Does Walking Help to Generate a Differential Diagnosis?

TheoryIn Medicine, arriving at the correct diagnosis is of paramount importance for patient health and safety, yet is a difficult task especially when a patient presents with symptoms that do not fit typical patterns of disease. This task can be further complicated by errors of judgment, with the failure to consider all possible diagnoses being the most common of such errors. In this study, we investigated the process of differential diagnosis generation within the growing evidence that diagnostic performance can be increased by activities such as walking as was previously shown in Oppezzo and Schwartz's 2014 study. Hypotheses: It was hypothesized that an increase in performance, as expressed by a greater number of plausible differential diagnoses, would be seen in the walking group. Method: Eighteen medical students in their last two months of pre-clerkship training and eighteen second year family medicine residents were shown four different lists of a constellation of signs and symptoms. Participants were asked to generate differential diagnoses over five minutes per each list. All participants sat when completing the first two lists (pretest phase), and then were equally and randomly assigned to sitting versus walking on a treadmill when completing the last two lists (post-test phase). The number of total and unique differential diagnoses generated was determined, before being submitted to a three-member expert panel who identified appropriate unique differential diagnoses. Results: Two-way mixed ANOVAs were conducted to investigate the impact of exercise on the number of total, unique, and appropriate unique ideas generated and compared between pretest and post-test phases. Conclusions: We conclude that there is neither an increase nor a decrease in the number or quality of differential diagnoses generated by the sitting and walking groups within a population that has acquired some level of expertise.

Feasibility of Intradialytic Cycling Program in a Remote Community Hemodialysis Unit: Mixed-Methods Analysis of Implementation.

BACKGROUND: There is growing evidence demonstrating the benefits of intradialytic cycling. However, there are relatively few centers where this practice has been adopted with no reports from hemodialysis units in rural, remote, and northern locations. Maintaining mobility and quality of life for patients on kidney replacement therapy living in remote northern communities is inhibited by inclement weather and lack of access to resources and infrastructure that support physical activity. The integration of intradialytic cycling during hemodialysis offers patients a form of safe physical activity year-round. OBJECTIVE: This study focuses on better understanding the feasibility and acceptability of implementing intradialytic cycling in a remote northern geographical context. DESIGN: A feasibility study using a mixed-methods explanatory design was adopted for this study. SETTING: The research is conducted in Prince George, British Columbia. PARTICIPANTS: The participants are patients attending a community-based dialysis unit in remote northern British Columbia and health professionals working in the same facility. METHODS: Quantitative measures were captured through cycling logbooks and quality of life measure, and qualitative data were obtained through semi-structured interviews and analyzed using thematic analysis. RESULTS: Six (43%) eligible patients used leg ergometers more than once for a median of 2.5 (interquartile range: 1-4) months and 87% of hemodialysis sessions. Participants cycled for a median of 65 (interquartile range: 39-76) minutes per session, with frequent variability noted between participants and different hemodialysis sessions for the same participant. Nine patients completed the European Quality of Life Health Questionnaire prestudy, with 5 (56%) also completing it poststudy. Interviews with 9 patients, 4 nurses, and 1 physiotherapist led to the identification of themes instrumental to implementation: a supportive community dialysis unit, shared responsibility, knowledge of patients/providers, and benefits associated with engagement. Themes that were identified as being key to acceptability in this remote dialysis unit were trust, connection, and engagement through common values. LIMITATIONS: Due to dialysis unit size, we had a small number of participants. CONCLUSIONS: This study demonstrates the feasibility of implementing best practice in a remote community and provides insight into the elements of context and participation that contribute to acceptability in the implementation of intradialytic cycling.

