediatricians, especially in the areas of professional recognition, patient communication, empathy and insight into patient care.

Synthesis of 2-Azanorbornanes via Strain-Release Formal Cycloadditions Initiated by Energy Transfer.

Rigid bicycles are becoming more popular in the pharmaceutical industry because they allow for expansion to new and unique chemical spaces. This work describes a new strategy to construct 2-azanorbornanes, which can act as rigid piperidine/pyrrolidine scaffolds with well-defined exit vectors. To achieve the synthesis of 2-azanorbornanes, new strain-release reagent, azahousane, is introduced along with its photosensitized strain-release formal cycloaddition with alkenes. Furthermore, new reactivity between a housane and an imine is disclosed. Both strategies lead to various substituted 2-azanorbornanes with good selectivities.

Conceptualisation and Development of a values-based scale of emergency physicians' professional identities.

BACKGROUND: Physicians' values about what constitute their professional identities are integral in understanding how they ascribe meaning to their practice. However, there is no general consensus on the conceptualization and measurement of physicians' professional identities. This study developed and validated a values-based scale for measuring physicians' professional identities. METHODS: A hybrid research method was used to gather both qualitative and quantitative data. We employed literature review, semi-structured interview, Q-sorting exercise to examine the conceptualization of emergency physicians' professional identities and to initially develop a 40-item scale. A panel of five experts assessed the scale's content validity. Using 150 emergency physicians as our sample, we conducted Confirmatory Factor Analyses (CFA) to test the fit of our hypothesised four-factor model based on our preliminary findings. RESULTS: Initial CFA suggested revisions to the model. Following theoretical assumptions and modification indices, the model was revised and adjusted to a four-factor 20 item Emergency Physicians Professional Identities Value Scale (EPPIVS) with acceptable fit statistics χ2 = 389.38, df = 164, Normed χ2 = 2.374, GFI = 0.788, CFI = 0.862, RMSEA = 0.096. The Cronbach's alpha, McDonald's Omega reliability and composite reliability of the subscales ranged from α: 0.748 to 0.868, Omega: 0.759 to 0.868 and CR: 0.748 to 0.851, respectively. CONCLUSION: The results indicate that the EPPIVS is a valid and reliable scale for measuring physicians' professional identities. Further research on the sensitivity of this instrument to important changes over career progression in emergency medicine is warranted.

Emergency residents' self-perceived readiness for practice: the association of milestones, entrustable professional activities, and professional identities-a multi-institutional survey.

Background: As a successful innovation, competency-based medical education and its assessment tools continue to be a key strategy in training future doctors and tracking their performance trajectories. Linked to professional identity, evidence suggests that clinical competence is related to thinking, acting and feeling like a physician. Thus, incorporating the values and attitudes of healthcare professions as part of their professional identity in the clinical workplace improves professional performance. Methods: Through a cross-sectional study, we examined the association of milestone, entrustable professional activities (EPA) and professional identity using self-reported tools among emergency medicine residents from 12 teaching hospitals across Taiwan. Milestone, EPA and professional identity were assessed using the Emergency Medicine Milestone Scale, Entrustable Professional Activity Scale and Emergency Physician Professional Identity and Value Scale, respectively. Results: The results of a Pearson correlation indicated a significant positive correlation between milestone-based core competencies and EPAs (r = 0.40 ~ 0.74, p < 0.01). The professional identity domain of skills acquisition, capabilities and practical wisdom was positively correlated with milestone-based core competencies of patient care, medical knowledge, practice-based learning and improvement, and system-based practice (r = 0.18 ~ 0.21, p ≤ 0.05), and six items of EPA (r = 0.16 ~ 0.22, p < 0.05). Additionally, the professional identity domain of professional recognition and self-esteem was positively correlated with practice-based learning and improvement, and system-based practice milestone competencies (r = 0.16 ~ 0.19, p < 0.05). Conclusion: This study demonstrates milestone and EPA assessment tools are highly linked and therefore, can be synergistically used by supervisors and clinical educators to evaluate clinical performance during residency training. Emergency physicians' professional identity is partly influenced by the advancement of skills and a resident's ability to learn, effectively perform tasks and make appropriate medical decisions at the system level in their clinical practice. Further research is warranted to understand the importance of residents' competency in relation to their professional identity development trajectory during clinical training.

