Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review update: BEME Guide No. 85.

BACKGROUND: Clinical teachers often struggle to record trainee underperformance due to lacking evidence-based remediation options. OBJECTIVES: To provide updated evidence-based recommendations for addressing academic difficulties among undergraduate and postgraduate medical learners. METHODS: A systematic review searched databases including MEDLINE, CINAHL, EMBASE, ERIC, Education Source, and PsycINFO (2016-2021), replicating the original Best Evidence Medical Education 56 review strategy. Original research/innovation reports describing intervention(s) for medical learners with academic difficulties were included. Data extraction used Michie's Behaviour Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraised used the Mixed Methods Appraisal Tool (MMAT). Authors synthesized extracted evidence by adapting GRADE approach to formulate recommendations. RESULTS: Eighteen articles met the inclusion criteria, primarily addressing knowledge (66.7%), skills (66.7%), attitudinal problems (50%) and learner's personal challenges (27.8%). Feedback and monitoring was the most frequently employed BCT. Study quality varied (MMAT 0-100%). We identified nineteen interventions (UG: n = 9, PG: n = 12), introducing twelve new thematic content. Newly thematic content addressed contemporary learning challenges such as academic procrastination, and use of technology-enhanced learning resources. Combined with previous interventions, the review offers a total dataset of 121 interventions. CONCLUSION: This review offers additional evidence-based interventions for learners with academic difficulties, supporting teaching, learning, faculty development, and research efforts.

Setting priorities for physical examination in pharmacy education: A Delphi study.

Background: As the scope of pharmacy practice is expanding, a growing number of pharmacists perform physical examination (PE) to gather additional information to monitor the effectiveness and safety of their patients' therapy. This professional activity calls for the development of comprehensive and valuable PE training. We sought to determine by consensus which PE tests should be given teaching priority in pharmacy education. Methods: Using existing PE literature in pharmacy, we conducted an online Delphi survey from December 2021 to April 2022 with 16 pharmacists who practise in a variety of settings and/or who are considered experts in PE. Results: After 2 Delphi rounds, consensus was reached to either include or exclude 27 PE tests in entry-to-practice programs. One last round allowed prioritizing the agreed-upon PE tests in terms of educational needs. Clinicians agreed that measuring blood pressure is indispensable and should be given teaching priority, followed by pulse rate, weight and blood glucose measurements. Endocrine system and head and neck examinations should be included in pharmacy programs, but their clinical usefulness was considered less important. Discussion: We compared our results with PE literature in other health care disciplines. We found that only a few PE tests truly influence drug therapy management, that some examinations can be quite difficult to perform accurately and that without proper training and opportunities to retrain, skill decay can lead to dangerous misinterpretations. Pharmacy programs should consider focusing on teaching PE tests supported by evidence as having an impact on drug therapy management. Can Pharm J (Ott) 2024;157:xx-xx.

Key to sessile gnesiotrochan rotifers: Families, monospecific species in Flosculariidae, species of Atrochidae, Conochilidae, and Limnias.

Accurate identification of species is key to understanding their ecological roles and evolutionary history. It is also essential in cataloging biodiversity for comparisons among habitat types, responses to climate change, effective management practices, and more. The paucity of taxonomic expertise is increasing and with it the ability to competently identify species, this is particularly true for small taxa including rotifers. In an effort to improve this situation, we collated information on morphological characters from the literature on all valid species of sessile Gnesiotrocha (phylum Rotifera) currently assigned to two orders and four families. We review Order Collothecaceae, which comprises families Atrochidae (3 spp.) and Collothecidae (50 spp.) and Order Flosculariaceae, which includes families Conochilidae (7 spp.) and Flosculariidae (71 species). Based on that information, we provide dichotomous keys to the Families, monospecific species in Flosculariidae, and species of Atrochidae, Conochilidae, and Limnias. These keys will aid researchers to identify species in these families and lead to a better understanding of freshwater biodiversity and eco-evolutionary processes.

Collaboration Scripts or Checklists to Engage Novice Observers in Immersive Simulation?

