Impact of the COVID-19 Pandemic on Students' Motivation in Relation to Asynchronous Anatomy Video Lectures.

Objectives: This study aimed to investigate medical students' motivation in relation to asynchronous anatomy video lectures, carried out during COVID-19 remote teaching. Methods: Repeated cross-sectional modified Instructional Materials Motivation Survey questionnaire, validated in Brazil, was applied to 255 students attending the first semester of the undergraduate medical course at the José do Rosário Vellano University, in June 2020 and November 2020. The data were analyzed considering the 95% confidence level as significant (p < 0.05). Results: The overall score of motivation attributed by the students was moderate to high (3.7/5, 74%). The same occurred in relation to all dimensions of the instrument: Interest (3.6/5, 72%), Confidence (3.7/5, 74%), Attention (3.5/5, 70%), and Expectation (3.7/5, 74%). Cluster analysis showed that 78% (n = 168) of the students had moderate (72% of the maximum score) or high (86% of the maximum score) degrees of motivation. The influence of social isolation on the students' emotional state did not affect the overall motivation scores (p = 0.217) or the dimensions of motivation: Interest (p = 0342), Confidence (p = 0.061), Attention (p = 0.625), and Expectation (p = 0.094). Conclusions: The students showed high motivation for the asynchronous video lectures of human anatomy. Although the majority of students are highly affected regarding their emotional state, due to the social isolation imposed by the COVID-19 pandemic, this fact did not interfere with the motivation for video lectures, probably due to the high intrinsic motivation that students in the first year have in relation to anatomy. These findings alert to the importance of asynchronous video lectures as an adequate strategy for the teaching and learning of human anatomy. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01714-7.

Estratégias de ensino do raciocínio clínico nos cursos de Medicina do Brasil - revisão integrativa / Teaching strategies for clinical reasoning in Brazilian medical schools - an integrative review

Resumo: Introdução: O raciocínio clínico é considerado uma das principais habilidades que devem ser desenvolvidas pelos estudantes de Medicina, porque permite a elaboração de hipóteses diagnósticas e orienta estratégias investigativas e diagnósticas de forma racional. Embora os educadores tradicionalmente foquem o ensino no modelo hipotético-dedutivo ou analítico, muitos professores de medicina enfrentam no seu dia a dia o desafio de encontrar novas estratégias para ajudar seus estudantes a desenvolver o raciocínio clínico. Objetivo: Este estudo realizou uma revisão integrativa da literatura para identificar as estratégias utilizadas no processo ensino-aprendizagem do raciocínio clínico, nas escolas médicas brasileiras. Método: A metodologia utilizada consistiu em seis etapas: 1. elaboração da pergunta da pesquisa; 2. definição dos critérios de inclusão e exclusão; 3. elenco das informações a serem extraídas; 4. avaliação dos estudos incluídos; 5. interpretação dos resultados; e 6. apresentação da revisão. Resultado: A maioria dos trabalhos apontam que o ensino do raciocínio clínico é realizado por meio de discussões de casos clínicos, de maneira incidental, em diversas disciplinas ou por meio do uso de metodologias ativas, como PBL, TBL e CBL. Apenas três trabalhos apresentados em congressos demonstraram experiências relacionadas à implantação de uma disciplina curricular obrigatória voltada especificamente ao ensino do raciocínio clínico. O ensino do raciocínio clínico é priorizado no internato em relação às fases clínicas e pré-clínicas. Conclusão: Poucos são os estudos que analisam a maneira como se dá o processo ensino-aprendizagem do raciocínio clínico nas escolas médicas brasileiras. Embora mais estudos sejam necessários, podemos verificar a falta de conhecimento teórico sobre raciocínio clínico como uma das principais causas de dificuldade para o desenvolvimento dessa competência pelos estudantes.

Abstract: Introduction: Clinical reasoning is considered one of the main skills that must be developed by medical students, as it allows the establishment of diagnostic hypotheses and directs investigative and diagnostic strategies using a rational approach. Although educators have traditionally focused the teaching method on the analytical model, many medical professors face the challenge in their daily lives of finding new strategies to help their students develop clinical reasoning. Objective: To carry out an integrative literature review to identify the strategies used in the teaching-learning process of clinical reasoning in Brazilian medical schools. Method: The methodology used consists of six steps: 1. creation of the research question; 2. definition of inclusion and exclusion criteria; 3. list of information to be extracted; 4. evaluation of included studies; 5. interpretation of results and 6. presentation of the review. Results: Most studies indicate that the teaching of clinical reasoning is carried out through discussions of clinical cases, incidentally, in different disciplines or through the use of active methodologies such as PBL, TBL and CBL. Only three studies presented at conferences disclosed experiences related to the implementation of a mandatory curricular discipline specifically aimed at teaching clinical reasoning. The teaching of clinical reasoning is prioritized in internships in relation to the clinical and pre-clinical phases. Final considerations: There are few studies that analyze how clinical reasoning is taught to medical students in Brazilian medical schools. Although more studies are needed, we can observe the lack of theoretical knowledge about clinical reasoning as one of the main causes of the students' difficulty in developing clinical reasoning.