Substrate-Gated Transformation of a Pre-Catalyst into an Iron-Hydride Intermediate [(NO)2(CO)Fe(µ-H)Fe(CO)(NO)2]- for Catalytic Dehydrogenation of Dimethylamine Borane.

Continued efforts are made on the development of earth-abundant metal catalysts for dehydrogenation/hydrolysis of amine boranes. In this study, complex [K-18-crown-6-ether][(NO)2Fe(µ-MePyr)(µ-CO)Fe(NO)2] (3-K-crown, MePyr = 3-methylpyrazolate) was explored as a pre-catalyst for the dehydrogenation of dimethylamine borane (DMAB). Upon evolution of H2(g) from DMAB triggered by 3-K-crown, parallel conversion of 3-K-crown into [(NO)2Fe(N,N'-MePyrBH2NMe2)]- (5) and an iron-hydride intermediate [(NO)2(CO)Fe(µ-H)Fe(CO)(NO)2]- (A) was evidenced by X-ray diffraction/nuclear magnetic resonance/infrared/nuclear resonance vibrational spectroscopy experiments and supported by density functional theory calculations. Subsequent transformation of A into complex [(NO)2Fe(µ-CO)2Fe(NO)2]- (6) is synchronized with the deactivated generation of H2(g). Through reaction of complex [Na-18-crown-6-ether][(NO)2Fe(η2-BH4)] (4-Na-crown) with CO(g) as an alternative synthetic route, isolated intermediate [Na-18-crown-6-ether][(NO)2(CO)Fe(µ-H)Fe(CO)(NO)2] (A-Na-crown) featuring catalytic reactivity toward dehydrogenation of DMAB supports a substrate-gated transformation of a pre-catalyst [(NO)2Fe(µ-MePyr)(µ-CO)Fe(NO)2]- (3) into the iron-hydride species A as an intermediate during the generation of H2(g).

Comparison of the effect of 360° versus two-dimensional virtual reality video on history taking and physical examination skills learning among undergraduate medical students: a randomized controlled trial.

Before caring for patients, video instruction is commonly used for undergraduate medical students, and 360° virtual reality (VR) videos have gained increasing interest in clinical medical education. Therefore, the effect of immersive 360° VR video learning compared with two-dimensional (2D) VR video learning in clinical skills acquisition should be evaluated. This randomized, intervention-controlled clinical trial was aimed to assess whether immersive 360° VR video improves undergraduate medical students' learning effectiveness and reduces the cognitive load in history taking and physical examination (H&P) training. From May 1 2018 to October 30 2018, 64 senior undergraduate medical students in a tertiary academic hospital were randomized to receive a 10-min immersive 360° (360° VR video group; n = 32) or 2D VR instructional video (2D VR video group; n = 32), including essential knowledge and competency of H&P. The demographic characteristics of the two groups were comparable for age, sex, and cognitive style. The total procedure skill score, physical examination score, learner's satisfaction score, and total cognitive load in the 360° VR video group were significantly higher than those in the 2D VR video group (effect sizes [95% confidence interval]: 0.72 [0.21-1.22], 0.63 [0.12-1.13], 0.56 [0.06-1.06], and 0.53 [0.03-1.03], respectively). This study suggested that a10-minute 360° VR video instruction helped undergraduate medical students perform fundamental H&P skills as effectively as 2D VR video. Furthermore, the 360° VR video might result in significantly better procedural metrics of physical examinations with higher learner satisfaction despite the higher cognitive load. Supplementary Information: The online version contains supplementary material available at 10.1007/s10055-022-00664-0.

Self-efficacy of caring for patients in the intensive care unit with delirium: Development and validation of a scale for intensive care unit nurses.

