Clinical reasoning in pharmacy: What do eye movements and verbal protocols tell us about the processing of a case task?

This study investigates pharmacy students' reasoning while solving a case task concerning an acute patient counselling situation in a pharmacy. Participants' (N = 34) reasoning processes were investigated with written tasks utilizing eye-tracking in combination with verbal protocols. The case was presented in three pages, each page being followed by written questions. Eye movements were recorded during case processing. Success in the task required differentiating the relevant information from the task redundant information, and initial activation of several scripts and verification of the most likely one, when additional information became available. 2nd (n = 16) and 3rd (n = 18)-year students' and better and worse succeeding students' processes were compared. The results showed that only a few 2nd-year students solved the case correctly, whereas almost all of the 3rd-year students were successful. Generally, the average total processing times of the case material did not differ between the groups. However, better-succeeding and 3rd-year students processed the very first task-relevant sentences longer, indicating that they were able to focus on relevant information. Differences in the written answers to the 2nd and 3rd question were significant, whereas differences regarding the first question were not. Thus, eye-tracking seems to be able to capture illness script activation during case processing, but other methods are needed to depict the script verification process. Based on the results, pedagogical suggestions for advancing pharmacy education are discussed.

Conceptual changes for and during working life.

Rapid and radical changes in science, technology and society may result in new scientific concepts and new workplace practices, which require fundamental restructuring of prior knowledge. Over the years a noteworthy body of research has documented the processes of conceptual change, the learning mechanisms involved, and the instructional methods and strategies that can promote conceptual changes. This research, however, focused young learners in school settings. Conceptual changes in working life go beyond traditional conceptual change consisting of processes and mechanisms that involve the interaction between expertise development and workplace learning processes.This Special Issue investigates whether and how conceptual change research can be extended from learning in schools to learning in professional life.

To guide or to follow? Teaching visual problem solving at the workplace.

Visual problem solving is essential to highly visual and knowledge-intensive professional domains such as clinical pathology, which trainees learn by participating in relevant tasks at the workplace (apprenticeship). Proper guidance of the visual problem solving of apprentices by the master is necessary. Interaction and adaptation to the expertise level of the learner are identified as key ingredients of this guidance. This study focuses on the effect of increased participation of the learner in the task on the interaction and adaptation of the guidance by masters. Thirteen unique dyads consisting of a clinical pathologist (master) and a resident (apprentice) discussed and diagnosed six microscope images. Their dialogues were analysed on their content. The dyads were divided in two groups according to the experience of the apprentice. For each dyad, master and apprentice both operated the microscope for half of the cases. Interaction was operationalised as the equal contribution of both master and apprentice to the dialogue. Adaptation was operationalised as the extent to which the content of the dialogues was adapted to the apprentice's level. The main hypothesis stated that the interaction and adaptation increase when apprentices operate the microscope. Most results confirmed this hypothesis: apprentices contributed more content when participating more and the content of these dialogues better reflected expertise differences of apprentices. Based on these results, it is argued that, for learning visual problem solving in a visual and knowledge-intensive domain, it is not only important to externalise master performance, but also that of the apprentice.

Expertise in clinical pathology: combining the visual and cognitive perspective.

Expertise studies in the medical domain often focus on either visual or cognitive aspects of expertise. As a result, characteristics of expert behaviour are often described as either cognitive or visual abilities. This study focuses on both aspects of expertise and analyses them along three overarching constructs: (1) encapsulations, (2) efficiency, and (3) hypothesis testing. This study was carried out among clinical pathologists performing an authentic task: diagnosing microscopic slides. Participants were 13 clinical pathologists (experts), 12 residents in pathology (intermediates), and 13 medical students (novices). They all diagnosed seven cases in a virtual microscope and gave post hoc explanations for their diagnoses. The collected data included eye movements, microscope navigation, and verbal protocols. Results showed that experts used lower magnifications and verbalized their findings as diagnoses. Also, their diagnostic paths were more efficient, including fewer microscope movements and shorter reasoning chains. Experts entered relevant areas later in their diagnostic process, and visited fewer of them. Intermediates used relatively high magnifications and based their diagnoses on specific abnormalities. Also, they took longer to reach their diagnosis and checked more relevant areas. Novices searched in detail, described findings by their appearances, and uttered long reasoning chains. These results indicate that overarching constructs can justly be identified: encapsulations and efficiency are apparent in both visual and cognitive aspects of expertise.

Expertise under the microscope: processing histopathological slides.