The use of deliberate reflection to reduce confirmation bias among orthopedic surgery residents / O uso da reflexão deliberada para reduzir o viés de confirmação em residentes de ortopedia

Introduction: cognitive biases might affect decision-making processes such as clinical reasoning and confirmation bias is among the most important ones. The use of strategies that stimulate deliberate reflection during the diagnostic process seems to reduce availability bias, but its effect in reducing confirmation bias needs to be evaluated. Aims: to examine whether deliberate reflection reduces confirmation bias and increases the diagnostic accuracy of orthopedic residents solving written clinical cases. Methods: experimental study comparing the diagnostic accuracy of orthopedic residents in the resolution of eight written clinical cases containing a referral diagnosis. Half of the written cases had a wrong referral diagnosis. One group of residents used deliberate reflection (RG), which stimulates comparison and contrast of clinical hypotheses in a systematic manner, and a control group (CG), was asked to provide differential diagnoses with no further instruction. The study included 55 third-year orthopedic residents, 27 allocated to the RG and 28 to the CG. Results: residents on the RG had higher diagnostic scores than the CG for clinical cases with a correct referral diagnosis (62.0±20.1 vs. 49.1±21.0 respectively; p = 0.021). For clinical cases with incorrect referral diagnosis, diagnostic accuracy was similar between residents on the RG and those on the CG (39.8±24.3 vs. 44.6±26.7 respectively; p = 0.662). We observed an overall confirmation bias in 26.3% of initial diagnoses (non-analytic phase) and 19.5% of final diagnoses (analytic phase) when solving clinical cases with incorrect referral diagnosis. Residents from RG showed a reduction in confirmation of incorrect referral diagnosis when comparing the initial diagnosis given in the non-analytic phase with the one provided as the final diagnosis (25.9±17.7 vs. 17.6±18.1, respectively; Cohen d: 0.46; p = 0.003). In the CG, the reduction in the confirmation of incorrect diagnosis was not statistically significant. Conclusions:confirmation bias was present when residents solved written clinical cases with incorrect referral diagnoses, and deliberate reflection reduced such bias. Despite the reduction in confirmation bias, diagnostic accuracy of residents from the RG was similar to those from the CG when solving the set of clinical cases with a wrong referral diagnosis.

Introdução: os vieses cognitivos podem afetar tanto os processos de tomada de decisão como o raciocínio clínico e o viés de confirmação está entre os mais importantes. O uso de estratégias que estimulem a reflexão deliberada durante o processo diagnóstico parece reduzir o viés de disponibilidade, mas seu efeito na redução do viés de confirmação precisa ser avaliado. Objetivos: examinar se a reflexão deliberada reduz o viés de confirmação e aumenta a acurácia do diagnóstico de residentes de ortopedia ao resolverem casos clínicos escritos. Métodos: estudo experimental comparando a acurácia diagnóstica de residentes de ortopedia na resolução de oito casos clínicos escritos contendo um diagnóstico de encaminhamento. Metade dos casos escritos tinha um diagnóstico de encaminhamento errado. Um grupo de residentes utilizou a reflexão deliberada (GR), que estimula a comparação e o contraste de hipóteses clínicas de maneira sistemática, e um grupo controle (GC) foi solicitado a fornecer diagnósticos diferenciais sem maiores instruções. O estudo incluiu 55 residentes de ortopedia do terceiro ano, 27 alocados no GR e 28 no GC. Resultados: residentes no GR tiveram escores diagnósticos mais altos do que o GC para casos clínicos com um diagnóstico de encaminhamento correto (62,0±20,1 vs. 49,1±21,0 respectivamente; p = 0,021). Para os casos clínicos com diagnóstico de encaminhamento incorreto, a acurácia diagnóstica foi semelhante entre os residentes do GR e os do GC (39,8±24,3 vs. 44,6±26,7 respectivamente; p = 0,662). Observamos viés geral de confirmação em 26,3% dos diagnósticos iniciais (fase não analítica) e 19,5% dos diagnósticos finais (fase analítica) na resolução de casos clínicos com diagnóstico de encaminhamento incorreto. Os residentes do GR mostraram uma redução na confirmação do diagnóstico de encaminhamento incorreto ao comparar o diagnóstico inicial dado na fase não analítica com aquele fornecido como diagnóstico final (25,9±17,7 vs. 17,6±18,1, respectivamente; Cohen d: 0,46; p = 0,003). No GC, a redução na confirmação do diagnóstico incorreto não foi estatisticamente significativa. Conclusões: o viés de confirmação esteve presente quando os residentes resolveram casos clínicos escritos com diagnósticos de encaminhamento incorretos e a reflexão deliberada reduziu esse viés. Apesar da redução do viés de confirmação, a acurácia diagnóstica dos residentes do GR foi semelhante à do GC na solução do conjunto de casos clínicos com diagnóstico de encaminhamento incorreto.

Exploring mechanisms underlying learning from deliberate reflection: An experimental study.