BACKGROUND: Improving the self-efficacy of intensive care unit nurses for delirium care could help them adapt to the changing situation of delirium patients. Validated measures of nurses' self-efficacy of delirium care are lacking OBJECTIVES: The objective of this study was to develop a Delirium Care Self-Efficacy Scale for assessing nurses' confidence about caring for patients in the intensive care unit and to examine the scale's psychometric properties. METHODS: Draft scale items were generated from a review of relevant literature and face-to-face interviews with intensive care unit nurses; content validity was conducted with a panel of five experts in delirium. A group of nurses were recruited by convenience sampling from intensive care units (N = 299) for item analysis of the questionnaire, assessment of validity, and reliability of the scale. Nurse participants were recruited from nine adult critical care units affiliated with a hospital in Taiwan. Data were collected from August 2020 to July 2021. RESULTS: Content validity index was 0.98 for the initial 26 items, indicating good validity. The critical ratio for item discrimination was 14.47-19.29, and item-to-total correlations ranged from 0.67 to 0.81. Principal component analysis reduced items to 13 and extracted two factors, confidence in delirium assessment and confidence in delirium management, which explained 66.82% of the total variance. Cronbach's alpha for internal consistency was 0.94 with good test-retest reliability (r = 0.92). High scale scores among participants were significantly associated with age (≥40 years), work experience in an intensive care unit (≥10 years), delirium education, and willingness to use delirium assessment tools. CONCLUSIONS: The newly developed Delirium Care Self-Efficacy Scale demonstrated acceptable reliability and validity as a measure of confidence for intensive care nurses caring for and managing patients with delirium in the intensive care unit.

Validation of a five-level triage system in pediatric trauma and the effectiveness of triage nurse modification: A multi-center cohort analysis.

Introduction: Triage is one of the most important tasks for nurses in a modern emergency department (ED) and it plays a critical role in pediatric trauma. An appropriate triage system can improve patient outcomes and decrease resource wasting. However, triage systems for pediatric trauma have not been validated worldwide. To ensure clinical reliability, nurses are allowed to override the acuity level at the end of the routine triage process. This study aimed to validate the Taiwan Triage and Acuity Scale (TTAS) for pediatric trauma and evaluate the effectiveness of triage nurse modification. Methods: This was a multicenter retrospective cohort study analyzing triage data of all pediatric trauma patients who visited six EDs across Taiwan from 2015 to 2019. Each patient was triaged by a well-trained nurse and assigned an acuity level. Triage nurses can modify their acuity based on their professional judgment. The primary outcome was the predictive performance of TTAS for pediatric trauma, including hospitalization, ED length of stay, emergency surgery, and costs. The secondary outcome was the accuracy of nurse modification and the contributing factors. Multivariate regression was used for data analysis. The Akaike information criterion and C-statistics were utilized to measure the prediction performance of TTAS. Results: In total, 45,364 pediatric patients were included in this study. Overall mortality, hospitalization, and emergency surgery rates were 0.17, 5.4, and 0.76%, respectively. In almost all cases (97.48%), the triage nurses agreed upon the original scale. All major outcomes showed a significant positive correlation with the upgrade of acuity levels in TTAS in pediatric trauma patients. After nurse modification, the Akaike information criterion decreased and C-statistics increased, indicating better prediction performance. The factors contributing to this modification were being under 6 years of age, heart rate, respiratory rate, and primary location of injuries. Conclusion: The TTAS is a reliable triage tool for pediatric trauma patients. Modification by well-experienced triage nurses can enhance its prediction performance. Younger age, heart rate, respiratory rate, and primary location of injuries contributed to modifications of the triage nurse. Further external validation is required to determine its role in pediatric trauma worldwide.

Exploring the Impact of Pre-course High-Fidelity Simulation on Professional Socialization of Medical Students in Emergency Medicine Internship Rotation-A Qualitative Approach.