INTRODUCTION: In simulation, students often observe their peers perform a task. It is still unclear how different types of instructional guidance can turn the observational phase into an active learning experience for novices. This mixed-method study aims to understand similarities and differences between use of collaboration scripts and checklists by observers in terms of cognitive load and perception of learning. METHODS: Second-year pharmacy students ( N = 162) were randomly assigned to 1 of 4 conditions when observing a simulation: collaboration scripts (heuristic to analyze in dyads while observing), checklists, both, or no guidance. We measured observers' intrinsic and extraneous cognitive load and self-perceived learning and conducted focus group interviews. RESULTS: Intrinsic cognitive load was significantly lower for checklists (M = 3.6/10) than for scripts (M = 4.7/10) or scripts and checklists combined (M = 4.7/10). Extraneous cognitive load was significantly lower for checklists (M = 1.5/10) than for scripts combined with checklists (M = 2.6/10) or no guidance (M = 1.8/10). There was no statistical difference between conditions for self-perceived learning. Coding of focus group interviews revealed 6 themes on observers' perception of learning under different conditions of instructional guidance. Students explained that collaboration scripts felt more complex, whereas checklists were perceived as a simple fact-checking exercise. Observing the simulation, regardless of guidance, was a meaningful learning experience. CONCLUSIONS: With or without guidance, observers are actively engaged with the simulation, but their effort differed depending on instructions. When choosing between checklists or collaboration scripts, educators should be guided by the type of simulation task.

[Feedback Guide for direct observation of family medicine residents in Canada: a francophone tool]. / Développement et mise à l'essai du Guide de rétroaction francophone pour l'observation directe des résidents en médecine familiale au Canada.

Background: There is no CanMEDS-FM-based milestone tool to guide feedback during direct observation (DO). We have developed a guide to support documentation of feedback for direct observation (DO) in Canadian family medicine (FM) programs. Methods: The Guide was designed in three phases with the collaboration of five Canadian FM programs with at least a French-speaking teaching site: 1) literature review and needs assessment; 2) development of the DO Feedback Guide; 3) testing the Guide in a video simulation context with qualitative content analysis. Results: Phase 1 demonstrated the need for a narrative guide aimed at 1) specifying mutual expectations according to the resident's level of training and the clinical context, 2) providing the supervisor with tools and structure in his observations 3) to facilitate documentation of feedback. Phase 2 made it possible to develop the Guide, in paper and electronic formats, meeting the needs identified. In phase 3, 15 supervisors used the guide for three levels of residence. The Guide was adjusted following this testing to recall the phases of the clinical encounter that were often forgotten during feedback (before consultation, diagnosis and follow-up), and to suggest types of formulation to be favored (stimulating questions, questions of clarification, reflections). Conclusion: Based on evidence and a collaborative approach, this Guide will equip French-speaking Canadian supervisors and residents performing DO in family medicine.

Three Weeks of Team-Based Leaning Do Not Overload Undergraduate Students.

CONTEXT: Team-based learning (TBL) is a flipped-classroom approach requiring students to study before class. Fully flipped curricula usually have fewer in-class hours. However, for practical reasons, several programs implement a few weeks of TBL without adjusting the semester timetable. Students fear that they will be overloaded by the individual and collaborative study hours needed to prepare for TBL. METHODS: We implemented three consecutive weeks of TBL in a 15-week lecture-based course on the renal system. In-class time and assessments were unchanged for all courses. Four hundred fifty-nine first-year undergraduate medical students (229 in 2018; 230 in 2019) were invited to complete weekly logs of their individual and collaborative study hours during lectures and TBL, along with questionnaires on cognitive load and perception of the course. Our program changed from A to E grading in 2018 to pass-fail grading in 2019. RESULTS: Participants (n = 324) spent a similar number of hours studying for TBL vs. lectures with a mean of 3.1 h/week. Collaborative study was minimal outside class (median 0.1 h/week). Results remained similar with pass-fail grading. If in-class time were reduced, 18% of participants said they would have used freed-up time to study for TBL. Studying for TBL generated similar extraneous cognitive load and lower intrinsic load compared to studying for lectures; students were less stressed, and maintained high levels of motivation and self-perceived learning. CONCLUSIONS: Three weeks of lectures were replaced by TBL without reducing in-class time. Students did not report overload in study hours or in cognitive load. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01314-x.

Simulation of Adult Surgical Cricothyrotomy for Anesthesiology and Emergency Medicine Residents: Adapted for COVID-19.