INTRODUCTION: Previous research suggests that, relative to generating a differential diagnosis, deliberate reflection during practice with clinical cases fosters learning from a subsequently studied scientific text and promotes interest in the subject matter. The present experiment aimed to replicate these findings and to examine whether motivational or cognitive mechanisms, or both, underlie the positive effects of reflection. METHODS: A total of 101 5th-year medical students participated in an experiment containing four phases: Students (a) diagnosed two clinical cases of jaundice-related diseases either through deliberate reflection or differential diagnosis; (b) reported their situational interest and awareness of knowledge gaps; (c) studied a text about jaundice, either under free or restricted time; and (d) recalled the text. Outcome measures were text-recall, situational interest and awareness of knowledge gaps. RESULTS: A main effect of diagnostic approach on recall of the text was found, with the reflection group recalling more studied material than the differential diagnosis group (means: 72.56 vs 58.80; P = .01). No interaction between diagnostic approach and study time (free or restricted) emerged, nor was there a main effect of the latter. Relative to the differential diagnosis group, students who reflected upon the cases scored significantly higher on both situational interest (means: 4.45 vs 3.99, P < .001) and awareness of knowledge gaps (means: 4.13 vs 3.85, P < .01). DISCUSSION: Relative to generating differential diagnoses, reflection upon clinical cases increased learning outcomes on a subsequent study task, an effect that was independent of study time, suggesting that cognitive mechanisms underlie this effect, rather than increases in motivation to study. However, higher scores on situational interest and awareness of knowledge gaps and a tendency towards larger gains when time was free suggest that higher motivation may also contribute to learning from reflection.

Análise de conteúdo de duas avaliações externas brasileiras de cursos de medicina: Enade e Revalida / Content analysis of two Brazilian external evaluations of medical programs: ENADE and REVALIDA

Resumo: Introdução: O Enade é prova cognitiva que avalia o desempenho dos cursos de graduação por meio dos egressos. O Revalida é exame específico para egressos de cursos de Medicina do exterior. Apesar de possuírem atribuições diferentes, as duas avalições são direcionadas a públicos semelhantes, podendo ser consideradas análogas. Objetivo: Este estudo teve como objetivos identificar e comparar os conteúdos avaliados pelo Enade e Revalida. Métodos: Trata-se de estudo descritivo que comparou o conteúdo do Enade 2013 e 2016 e do Revalida 2015 e 2016, com base na Matriz de Correspondência Curricular do Revalida (MCCR). Na primeira etapa do estudo, dois médicos, professores de Medicina, analisaram de forma independente os itens das quatro avaliações e listaram os conteúdos abordados nos enunciados e nas alternativas. Posteriormente, consolidaram-se os resultados. A análise foi realizada por meio da distribuição de frequência de temas e áreas de concentração de acordo com o exame, da comparação entre as áreas de concentração e dos temas coincidentes em cada exame. Resultados: Das 46 áreas de concentração da MCCR, dez não foram abordadas no Enade 2013, seis no ENADE 2016 e duas no Revalida 2015. O Revalida 2016 abordou todas as áreas. Em relação aos 749 temas específicos da MCCR, as duas edições do Enade, em conjunto, abordaram 241 (32,2%) deles, enquanto as duas edições do Revalida abordaram 468 temas (62,5%). Na análise dos 241 temas abordados pelo Enade, 45 deles foram comuns às duas edições, enquanto, de um total de 468 temas, 247 foram abordados nas duas edições do Revalida. Quando se analisou a repetição de temas em cada edição dos exames, observou-se que cerca de 80,0% dos temas foram considerados apenas uma vez nas duas edições do Enade, em comparação com 50,0% nas edições do Revalida. Conclusão: Os resultados indicam que as edições 2013 e 2016 do Enade apresentam baixa abrangência de conteúdos em comparação com as edições 2015 e 2016 do Revalida, tendo como referência a MCCR. Identificaram-se também concentração da abordagem em grupos específicos de temas e repetição de um pequeno grupo de temas nas edições analisadas do Enade.

Abstract: Introduction: Enade is a cognitive test that evaluates the performance of undergraduate programs through its students. Revalida is a specific exam for graduates from foreign medicine programs. Despite having different functions, the two tests assess the same target audience and can be considered analogous. Objective: The objective was to identify and compare the contents of ENADE and REVALIDA. Methods: a descriptive study that compared the contents of ENADE 2013 and 2016 and REVALIDA 2015 and 2016 with reference to the contents of the REVALIDA Curriculum Correspondence Matrix (RCCM). In the first stage of the study, two doctors, professors of Medicine, independently analyzed the items of the four tests and listed the contents covered in the statements and alternatives. The results were subsequently consolidated. The content analysis of the exams was carried out using frequency distribution of the concentration areas and the themes according to the test and comparison between the areas of concentration and themes that coincided in each test. Results: considering the 46 areas of concentration of the RCCM, 10 areas were not covered in ENADE 2013, six in Enade 2016 and two in Revalida 2015. Revalida 2016 covered all areas. Regarding the 749 specific themes of the RCCM, the two editions of Enade, together, addressed 241 (32.2%) of them, whereas the two editions of Revalida addressed 468 (62.5%) themes. Analysis of the topics covered showed that of the 241 of Enade, 45 were common to both editions, while 247 of a total of 468 were addressed in both editions of Revalida. When considering repetition of the same topic in each edition of each exam, it was found that around 80.0% of the topics were considered only once in the two editions of ENADE compared to 50.0% in the editions of Revalida. Conclusion: the results indicate that ENADE has a lower content validity than Revalida. There was also a concentration in specific groups of themes, and repetition of a small group of themes in the analyzed editions of ENADE, which also reduces the reliability of the exam.