Background: Medical students in block clerkships constantly adapt to new environments and learn to interact with new people as they rotate between specialties. This frequent change potentially limited interns' opportunities for participation in real clinical practice. The aims of this study were to explore interns' conceptualization of their learning opportunities and experiences in the workplace during an emergency medicine (EM) block internship. In addition, the study also explored how participating in the pre-rotation high-fidelity simulation (HFS) orientation influenced interns' perception of their transition, participation and learning experiences in the real EM setting. Methods: We implemented a newly developed pre-EM rotation orientation curriculum for interns. This orientation took place on the first day of the 2-week EM internship rotation. Two focus group discussions were held after each simulation training, one immediately after simulation to understand the students' perception and the educational impact of this activity, the other at the end of EM rotation to explore and compare their roles and perception in both simulation activity and the real clinical practice. A total of 151 seventh-year medical students enrolled in the pre-course HFS and post-hoc focus group discussions between 2017 and 2019. We applied thematic analysis to systemically identify, examine, and construct themes. Results: Four major themes were constructed from the data; 1. Challenges in finding authentic learning experiences within the context of emergency medicine; 2. Effectiveness of the pre-course HFS 3. Limitations of EM internship rotation curriculum and pre-course simulation. 4. Suggestions for EM block-internship curriculum reforms. Our study's key findings indicate that pre-rotation orientation HFS activity, which offered a psychologically safe space for students to explore facets of EM and gain a contextualized understanding of the emergency work culture and environment, was essential for enhancing students' ability to identify and maximize practice affordances in real workplace. Conclusion: Simulation, facilitates interns' negotiation of legitimate peripheral participation opportunities as they transition into the EM community of practice during their block internship rotation; putting students at the center of the learning process.

Responding to change in a medical student rural community service: Insights from activity theory.

INTRODUCTION: Medical students have voluntarily initiated service-learning programmes with the aim of providing assistance to medically underserved communities, especially within remote indigenous villages. However, their values and goals have been challenged because rural health care demands have changed considerably since the introduction of integrated delivery system (IDS) programmes, that is, programmes that integrate local health care providers with outreach services provided by contracted hospitals. Our study aimed to explore how a health care service-learning group negotiates its position and how it responds to the tension of IDS implementation and changes in rural health care demand. METHODS: Medical students who have been engaged in building or operating the health care service-learning group of one university in Taiwan were invited to participate in the study. We used cultural-historical activity theory (CHAT) to help us interpret the interactions between students, indigenous communities and the public health sectors and to understand the evolution of the service-learning relationship and its effectiveness. RESULTS: Eighteen participants were recruited for in-depth interviews. The implementation of IDS programmes brought change to the rural community and challenges to students' service learning. Utilising cultural-historical activity theory, we highlighted points of fragmentation within the system. This tension lead to medical students' personal conflict and also served as an impetus for change and learning. Flexible goal setting and coping ability were considered critical to the sustainability and maintenance of students' value systems. CONCLUSIONS: IDS implementation can upset the balance of rural health care supply and demand, resulting in accumulating tensions within and between activity systems. Those contradictions exposed medical students to an expansive learning cycle, resulting in transformational change and learning. Under the context of IDS programmes, health care service-learning can create a 'win-win' situation. Not merely medical students but also community residents gain benefits. This result may be extrapolated to health care service-learning programmes with similar context.

Bridging the Gap: Using Consensus to Explore Entrustment Decisions and Feedback Receptivity in Competency-Based Emergency Medicine Residency Programs Through the Construction of a Q-Sample Incorporating a Delphi Technique.