Introduction: In a CICO (cannot intubate, cannot oxygenate) situation, anesthesiologists and acute care physicians must be able to perform an emergency surgical cricothyrotomy (front-of-neck airway procedure). CICOs are high-acuity situations with rare opportunities for safe practice. In COVID-19 airway management guidelines, bougie-assisted surgical cricothyrotomy is the recommended emergency strategy for CICO situations. Methods: We designed a 4-hour procedural simulation workshop on surgical cricothyrotomy to train 16 medical residents. We provided prerequisite readings, a lecture, and a videotaped demonstration. Two clinical scenarios introduced deliberate practice on partial-task neck simulators and fresh human cadavers. We segmented an evidence-based procedure and asked participants to verbalize the five steps of the procedure on multiple occasions. Results: Thirty-two residents who participated in the workshops were surveyed, with a 97% response rate (16 of 16 from anesthesiology, 15 of 16 from emergency medicine). Participants commented positively on the workshop's authenticity, its structure, the quality of the feedback provided, and its perceived impact on improving skills in surgical cricothyrotomy. We analyzed narrative comments related to three domains: preparation for the procedure, performing the procedure, and maintaining the skills. Participants highlighted the importance of performing the procedure many times and mentioned the representativeness of fresh cadavers. Discussion: We developed a surgical cricothyrotomy simulation workshop for anesthesiology and emergency medicine residents. Residents in the two specialities uniformly appreciated its format and content. We identified common pitfalls when executing the procedure and provided practical tips and material to facilitate implementation, in particular to face the COVID-19 pandemic.

Analysis of Supervisors' Feedback to Residents on Communicator, Collaborator, and Professional Roles During Case Discussions.

BACKGROUND: Literature examining the feedback supervisors give to residents during case discussions in the realms of communication, collaboration, and professional roles (intrinsic roles) focuses on analyses of written feedback and self-reporting. OBJECTIVES: We quantified how much of the supervisors' verbal feedback time targeted residents' intrinsic roles and how well feedback time was aligned with the role targeted by each case. We analyzed the educational goals of this feedback. We assessed whether feedback content differed depending on whether the residents implied or explicitly expressed a need for particular feedback. METHODS: This was a mixed-methods study conducted from 2017 to 2019. We created scripted cases for radiology and internal medicine residents to present to supervisors, then analyzed the feedback given both qualitatively and quantitatively. The cases were designed to highlight the CanMEDS intrinsic roles of communicator, collaborator, and professional. RESULTS: Radiologists (n = 15) spent 22% of case discussions providing feedback on intrinsic roles (48% aligned): 28% when the case targeted the communicator role, 14% for collaborator, and 27% for professional. Internists (n = 15) spent 70% of discussions on intrinsic roles (56% aligned): 66% for communicator, 73% for collaborator, and 72% for professional. Radiologists' goals were to offer advice (66%), reflections (21%), and agreements (7%). Internists offered advice (41%), reflections (40%), and clarifying questions (10%). We saw no consistent effects when residents explicitly requested feedback on an intrinsic role. CONCLUSIONS: Case discussions represent frequent opportunities for substantial feedback on intrinsic roles, largely aligned with the clinical case. Supervisors predominantly offered monologues of advice and agreements.

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review: BEME Guide No. 56.

Background: Clinical teachers often struggle to report unsatisfactory trainee performance, partly because of a lack of evidence-based remediation options. Objectives: To identify interventions for undergraduate (UG) and postgraduate (PG) medical learners experiencing academic difficulties, link them to a theory-based framework and provide literature-based recommendations around their use. Methods: This systematic review searched MEDLINE, CINAHL, EMBASE, ERIC, Education Source and PsycINFO (1990-2016) combining these concepts: medical education, professional competence/difficulty and educational support. Original research/innovation reports describing intervention(s) for UG/PG medical learners with academic difficulties were included. Data extraction employed Michie's Behavior Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraisal used the Mixed Methods Appraisal Tool (MMAT). The authors synthesized extracted evidence by adapting the GRADE approach to formulate recommendations. Results: Sixty-eight articles met the inclusion criteria, most commonly addressing knowledge (66.2%), skills (53.9%) and attitudinal problems (26.2%), or learner personal issues (41.5%). The most common BCTs were Shaping knowledge, Feedback/monitoring, and Repetition/substitution. Quality appraisal was variable (MMAT 0-100%). A thematic content analysis identified 109 interventions (UG: n = 84, PG: n = 58), providing 24 strong, 48 moderate, 26 weak and 11 very weak recommendations. Conclusion: This review provides a repertoire of literature-based interventions for teaching/learning, faculty development, and research purposes.

McKittrick-Wheelock Syndrome Presenting with Acute Kidney Injury and Metabolic Alkalosis: Case Report and Narrative Review.

A rare combination of severe volume depletion and electrolyte imbalance caused by a rectal villous adenoma is often referred to as the McKittrick-Wheelock syndrome. Patients usually seek medical care because of chronic hypersecretory diarrhea and display renal failure, metabolic acidosis, hyponatremia, and hypokalemia. We report the case of a 68-year-old woman who presented with this condition but showed unusual features such as severe hypokalemia and metabolic alkalosis, without diarrhea. She subsequently underwent transanal endoscopic microsurgery (TEMS), an innovative procedure in the management of large rectal adenomas. We also provide a narrative review of the literature on this rare entity.