CONTEXTE: De plus en plus d'études attestent des bienfaits du cyclisme intradialytique. Relativement peu de centres ont cependant adopté cette pratique et aucun rapport ne fait état de son intégration dans les unités d'hémodialyse des régions rurales, éloignées et nordiques. Dans ces communautés, les conditions météorologiques défavorables et le manque d'accès aux ressources et aux infrastructures encourageant l'activité physique sont une entrave au maintien de la mobilité et de la qualité de vie des patients sous thérapie de remplacement rénal. L'intégration du cyclisme intradialytique permettrait aux patients de pratiquer une forme d'activité physique sécuritaire à longueur d'année. OBJECTIFS: L'étude examine la faisabilité et l'acceptabilité relativement à l'instauration du cyclisme intradialytique dans l'unité d'hémodialyse d'une région géographique nordique éloignée. TYPE D'ÉTUDE: Étude de faisabilité à visée explicative utilisant une méthode mixte. CADRE: L'étude est menée à Prince George, en Colombie-Britannique. PARTICIPANTS: Des patients qui fréquentent une unité de dialyse communautaire dans le nord de la Colombie-Britannique et des professionnels de la santé qui travaillent dans le même établissement. MÉTHODOLOGIE: Les mesures quantitatives ont été saisies au moyen de carnets de bord de cyclisme et de mesures de la qualité de vie. Les données qualitatives ont été obtenues au moyen d'entrevues semi-structurées et analysées à l'aide d'analyses thématiques. RÉSULTATS: Les résultats portent sur les six (43 %) patients admissibles ayant utilisé une bicyclette ergométrique plus d'une fois pendant une médiane de 2,5 mois (intervalle interquartile : 1-4 fois) et 87 % des séances d'hémodialyse. Les participants ont pédalé 65 minutes en moyenne (intervalle interquartile : 39-76 minutes) par séance; de fréquentes variations ayant été observées entre les participants et entre les différentes séances d'hémodialyse pour un même participant. Neuf patients ont rempli le questionnaire européen sur la qualité de vie et la santé avant l'étude et cinq patients (56 %) l'ont fait après l'étude. Des entrevues avec neuf patients, quatre infirmières et un physiothérapeute ont permis de dégager les thèmes essentiels pour l'instauration du cyclisme intradialytique : un environnement favorable dans l'unité de dialyse communautaire, une responsabilité partagée, la connaissance des patients/fournisseurs de soins et les bienfaits associés à l'engagement. Les thèmes jugés essentiels à l'acceptabilité dans l'unité de dialyse examinée étaient la confiance, l'établissement d'une bonne relation et l'engagement par le biais de valeurs communes. LIMITES: La taille de l'unité de dialyse explique le faible nombre de participants. CONCLUSION: Cette étude démontre qu'il est possible d'instaurer de meilleures pratiques dans une communauté éloignée. Elle donne également un aperçu des éléments de contexte et de participation qui favorisent l'acceptabilité du cyclisme intradialytique.

Does walking improve diagnosis of skin conditions at varying levels of medical expertise?

The use of walking workstations in educational and work settings has been shown to improve cognitive abilities. At the same time, it has been repeatedly shown that medical residents around the world do not meet exercise guidelines, mainly due to a scarcity of available free time. Our study investigates the boundaries of the previously observed phenomenon of improved cognitive performance with physical activity using materials that represent real life tasks. Participants had different level of expertise and involved second year psychology students, medical students, and family medicine residents. We examined the effect of being physically inactive (i.e., sitting) or active (i.e., walking) while diagnosing multiple complex presentations of four skin conditions. We assumed that being physically active, irrespective of the level of expertise, will bolster diagnostic performance. Our findings show, however, that being physically active does not change the performance level of participants with different levels of medical expertise. Implications for medical education and suggestions for further research will be discussed.

Cognitive load imposed by knobology may adversely affect learners' perception of utility in using ultrasonography to learn physical examination skills, but not anatomy.

Ultrasonography is increasingly used for teaching anatomy and physical examination skills but its effect on cognitive load is unknown. This study aimed to determine ultrasound's perceived utility for learning, and to investigate the effect of cognitive load on its perceived utility. Consenting first-year medical students (n = 137) completed ultrasound training that includes a didactic component and four ultrasound-guided anatomy and physical examination teaching sessions. Learners then completed a survey on comfort with physical examination techniques (three items; alpha = 0.77), perceived utility of ultrasound in learning (two items; alpha = 0.89), and cognitive load on ultrasound use [measured with a validated nine-point scale (10 items; alpha = 0.88)]. Learners found ultrasound useful for learning for both anatomy and physical examination (mean 4.2 ± 0.9 and 4.4 ± 0.8, respectively; where 1 = very useless and 5 = very useful). Principal components analysis on the cognitive load survey revealed two factors, "image interpretation" and "basic knobology," which accounted for 60.3% of total variance. Weighted factor scores were not associated with perceived utility in learning anatomy (beta = 0.01, P = 0.62 for "image interpretation" and beta = -0.04, P = 0.33 for "basic knobology"). However, factor score on "knobology" was inversely associated with perceived utility for learning physical examination (beta = -0.06; P = 0.03). While a basic introduction to ultrasound may suffice for teaching anatomy, more training may be required for teaching physical examination. Prior to teaching physical examination skills with ultrasonography, we recommend ensuring that learners have sufficient knobology skills.