Background: Recent changes in medical education calls for a shift toward student-centered learning. Therefore, it is imperative that clinical educators transparently assess the work-readiness of their medical residents through entrustment-based supervision decisions toward independent practice. Similarly, it is critical that medical residents are vocal about the quality of supervision and feedback they receive. This study aimed to explore the factors that influence entrustment-based supervision decisions and feedback receptivity by establishing a general consensus among Taiwanese clinical educators and medical residents regarding entrustment decisions and feedback uptake, respectively. Methods: In Q-methodology studies, a set of opinion statement (i.e., the Q-sample) is generated to represent the phenomenon of interest. To explore the factors that influence entrustment-based supervision decisions and feedback receptivity, a Q-sample was developed using a four-step approach: (1) literature search using electronic databases, such as PubMed and Google Scholar, and interviews with emergency clinical educators and medical residents to generate opinion statements, (2) thematic analysis and grouping using The Model of Trust, the Ready, Wiling, and Able model, and the theory of self-regulated learning, (3) translation, and (4) application of a Delphi technique, including two expert panels comprised of clinical educators and medical residents, to establish a consensus of the statements and validation for a subsequent Q-study. Results: A total of 585 and 1,039 statements from the literature search and interviews were extracted to populate the sample of statements (i.e., the concourse) regarding entrustment-based supervision decisions for clinical educators and feedback receptivity emergency medicine residents, respectively. Two expert panels were invited to participate in a Delphi Technique, comprised of 11 clinical educators and 13 medical residents. After two-rounds of a Delphi technique, the panel of clinical educators agreed on 54 statements on factors that influence entrustment-based supervision decisions and were categorized into five themes defined by the Model of Trust. Similarly, a total of 60 statements on the factors that influence feedback receptivity were retained by the panel of medical residents and were categorized into five themes defined by the Ready, Willing, and Able model and the theory of self-regulated learning. Conclusion: Though not exhaustive, the key factors agreed upon by clinical educators and medical residents reflect the characteristics of entrustment-based supervision decisions and feedback receptivity across specialties. This study provides insight on an often overlooked issue of the paths to teaching and learning in competency-based residency training programs. Additionally, incorporation of the Delphi technique further adds to the existing literature and puts emphasis as an important tool that can be used in medical education to rigorously validate Q-statements and develop Q-samples in various specialties.

Strain-Release [2π + 2σ] Cycloadditions for the Synthesis of Bicyclo[2.1.1]hexanes Initiated by Energy Transfer.

Saturated bicycles are becoming ever more important in the design and development of new pharmaceuticals. Here a new strategy for the synthesis of bicyclo[2.1.1]hexanes is described. These bicycles are significant because they have defined exit vectors, yet many substitution patterns are underexplored as building blocks. The process involves sensitization of a bicyclo[1.1.0]butane followed by cycloaddition with an alkene. The scope and mechanistic details of the method are discussed.

Multimodal In-training Examination in an Emergency Medicine Residency Training Program: A Longitudinal Observational Study.

Background: In-training examination (ITE) has been widely adopted as an assessment tool to measure residents' competency. We incorporated different formats of assessments into the emergency medicine (EM) residency training program to form a multimodal, multistation ITE. This study was conducted to examine the cost and effectiveness of its different testing formats. Methods: We conducted a longitudinal study in a tertiary teaching hospital in Taiwan. Nine EM residents were enrolled and followed for 4 years, and the biannual ITE scores were recorded and analyzed. Each ITE consisted of 8-10 stations and was categorized into four formats: multiple-choice question (MCQ), question and answer (QA), oral examination (OE), and high-fidelity simulation (HFS) formats. The learner satisfaction, validity, reliability, and costs were analyzed. Results: 486 station scores were recorded during the 4 years. The numbers of MCQ, OE, QA, and HFS stations were 45 (9.26%), 90 (18.5%), 198 (40.7%), and 135 (27.8%), respectively. The overall Cronbach's alpha reached 0.968, indicating good overall internal consistency. The correlation with EM board examination was highest for HFS (ρ = 0.657). The average costs of an MCQ station, an OE station, and an HFS station were ~3, 14, and 21 times that of a QA station. Conclusions: Multi-dimensional assessment contributes to good reliability. HFS correlates best with the final training exam score but is also the most expensive format among ITEs. Increased testing domains with various formats improve ITE's overall reliability. Program directors must understand each test format's strengths and limitations to bring forth the best combination of exams under the local context.