Psychometric assessment of the Instructional Materials Motivation Survey (IMMS) instrument in a remote learning environment / Avaliação psicométrica do instrumento Instructional Materials Motivation Survey (IMMS) em ambiente remoto de aprendizagem

Abstract: Introduction: Motivation contributes greatly to learning, being a predictor of student performance. Thus, instruments that assess motivation after exposure to different teaching strategies and materials can contribute to the analysis and decision on its effectiveness. In this sense, the Instructional Materials Motivation Survey (IMMS) instrument measures students' motivation after instructional activities. Objective: This study aimed to evaluate the evidence of validity of the IMMS, previously translated and cross-culturally adapted to Brazilian Portuguese. Method: Cross-sectional study used to evaluate the psychometric properties of the IMMS questionnaire, applied to 211 students from the first, third and fourth semesters of the medical course at José do Rosário Vellano University (Unifenas - Campus Belo Horizonte). The principal component analysis (PCA) with Varimax rotation and Cronbach's alpha coefficient were used to assess the validity and reliability of the instrument. Results: The PCA reduced the instrument's items from 36 to 25 items, distributed in four dimensions. The saturation of the items in the dimensions ranged from 0.529 to 0.790 and the total explained variance was 63.12%. The reliability of the modified IMMS (IMMS-BRV), measured by Cronbach's alpha, ranged from 0.76 (Attention dimension) to 0.93 (Interest dimension). Conclusion: The IMMS application in the remote education scenario, through asynchronous video lectures of human anatomy, resulted in an alternative instrument (IMMS-BRV), with fewer items (more parsimonious) and good internal consistency, demonstrating preliminary evidence of its validity and reliability adequacy.

Resumo: Introdução: A motivação contribui sobremaneira para a aprendizagem, sendo um fator preditor da performance do estudante. Assim, instrumentos que avaliam a motivação, após exposição a diferentes estratégias e materiais de ensino, podem contribuir para a análise de sua efetividade e decisão sobre esta. Nesse sentido, o instrumento Instructional Materials Motivation Survey (IMMS) mede a motivação dos estudantes após atividades instrucionais. Objetivo: Esta pesquisa teve como objetivo avaliar as evidências de validade do IMMS, previamente traduzido e adaptado transculturalmente para o português brasileiro. Método: Trata-se de um estudo transversal de avaliação das propriedades psicométricas do questionário IMMS, aplicado a 211 estudantes do primeiro, terceiro e quarto períodos do curso de Medicina da Universidade José do Rosário Vellano (Unifenas - câmpus de Belo Horizonte). Adotaram-se a análise de componentes principais (ACP) com rotação Varimax e o coeficiente alfa de Cronbach para avaliação da validade e da confiabilidade do instrumento. Resultado: A ACP reduziu os itens do instrumento de 36 para 25, distribuídos em quatro dimensões. A saturação dos itens nas dimensões variou de 0,529 a 0,790, e a variância total explicada foi de 63,12%. A confiabilidade do IMMS modificado (IMMS-BRV), medida pelo alfa de Cronbach, variou de 0,76 (dimensão atenção) a 0,93 (dimensão interesse). Conclusão: A aplicação do IMMS no cenário de ensino remoto, por meio de videoaulas assíncronas de anatomia humana, resultou em instrumento alternativo (IMMS-BRV), modificado com menor número de itens (mais parcimonioso) e boa consistência interna, demonstrando evidências preliminares de adequação de sua validade e confiabilidade.

'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment.

BACKGROUND: Diagnostic errors have often been attributed to biases in physicians' reasoning. Interventions to 'immunise' physicians against bias have focused on improving reasoning processes and have largely failed. OBJECTIVE: To investigate the effect of increasing physicians' relevant knowledge on their susceptibility to availability bias. DESIGN, SETTINGS AND PARTICIPANTS: Three-phase multicentre randomised experiment with second-year internal medicine residents from eight teaching hospitals in Brazil. INTERVENTIONS: Immunisation: Physicians diagnosed one of two sets of vignettes (either diseases associated with chronic diarrhoea or with jaundice) and compared/contrasted alternative diagnoses with feedback. Biasing phase (1 week later): Physicians were biased towards either inflammatory bowel disease or viral hepatitis. Diagnostic performance test: All physicians diagnosed three vignettes resembling inflammatory bowel disease, three resembling hepatitis (however, all with different diagnoses). Physicians who increased their knowledge of either chronic diarrhoea or jaundice 1 week earlier were expected to resist the bias attempt. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy, measured by test score (range 0-1), computed for subjected-to-bias and not-subjected-to-bias vignettes diagnosed by immunised and not-immunised physicians. RESULTS: Ninety-one residents participated in the experiment. Diagnostic accuracy differed on subjected-to-bias vignettes, with immunised physicians performing better than non-immunised physicians (0.40 vs 0.24; difference in accuracy 0.16 (95% CI 0.05 to 0.27); p=0.004), but not on not-subjected-to-bias vignettes (0.36 vs 0.41; difference -0.05 (95% CI -0.17 to 0.08); p=0.45). Bias only hampered non-immunised physicians, who performed worse on subjected-to-bias than not-subjected-to-bias vignettes (difference -0.17 (95% CI -0.28 to -0.05); p=0.005); immunised physicians' accuracy did not differ (p=0.56). CONCLUSIONS: An intervention directed at increasing knowledge of clinical findings that discriminate between similar-looking diseases decreased physicians' susceptibility to availability bias, reducing diagnostic errors, in a simulated setting. Future research needs to examine the degree to which the intervention benefits other disease clusters and performance in clinical practice. TRIAL REGISTRATION NUMBER: 68745917.1.1001.0068.