OBJECTIVES: Although the obvious goal of training in clinical pathology is to bring forth capable diagnosticians, developmental stages and their characteristics are unknown. This study therefore aims to find expertise-related differences in the processing of histopathological slides using a combination of eye tracking data and verbal data. METHODS: Participants in this study were 13 clinical pathologists (experts), 12 pathology residents (intermediates) and 13 medical students (novices). They diagnosed 10 microscopic images of colon tissue for 2 seconds. Eye movements, the given diagnoses, and the vocabulary used in post hoc verbal explanations were registered. Eye movements were analysed according to changes over trial time and the processing of diagnostically relevant areas. The content analysis of verbal data was based on a categorisation system developed from the literature. RESULTS: Although experts and intermediates showed equal levels of diagnostic accuracy, their visual and cognitive processing differed. Whereas experts relied on their first findings and checked the image further for other abnormalities, intermediates tended to double-check their first findings. In their explanations, experts focused on the typicality of the tissue, whereas intermediates mainly mentioned many specific pathologies. Novices looked less often at the relevant areas and were incomplete, incorrect and inconclusive in their explanations. Their diagnostic accuracy was correspondingly poor. CONCLUSIONS: This study indicates that in the case of intermediates and experts, different visual and cognitive strategies can result in equal levels of diagnostic accuracy. Lessons for training underline the relevance of the distinction between normal and abnormal tissue for novices, especially when the mental rotation of 2-D images is required. Intermediates need to be trained to see deviations in abnormalities. Feedback and an educational design that is specific to these developmental stages might improve training.

The Handover Toolbox: a knowledge exchange and training platform for improving patient care.

BACKGROUND: Safe and effective patient handovers remain a global organisational and training challenge. Limited evidence supports available handover training programmes. Customisable training is a promising approach to improve the quality and sustainability of handover training and outcomes. OBJECTIVE: We present a Handover Toolbox designed in the context of the European HANDOVER Project. The Toolbox aims to support physicians, nurses, individuals in health professions training, medical educators and handover experts by providing customised handover training tools for different clinical needs and contexts. METHODS: The Handover Toolbox uses the Technology Enhanced Learning Design Process (TEL-DP), which encompasses user requirements analysis; writing personas; group concept mapping; analysis of suitable software; plus, minus, interesting rating; and usability testing. TEL-DP is aligned with participatory design approaches and ensures development occurs in close collaboration with, and engagement of, key stakeholders. RESULTS: Application of TEL-DP confirmed that the ideal formats of handover training differs for practicing professionals versus individuals in health profession education programmes. Training experts from different countries differed in their views on the optimal content and delivery of training. Analysis of suitable software identified ready-to-use systems that provide required functionalities and can be further customised to users' needs. Interest rating and usability testing resulted in improved usability, navigation and uptake of the Handover Toolbox. CONCLUSIONS: The design of the Handover Toolbox was based on a carefully led stakeholder participatory design using the TEL-DP approach. The Toolbox supports a customisable learning approach that allows trainers to design training that addresses the specific information needs of the various target groups. We offer recommendations regarding the application of the Handover Toolbox to medical educators.

When only the real thing will do: junior medical students' learning from real patients.

OBJECTIVES: This study aimed to explore how medical students experience contacts with real patients and what they learn from them. METHODS: We carried out a post hoc, single-group study in one teaching sector of a 5-year, problem-based, horizontally integrated, outcome-based and community-oriented undergraduate programme, in which students lacked clinical exposure in the pre-clerkship phase. Subjects comprised five cohorts of students on their first clerkships. Data consisted of purposively selected, voluntary, self-report statements regarding real patient learning (RPL). Constant comparative analysis was performed by two independent researchers. RESULTS: Respondents valued patients as an instructional resource that made learning more real. They reported learning through visual pattern recognition as well as through dialogue and physical examination. They more often used social than professional language to describe RPL. They reported affective outcomes including enhanced confidence, motivation, satisfaction and a sense of professional identity. They also reported cognitive outcomes including perspective, context, a temporal dimension, and an appreciation of complexity. Real patient learning helped respondents link theory learned earlier with reality as represented by verbal, visual and auditory experiences. It made learning easier, more meaningful and more focused. It helped respondents acquire complex skills and knowledge. Above all, RPL helped learners to remember subject matter. Most negative responses concerned the difficulty of acquiring appropriate experience, but RPL made a minority of respondents feel uncomfortable and incompetent. CONCLUSIONS: Real patient learning led to a rich variety of learning outcomes, of which at least some medical students showed high metacognitive awareness. Sensitivity from clinical mentors towards the positive and negative outcomes of RPL reported here could support reflective clinical learning.

Scripts and clinical reasoning.