Pediatric Training Crisis of Emergency Medicine Residency during the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) is an emerging viral disease that has caused a global pandemic. Among emergency department (ED) patients, pediatric patient volume mostly and continuously decreased during the pandemic period. Decreased pediatric patient volume in a prolonged period could results in inadequate pediatric training of Emergency Medicine (EM) residents. We collected data regarding pediatric patients who were first seen by EM resident physicians between 1 February 2019, and 31 January 2021, which was divided into pre-epidemic and epidemic periods by 1 February 2020. A significant reduction in pediatric patients per hour (PPH) of EM residents was noted in the epidemic period (from 1.55 to 0.81, p < 0.001). The average patient number was reduced significantly in the classification of infection (from 9.50 to 4.00, p < 0.001), respiratory system (from 84.00 to 22.00, p < 0.001), gastrointestinal system (from 52.00 to 34.00, p = 0.007), otolaryngology (from 4.00 to 2.00, p = 0.022). Among the diagnoses of infectious disease, the most obvious drop was noted in the diagnosis of influenza and enterovirus infection. Reduced pediatric patient volume affected clinical exposure to pediatric EM training of EM residency. Changes in the proportion of pediatric diseases presented in the ED may induce inadequate experience with common and specific pediatric diseases.

Does seniority always correlate with simulated intubation performance? Comparing endotracheal intubation performance across medical students, residents, and physicians using a high-fidelity simulator.

BACKGROUND: Endotracheal intubation is crucial in emergency medical care and anaesthesia. Our study employed a high-fidelity simulator to explore differences in intubation success rate and other skills between junior and senior physicians. METHODS: We examined the performance of 50 subjects, including undergraduate students (UGY), postgraduate trainees (PGY), residents (R), and attending physicians (VS). Each participant performed 12 intubations (i.e. 3 devices x 4 scenarios) on a high-fidelity simulator. Main outcome measures included success rate, time for intubation, force applied on incisor and tongue, and Cormack Lehane grades. RESULTS: There was no primary effect of seniority on any outcome measure except success rate and Cormack Lehane grades. However, VS demonstrated shorter duration than medical students using Glidescope and direct laryngoscopy, whereas VS and R applied significantly more force on the incisor in the normal airway and rigid neck scenario respectively. DISCUSSION: Seniority does not always correlate with skill perfection in detailed processes. Our study suggests that the use of video laryngoscopy enhances the intubation success rate and speed, but the benefit only accrues to senior learners, whereby they applied more force on the incisor at a single peak under difficult scenarios. These findings are discussed in terms of psychological and cognitive perspectives. CONCLUSION: Speed and safety are essential for high quality critical medical procedures. A tool should be designed and implemented to educate junior physicians with an emphasis on practice and efficiency, which should also contribute to updating senior physicians' knowledge and competence by providing instant feedback on their performance. This type of fine-grained feedback could serve as a complement to traditional training and provide a sustainable learning model for medical education.

Undergraduates' preparedness for practice is associated with professional identity and perception of educational environment: A validation study.

BACKGROUND: Medical schools prepare undergraduates for clinical practice. Clinical competencies build up gradually and continuously. Existing literature suggests that new graduates are often unprepared for independent practice. This study aims to validate a Chinese version of a Preparedness for Hospital Practice Questionnaire (PHPQ) in a Taiwanese undergraduate cohort. METHODS: The original eight-domain English version PHPQ was translated into Chinese and back-translated for expert panel discussion. The eight domains encompass interpersonal skills, confidence, collaboration, management, science, prevention, holistic care, and self-directed learning. Reliability and validity were checked by Cronbach's alpha and by confirmatory factor analysis (CFA), respectively. Participants were divided into higher and lower preparedness groups according to PHPQ results, and compared by age, sex, professional identity, and perception of educational environment. RESULTS: A total of 129 undergraduate medical students (55% males) participated in the study. The overall Cronbach's alpha was 0.94. Participants were found to be best prepared in the domain of disease prevention (M = 4.37, SD = 0.68) and least prepared in interpersonal skills (M = 2.68, SD = 0.77). A satisfactory goodness of fit data was yield from CFA with a CMIN/DF of 2.02. Higher levels of preparedness are associated with stronger professional identity (p < 0.001) and better perceived learning environment (p < 0.001). CONCLUSION: The Chinese version of PHPQ showed good reliability and validity. Preparedness for practice was associated with how learners feel about themselves as doctors and how well they had integrated into medical teamwork.