Learning by teaching basic life support: a non-randomized controlled trial with medical students.

BACKGROUND: Cardiopulmonary resuscitation is usually taught in universities through theoretical lectures and simulations on mannequins with low retention of knowledge and skills. New teaching methodologies have been used to improve the learning, placing the student at the center of the process. Likewise, the outside community knows next to nothing about cardiopulmonary resuscitation. Patients who have an out-of-hospital cardiac arrest will die if the effective maneuvers are not promptly done. Learning by teaching could be a way to answer both requirements. It was therefore decided to evaluate whether the medical students' cardiopulmonary resuscitation performance would improve when they teach other people, and if those people could learn with them effectively. METHODS: A non-randomized controlled trial was designed to assess whether teaching Basic Life Support would increase students' learning. Socially engaged, seeking to disseminate knowledge, 92 medical students were trained in Basic Life Support and who subsequently trained 240 community health professionals. The students performed theoretical and practical pre- and post-tests whereas the health professionals performed theoretical pre- and post-tests and one practical test. In order to assess the impact of teaching on students' learning, they were divided into two groups: a case group, with 53 students, reassessed after teaching health professionals, and a control group, with 39 students, reassessed before teaching. RESULTS: The practical students' performance of the case group went from 13.3 ± 2.1 to 15.3 ± 1.2 (maximum = 17, p < 0.001) and theoretical from 10.1 ± 3.0 to 16.4 ± 1.7 (maximum = 20, p < 0.001) while the performance of the control group went from 14.4 ± 1.6 to 14.4 ± 1.4 (p = 0.877) and from 11.2 ± 2.6 to 15.0 ± 2.3 (p < 0.001), respectively. The theoretical performance of the health professionals changed from 7.9 ± 3.6 to 13.3 ± 3.2 (p < 0.001) and the practical performance was 11.7 ± 3.2. CONCLUSIONS: The students who passed through the teaching activity had a theoretical and practical performance superior to that of the control group. The community was able to learn from the students. The study demonstrated that the didactic activity can be an effective methodology of learning, besides allowing the dissemination of knowledge. The University, going beyond its academic boundaries, performs its social responsibility.

Impacto do Treinamento de Habilidades de Comunicação e do Registro Médico na Prática do Método Clínico de Atendimento Integral à Pessoa / Impact of Communication Skills Training and Medical Records in the Practice of Patient-Centered Care

RESUMO Introdução A prática do atendimento clínico integral à pessoa é um desafio enfrentado pelo educador médico, por instituições de ensino e por pesquisadores que tentam contribuir para que os estudantes desenvolvam competências educacionais que sintetizem conhecimentos, habilidades e atitudes para esse modelo. Objetivo O objetivo deste estudo foi avaliar o impacto do treinamento de habilidades de comunicação na prática do método clínico de atendimento integral à pessoa, com ou sem o uso de registro específico para o atendimento. Métodos Participaram do estudo 46 estudantes do sétimo período do curso de Medicina da Universidade Federal de Minas Gerais (UFMG). Uma combinação de atividades educacionais foi utilizada para propiciar a aquisição de habilidades de comunicação para o atendimento clínico integral à pessoa, como modeling example, seguido de reflexão individual e discussão, aula expositiva interativa e uso de formulário de registro específico para o atendimento clínico integral à pessoa (RACIP). O estudo foi dividido em quatro fases: (1) pré-treinamento: filmagem de atendimento clínico em ambiente simulado, realizado pelos 46 estudantes, com a utilização do modelo de registro de consulta vigente no HC-UFMG; (2) treinamento: os estudantes foram divididos em três grupos: G1 - submetidos à atividade educacional não relacionada ao atendimento clínico; G2 e G3 - submetidos a treinamento de habilidades de comunicação; (3) avaliação: filmagem de consulta em ambiente simulado, realizada por todos os grupos, sendo que G1 e G3 utilizaram o RACIP, e G2, o modelo de registro vigente; (4) feedback e oportunidade de mesma aprendizagem para todos os grupos. Os vídeos dos atendimentos clínicos realizados pelos estudantes, pré e pós-treinamento, foram avaliados por uma banca constituída por três avaliadores, utilizando-se o instrumento AVACIP (avaliação de atendimento clínico integral à pessoa), levando-se em consideração cinco domínios: início da consulta; expectativas do paciente sobre a consulta; perspectiva do paciente sobre sua doença; comportamento e hábitos de vida; uso de propedêutica complementar e aliança terapêutica. Resultado O escore total de atitudes positivas de cada grupo foi maior na Fase 3 em relação à 1 (p = 0,001), mostrando que todas as estratégias promoveram a melhora das habilidades de comunicação, mas não houve diferença entre os grupos em cada fase (p > 0,310). Quando os escores foram analisados por domínio, observou-se que o G3 apresentou melhor desempenho do que os outros. Conclusão O treinamento de habilidades em comunicação e o uso de modelo de registro específico para o atendimento melhoram o desempenho dos estudantes em relação ao atendimento clínico integral à pessoa.