CONTEXT: Each clinical encounter represents an amazing series of psychological events: perceiving the features of the situation; quickly accessing relevant hypotheses; checking for signs and symptoms that confirm or rule out competing hypotheses, and using related knowledge to guide appropriate investigations and treatment. OBJECTIVE: Script theory, issued from cognitive psychology, provides explanations of how these events are mentally processed. This essay is aimed at clinical teachers who are interested in basic sciences of education. It describes the script concept and how it applies in medicine via the concept of the 'illness script'. METHODS: Script theory asserts that, to give meaning to a new situation in our environment, we use goal-directed knowledge structures adapted to perform tasks efficiently. These integrated networks of prior knowledge lead to expectations, as well as to inferences and actions. Expectations and actions embedded in scripts allow subjects to make predictions about features that may or may not be encountered in a situation, to check these features in order to adequately interpret (classify) the situation, and to act appropriately. CONCLUSIONS: Theory raises questions about how illness scripts develop and are refined with clinical experience. It also provides a framework to assist their acquisition.

The cognitive validity of the Script Concordance Test: a processing time study.

BACKGROUND: According to the theory on which the Script Concordance Test (SCT) is based, scripts contain expectations on features that are associated with each illness and about the range of values that are typical, atypical, or incompatible. PURPOSE: To document the construct validity of the SCT, we investigated the theory prediction that once a script is activated, new incoming information (e.g., additional clinical features) is processed faster if it is typical for that script than if it is atypical. If it is incompatible, processing time falls in between. METHODS: We presented 2 groups of participants (30 fourth-year medical students and 30 full-time geriatricians) with 64 clinical vignettes (divided over 5 types of prevalent clinical presentations in geriatrics), each accompanied by a diagnostic hypothesis aimed to instantiate an appropriate script. Next, we presented a new finding, which could be typical, atypical, or incompatible given the hypothesis. Participants had to decide as quickly and accurately as possible whether the new finding increased, decreased, of did not affect the likelihood of the diagnostic hypothesis. We administered the test on a computer. The dependent variable was processing time. We analyzed data with a repeated measure 2 x 3 analysis of variance. RESULTS: Typical information was processed faster than atypical and incompatible information (M = 10.6 sec vs. 19.2 sec and 16.4 sec, respectively; p lt; .001 for both). Incompatible information was processed faster than atypical information (16.4 sec vs. 19.2; p < .001). There was no significant difference between the groups of geriatricians and students. CONCLUSION: It is possible to predict what kind of information will be processed faster depending of the typicality and compatibility of clinical data for given hypotheses. Results support SCT construct validity.

Students' opinions about their preparation for clinical practice.

INTRODUCTION: There are data that suggest that medical students do not feel sufficiently prepared for clinical practice in the clerkships. The transition from pre-clinical to clinical training causes problems. OBJECTIVES: To seek quantitative verification of qualitative findings from an earlier focus group study on problems medical students encounter when entering the clinical phase of undergraduate training. METHODS: At the start of the clinical phase, all Year 4 students at Maastricht Medical School were surveyed on the transition from pre-clinical to clinical training and its effects on workload, knowledge, skills and learning. RESULTS: The response rate was 67%. Students were uncertain as to how to behave and act, mainly because they did not know what was expected of them. They experienced a drastic increase in workload and a lack of time for studying. They considered themselves to be moderately prepared with regard to knowledge and they regarded their physical examination skills as satisfactory. Students reported having difficulty applying theoretical knowledge in clinical practice and perceived shortcomings in basic science knowledge. In addition, they felt compelled to change their learning strategies. DISCUSSION: The results of this study confirm the findings of the focus group study. The students experienced problems related to professional socialisation and workload and deficiencies in knowledge and the organisation of knowledge. A good starting point for improvement may involve exploring students' suggestions of an extensive introduction into the clerkships, a more gradual transition with regard to workload and closer integration of pre-clinical and clinical education.

General competencies of problem-based learning (PBL) and non-PBL graduates.

INTRODUCTION: Junior doctors have reported shortcomings in their general competencies, such as organisational skills and teamwork. We explored graduates' perceptions of how well their training had prepared them for medical practice and in general competencies in particular. We compared the opinions of graduates from problem-based learning (PBL) and non-PBL schools, because PBL is supposed to enhance general competencies. METHOD: We analysed the responses of 1159 graduates from 1 PBL and 4 non-PBL schools to a questionnaire survey administered 18 months after graduation. RESULTS: Compared with their non-PBL colleagues, the PBL graduates gave higher ratings for the connection between school and work, their medical training and preparation for practice. According to the graduates, the most frequently used competencies with sufficient coverage during medical training were expert knowledge, profession-specific skills and communication skills. The majority of the PBL graduates, but less than half of the non-PBL graduates, indicated that communication skills had been covered sufficiently. All the graduates called for more curriculum attention on working with computers, planning and organisation, and leadership skills. More PBL graduates than non-PBL graduates indicated that they had learned profession-specific methods, communication skills and teamwork in medical school. DISCUSSION: Overall, the graduates appeared to be satisfied with their knowledge and skills. The results suggest that the PBL school provided better preparation with respect to several of the competencies. However, both PBL and non-PBL graduates identified deficits in their general competencies, such as working with computers and planning and organising work. These competencies should feature more prominently in undergraduate medical education.