ABSTRACT Introduction The practice of comprehensive clinical care of the individual is a challenge faced by medical educators, educational institutions, and researchers seeking to contribute to the development of students' educational skills that combine knowledge, skills and attitudes for this model. Objective To evaluate the impact of communication skills training in the practice of the clinical method of comprehensive clinical care, with or without the use of a specific medical record. Methods Forty-six students in the 7th Period of medical school participated in the study. A combination of educational activities was used to facilitate the acquisition of communication skills for comprehensive clinical care, including: a modeling example, followed by individual reflection and discussion, an interactive lecture, and the use of a specific medical appointment for comprehensive clinical care of the individual (RACIP). The study was divided into four Phases: Phase 1 − Pre-training: filming of clinical care in a simulated environment, carried out by the 46 students, using the current medical appointment in the HC-UFMG. Phase 2 − Training: students were divided into three groups: G1: performed an educational activity not related to clinical care; G2 and G3: received communication skills training. Phase 3 − Evaluation: filming of a consultation in a simulated environment, performed by all the groups, with G1 and G3 using RACIP, and G2, the current medical appointment model. Phase 4 − Feedback and learning opportunity for all the groups. The videos of the clinic visits performed by the students, pre- and post-training, were evaluated by a panel consisting of three evaluators, using the AVACIP instrument (evaluation of comprehensive clinical care of the individual). This takes into account five domains: the initial approach to the consultation; the patient's expectations; the patient's perspective of his/her illness; behavior and lifestyle habits; use of complementary propaedeutic and therapeutic alliance. Results The total positive attitude score for each group was higher in Phase 3 than in Phase 1 (p = 0.001), showing that all the strategies promoted an improvement in communication skills, but there were no differences between groups in each phase (p > 0.310). Analyzing the scores by domain, it was observed that G3 performed better than the others. Conclusion The communication skills training and the use of the RACIP improved the students' performance in relation to comprehensive clinical care of the individual.

Effects of deliberate reflection on students' engagement in learning and learning outcomes.

CONTEXT: Reflection in practice is assumed to enhance interest in knowing more about a topic, increasing engagement in learning and learning outcomes. However, this claim lacks empirical evidence, particularly in medical education. The authors investigated the effects of deliberate reflection upon clinical cases on medical students' engagement in a learning activity and learning outcomes. METHODS: A three-task (diagnostic task; learning activity; test) experiment was conducted in August 2017. Seventy-two fourth-year students from UNIFENAS-BH Medical School, Brazil, diagnosed two clinical cases with jaundice as the chief complaint, either by following a deliberate reflection procedure or making differential diagnosis. Subsequently, all participants received the same study material on the diagnosis of jaundice. Finally, they took a recall test on the study material. Outcome measurements were study time and test scores. RESULTS: There was a significant effect of experimental condition on students' engagement in the learning activity and on learning outcomes. Students who deliberately reflected upon the cases invested more time in studying the material than those who made a differential diagnosis (respectively, mean = 254.97, standard deviation = 115.45 versus mean = 194.96, standard deviation = 111.68; p = 0.02; d = 0.53). Deliberate reflection was also related to higher scores in the test relative to differential diagnosis (respectively, mean = 22.08, standard deviation = 14.94 versus mean = 15.75, standard deviation = 9.24; p = 0.03; d = 0.51). Medium effect sizes (Cohen's d) were observed in both measurements. CONCLUSIONS: Relative to making differential diagnosis, deliberate reflection while diagnosing cases fostered medical students' engagement in learning and increased learning outcomes. Teachers can employ this relatively easy procedure, possibly both with simulated and real scenarios, to motivate their students and help them expand their knowledge, an important requirement for their professional development.

Processos de Desenvolvimento do Raciocínio Clínico em Estudantes de Medicina / Clinical Reasoning Development in Medical Students

RESUMO O raciocínio clínico se refere ao processo cognitivo, através do qual, o médico é capaz de estabelecer o diagnóstico correto e propor uma conduta adequada frente a um problema clínico encontrado. Apesar da grande evolução do conhecimento médico ao longo dos tempos, a prática clínica é ainda hoje, muito dependente da habilidade profissional de elaborar um diagnóstico correto e, a partir deste, definir a melhor conduta. Trabalhos recentes vêm demonstrando que erros diagnósticos constituem fonte de doenças evitáveis e morte, promovendo prejuízos clínicos e financeiros a pacientes, familiares e à nação. As escolas médicas e seus docentes têm o desafio de facilitar a aquisição desta competência pelos estudantes, pois, trata-se de um dos maiores atributos a ser desenvolvido durante o curso médico. Nas últimas três décadas, os processos envolvidos no aprendizado e desenvolvimento do raciocínio clínico vêm sendo estudados e muito já se sabe sobre as fases envolvidas na formação desta importante habilidade. Teorias e estudos cognitivos sobre a formação e o uso da memória podem ser encontrados em diversas áreas do conhecimento. No entanto, pouco material existe com uma discussão direcionada para o ensino médico. Este é um dos objetivos deste artigo, apresentar uma revisão das principais teorias e pesquisas sobre os processos do desenvolvimento do raciocínio clínico, fornecendo aos professores um material que permita a compreensão desta fascinante área do ensino médico. Espera-se assim, contribuir para a formação docente, estimular o desenvolvimento da pesquisa em educação médica e fornecer subsídio técnico para o planejamento de estratégias instrucionais orientadas pelos princípios do aprendizado do raciocínio clínico. Para facilitar a compreensão, as teorias serão apresentadas em tópicos. No entanto, uma vez que o raciocínio clínico é uma atividade cognitiva complexa, é importante lembrar que os mecanismos propostos em cada tópico apresentam fatores que se sobrepõem e muitas vezes ocorrem simultaneamente.