Students' and tutors' perceptions of problems in PBL tutorial groups at a Brazilian medical school.

INTRODUCTION: There are few published studies that address the problem of dysfunctional tutorial groups. Most studies are restricted to student or faculty opinions separately and to specific aspects affecting the tutorial group function. This study examined teacher and student perceptions of frequency and importance of problems observed in tutorial groups in a new PBL program. METHODS: Tutors (n=30) and students in the second (n=75) and third (n=53) year completed a questionnaire at the beginning of the 1999 academic year. The questionnaire had 33 items grouped as seven "factors" related to tutor performance, feedback, assessment, educational resources, student performance, educational problems and external factors RESULTS: The most important problems identified were related to tutors (mainly in training aspects) and students (mainly in problem discussion). Students and feedback (quality) were the most frequent. There were statistically significant differences between tutors' and students' (higher) and between second and third year (higher) students' perceptions of different factors. CONCLUSIONS: (1) Marilia Medical School (FAMEMA) has problems in the tutorial group function mainly related to contributions of students and tutors. (2) Students' and tutors' opinions, as well as those of second and third year students, differ and therefore all need to be consulted to solve tutorial group problems. (3) It is necessary to develop a better student training program and also to improve the tutors training program. (4) There is a need for continued evaluation of problem-based learning at FAMEMA. We must look at perceptions of students from all years.

Long-term retention of a theatrical script by repertory actors: the role of context.

Four actors were requested to perform Sartre's No Exit after a retention interval of more than 5 months. Their recall of the play was studied either with the spatial and visual contextual cues normally available during a performance or without such cues. Total recall was still considerable, equalling 85%. The number of paraphrases of, and inferences on, the original text was however quite large (32%), suggesting that the actors had learned their lines according to their meaning rather than as a result of rote memorisation. The context manipulation showed that actors' recall is facilitated by the availability of spatial-visual information, but only to a limited extent. The relative importance of textual and contextual cues in the long-term retention of a play is discussed.

The robustness of medical expertise: clinical case processing by medical experts and subexperts.

Medical specialists confronted with problems in their domain of expertise do not rely on intentional causal reasoning, using explicit principles or rules. Rather, reasoning is an automatic process, using knowledge in an encapsulated mode. Less clear is what happens when medical specialists encounter problems outside their specialties. To shed light on this issue, we asked cardiologists and pulmonologists to evaluate 4 clinical cases, 2 in the domain of cardiology and 2 in pulmonology. Their task was to study, diagnose, recall, and explain the signs and symptoms of the clinical case descriptions. The cardiologists and pulmonologists alike processed cases in their specialties faster and more accurately, but recall and pathophysiological explanations did not reveal significant differences. These results suggest that medical specialists do not process cases outside their specialties in a qualitatively different mode from cases within their specialties.

A Qualitative Analysis of the Transition from Theory to Practice in Undergraduate Training in a PBL-Medical School.

In spite of numerous curricular innovations, the problems medical students encounter in making the transition from theoretical training to clinical training remain unresolved and the problem has received scant attention in the literature. We performed a qualitative study to explore students' perceptions and attitudes regarding this transition in undergraduate medical training. Twenty fifth-year students of the Maastricht Medical School participated in focus group discussions about the transition from the preclinical phase to the clinical phase of the curriculum. All focus group discussions were videotaped, literally transcribed and qualitatively analysed using content analysis. The results suggest that students have difficulty in bridging the gap between the theoretical and clinical phase of the curriculum. The problems they experience arise largely from professional socialisation processes. However, students also find it difficult to apply theoretical knowledge in clinical practice. Students find contacts with real patients highly motivating. In the clinical phase their learning changes from passive acquisition of knowledge to more active learning.Since the problem-based learning approach is supposed to enhance application of basic science concepts to clinical problems, it is surprising that students experience difficulties in applying their knowledge in practice. To facilitate the transition from theory to practice in the Maastricht Medical School some curricular changes could be introduced, such as early patient contacts to motivate students and help them learn usable knowledge. Furthermore, the advantages of a problem-based preclinical curriculum to student learning should be fully exploited. Finally, the assessment system must be congruent with the educational programme, because examinations have a powerful effect on student learning.