ABSTRACT Clinical reasoning refers to the cognitive process by which the physician is able to provide a correct diagnosis and appropriate treatment for a clinical problem. Despite the great medical knowledge evolution over the time, clinical practice is still very dependent on professional ability to make a correct diagnosis. Studies have shown that diagnostic errors are an important source of preventable diseases and death, promoting clinical and financial damage to patients, families and nation. Medical schools and teachers face the challenge of promoting the development of this competence in medical students as it is one of the greatest attributes to be developed during medical school. In the last three decades, the processes involved in learning and developing clinical reasoning have been studied and now much is known about the stages involved in the formation of this important skill. Theories and cognitive studies on memory building and function can be found in several areas of knowledge, however, little information exists with a discussion focused on medical education. The aim of this work is present a review of the main theories and researches on clinical reasoning, providing teachers with a comprehensive review that allows understanding this fascinating medical education area. It is hoped, to offer a contribution on medical education, providing medical teachers with technical material for planning their instructional strategies guided by clinical reasoning learning principles and stimulate research on medical education. To favor comprehension, the theories will be presented by topics, however, since clinical reasoning is a complex cognitive activity, it is important remember that the information proposed in each topic have factors that overlap and often occur simultaneously.

The effect of self-explanation of pathophysiological mechanisms of diseases on medical students' diagnostic performance.

Self-explanation while diagnosing clinical cases fosters medical students' diagnostic performance. In previous studies on self-explanation, students were free to self-explain any aspect of the case, and mostly clinical knowledge was used. Elaboration on knowledge of pathophysiological mechanisms of diseases has been largely unexplored in studies of strategies for teaching clinical reasoning. The purpose of this two-phase experiment was to investigate the effect of self-explanation of pathophysiology during practice with clinical cases on students' diagnostic performance. In the training phase, 39 4th-year medical students were randomly assigned to solve 6 criterion cases (3 of jaundice; 3 of chest pain), either self-explaining the pathophysiological mechanisms of the findings (n = 20) or without self-explaining (n = 19). One-week later, in the assessment phase, all students solved 6 new cases of the same syndromes. A repeated-measures analysis of variance on the mean diagnostic accuracy scores showed no significant main effects of study phase (p = 0.34) and experimental condition (p = 0.10) and no interaction effect (p = 0.42). A post hoc analysis found a significant interaction (p = 0.022) between study phase and syndrome type. Despite equal familiarity with jaundice and chest pain, the performance of the self-explanation group (but not of the non-self-explanation group) on jaundice cases significantly improved between training and assessment phases (p = 0.035) whereas no differences between phases emerged on chest pain cases. Self-explanation of pathophysiology did not improve students' diagnostic performance for all diseases. Apparently, the positive effect of this form of self-explanation on performance depends on the studied diseases sharing similar pathophysiological mechanisms, such as in the jaundice cases.

Versão brasileira do Attribution Questionnaire – Adaptação transcultural e validação de propriedades psicométricas / Brazilian version of the Attribution Questionnaire – Cross cultural adaptation and validation of psychometric properties

RESUMO Objetivo Realizar a adaptação transcultural do Attribution Questionnaire – AQ27 para o português falado no Brasil a partir da versão de Portugal e validar as propriedades psicométricas da escala por meio da análise fatorial exploratória. Métodos Após a adaptação semântica e cultural, o questionário foi aplicado a 431 alunos do 1º ao 6º ano do Curso de Medicina Unifenas-BH, Brasil, e, em seguida, conduziu-se análise fatorial exploratória pelo método de extração de componentes principais e rotação Varimax. Resultados A versão final brasileira do Questionário de Atribuição (AQ-26B) apresentou um fator a menos que a versão original em inglês e a portuguesa devido à fusão dos fatores Medo e Percepção de Perigo, o que gerou a supressão da questão 11 do questionário brasileiro por não apresentar valores psicométricos adequados. Dificuldades linguísticas relacionadas à interpretação da questão 11 e sua maior complexidade de significado latente parecem ter contribuído com esse resultado. Conclusões O questionário brasileiro (AQ-26B) manteve parâmetros de validade e confiabilidade adequados observando-se coerência com o modelo teórico original. Além disso, mostrou-se de fácil aplicação, demonstrando ser um instrumento útil para avaliar o estigma relacionado à doença mental entre alunos de medicina de escolas médicas brasileiras.

ABSTRACT Objective A cross-cultural adaptation of the Portuguese version of the Attribution Questionnaire – AQ27 for Brazilian speakers and an exploratory factor analysis were conducted in order to validate the scale’s psychometric properties. Methods After semantic and cultural adaptation of the questionnaire, exploratory factor analysis was conducted through principal component extraction and Varimax rotation methods in 431 students, from the first to the last years of the course, at Unifenas Medical Course in Belo Horizonte, Brazil. Results The final Brazilian version of the Attribution Questionnaire (AQ-26B) had 8 factors instead of 9 from the original American and Portuguese versions. This change was due to the merger of Fear and Dangerousness factors. Question 11 was removed from the Brazilian version because it did not present adequate psychometric values. Language difficulties, related to the interpretation of its meaning and its complex latent meaning, seemed to have contributed to this result. Conclusions The Brazilian version of the Attribution Questionnaire (AQ-26B) presented suitable validity and reliability parameters as well as theoretical coherence to the original model. Moreover, it proved easy to apply, showing to be a useful tool to evaluate the stigma attached to mental illness in Brazilian medical students.

Validação de Instrumento de Registro do Atendimento Clínico Centrado na Pessoa / Validation of a Patient-Centered Instrument of Medical Appointment Recording

Diante do desafio de formar médicos para o século XXI, em que se pretende uma abordagem integral da pessoa, incluindo seus sentimentos e o contexto que a cerca, este trabalho teve como objetivo validar, para a realidade de uma cidade brasileira, um modelo de registro de atendimento clínico centrado na pessoa, com base numa proposta reconhecida internacionalmente. O documento resultante representa um instrumento que poderá facilitar o aprendizado e a adesão do estudante de Medicina ao método clínico centrado na pessoa, por se tratar de uma sistematização do roteiro para o registro da consulta médica, guiando a entrevista no formato centrado na pessoa. Os autores acreditam que a utilização deste roteiro de registro contribuirá de forma relevante para que os estudantes de Medicina, iniciantes no ofício e mais dependentes de guias de registro, desenvolvam de forma plena, em cenários simulados e reais, as habilidades necessárias ao atendimento clínico centrado na pessoa.

Given the challenge of preparing doctors for the 21st century, striving for a comprehensive approach to the patient, her feelings, background and situation, the aim of this study was to validate a patient-centered care recording model, in view of the reality of a Brazilian city. Following a literature review, Donnelly’s model was selected and the validation was performed according to Malhotra’s method. The resulting recording model represents an instrument that intends to contribute toward improving health care in Brazil and, therefore, enhancing the clinical outcome of the person under care. This could help the learning process and students’ adherence to the patient-centered clinical method due to the documents which clarify and organize the framework for registering the medical appointment and guide the interview towards a patient-centered format. Since medical students and beginner physicians usually depend on recording guides, the authors believe that the use of this recording guide will contribute greatly to the full development of new professionals and their essential skills in patient-centered medical care.

Perspectivas para o desenvolvimento de investigação científica em Educação Médica / Prospects for the development of scientific research in Medical Education

Pretende-se, com este texto, apresentar aos profissionais envolvidos na docência e formação médica potenciais temas de pesquisa científica na área da Educação Médica. É premente a necessidade de promover a competência docente nesta área de forma a compreendê-la como um campo profícuo de investigação e condução de estudos experimentais.

This text intends to present potential themes of scientific research, in the area of medical education, to professionals involved in teaching and medical training. The need to promote teaching competencies in this area is pressing in order to understand it as a fruitful of research, and execute experimental studies.

How can students' diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases.

PURPOSE: To develop diagnostic competence, students should practice with many examples of clinical problems to build rich mental representations of diseases. How to enhance learning from practice remains unknown. This study investigated the effects of reflection on cases compared with generating a single or differential diagnosis. METHOD: In 2012, during the learning phase, 110 fourth-year medical students diagnosed four cases of two criterion diseases under three different experimental conditions: structured reflection, single-diagnosis, or differential-diagnosis. One week later, they diagnosed two novel exemplars of each criterion disease and four cases of new diseases that were not among the cases of the learning phase but were plausible alternative diagnoses. RESULTS: Diagnostic performance did not differ among the groups in the learning phase. One week later, the reflection group obtained higher mean diagnostic accuracy scores (range: 0-1) than the other groups when diagnosing new exemplars of criterion diseases (reflection: 0.67; single-diagnosis: 0.36, P < .001; differential-diagnosis: 0.51, P = .014) and cases of new diseases (reflection: 0.44; single-diagnosis: 0.32, P = .010; differential-diagnosis: 0.33, P = .015). No difference was found between the single-diagnosis and the differential-diagnosis conditions. CONCLUSIONS: Structured reflection while practicing with cases enhanced learning of diagnosis both of the diseases practiced and of their alternative diagnoses, suggesting that reflection not only enriched mental representations of diseases practiced relative to more conventional approaches to clinical learning but also influenced the representations of adjacent but different diseases. Structured reflection seems a useful addition to the existing clinical teaching methods.

Improving communication skill training in patient centered medical practice for enhancing rational use of laboratory tests: The core of bioinformation for leveraging stakeholder engagement in regulatory science.

Requests for laboratory tests are among the most relevant additional tools used by physicians as part of patient's health problemsolving. However, the overestimation of complementary investigation may be linked to less reflective medical practice as a consequence of a poor physician-patient communication, and may impair patient-centered care. This scenario is likely to result from reduced consultation time, and a clinical model focused on the disease. We propose a new medical intervention program that specifically targets improving the patient-centered communication of laboratory tests results, the core of bioinformation in health care. Expectations are that medical students training in communication skills significantly improve physicians-patient relationship, reduce inappropriate use of laboratorial tests, and raise stakeholder engagement.