Value for money in self-regulated procedural simulation.

BACKGROUND: In self-regulated procedural simulation, learners practise on many simulators (e.g. paracentesis), self-regulating their choice of simulators, time and goals. Current needs assessments cannot predict the number of simulators needed to plan cost-effective self-regulated simulation. Knowing the ratios of simulators and participants would allow for better-informed purchase decisions to be made. METHODS: We designed 90-minute sessions of self-regulated procedural simulation for internal medicine residents. In Phase 1, 51 participants (8.5 per group) could use 22 simulators (US$69 925): ultrasound-guided central (n = 6) and peripheral (n = 2) venous catheterisation; thoracocentesis (n = 2); paracentesis (n = 2); lumbar puncture (n = 6); and arthrocentesis (n = 4). We calculated minimal numbers of simulators based on the time that participants used each simulator in order to design a resource-effective Phase 2, with 24 participants (with 12 per group) using 14 simulators (US$48 720) to meet their needs. RESULTS: Calculated from time of use (83 minutes in total), the optimal ratios of simulators expressed for 10 participants were 9.2: 3.7 for jugular and subclavian venous catheterisation (33 minutes); 1.5 for thoracocentesis (13 minutes), 1.0 for femoral venous catheterisation (9 minutes), 1.0 for lumbar puncture (9 minutes), 0.8 for peripheral venous catheterisation (8 minutes), 0.7 for paracentesis (6 minutes) and 0.5 for arthrocentesis (5 minutes). In Phase 2, the usage rate of simulators increased from 35.5% to 76.6%, maintaining the total time of use at 80.4 minutes. CONCLUSIONS: We present a replicable method for the cost-effective planning of self-regulated simulation by measuring the use of simulators. Expressed as ratios of simulators per participant, this information can support purchase decisions and be shared with similar programmes.

How to Convince Clinicians that 'Soft' Skills Save Lives? Practical Tips to Use Clinical Studies to Teach Physicians' Roles.

This article was migrated. The article was marked as recommended. The implementation of competency-based medical education is hampered by unsupported arguments like 'soft' skills are important, but they don't save lives. When implementing teaching and assessment methods targeting non-medical expert roles, student and physician buy-in is crucial. These intrinsic roles (e.g. collaborator or professional) are unfortunately misinterpreted and underused by supervisors, in part because of the false assumption that those skills have minimal impact on patient outcomes. On the contrary, although not worded in those terms, many clinical studies prove the impact of those roles on patient mortality, morbidity, readmission rate, or compliance. Whereas physicians feel that they are properly trained to give feedback, they struggle in making this connection between clinical studies and intrinsic roles in their everyday teaching habits. In this article, we provide practical tips on why and how to use high-impact clinical studies to enlighten supervisors and trainees about the educational and clinical importance of those skills. A slide kit, to be presented in clinical settings, provides a selection of 30 examples of 'hard' evidence on those so-called 'soft' skills, reinforcing the fact that intrinsic roles are intertwined with the medical expert role to improve patient care.

Adjusting to duty hour reforms: residents' perception of the safety climate in interdisciplinary night-float rotations.

BACKGROUND: New scheduling models were needed to adjust to residents' duty hour reforms while maintaining safe patient care. In interdisciplinary night-float rotations, four to six residents from most residency programs collaborated for after-hours cross-coverage of most adult hospitalised patients as part of a Faculty-led rotation. Residents worked sixteen 12-hour night shifts over a month. METHODS: We measured residents' perception of the patient safety climate during implementation of night-float rotations in five tertiary hospitals. We surveyed 267 residents who had completed the rotation in 2015-2016 with an online version of the Safety Attitudes Questionnaire. First year residents came from most residency programs, second- and third-year residents came from internal medicine. RESULTS: One-hundred-and-thirty residents completed the questionnaire. Scores did not differ across hospitals and residents' years of training for all six safety-related climate factors: teamwork climate, job satisfaction, perceptions of management, safety climate, working conditions, and stress recognition. CONCLUSION: Simultaneous implementation in five hospitals of a Faculty-led interdisciplinary night-float rotation for most junior residents proved to be logistically feasible and showed similar and reassuring patient safety climate scores.

CONTEXTE: De nouveaux horaires de garde en établissements hospitaliers étaient nécessaires pour s'adapter aux réformes des heures de travail des résidents tout en maintenant des soins sécuritaires pour les patients. Dans les stages cliniques de nuit interdisciplinaires, quatre à six résidents de la plupart des programmes de résidence ont collaboré pour assurer une couverture croisée, après les heures normales de travail, de la plupart des patients adultes hospitalisés. Les résidents ont travaillé seize nuits de 12 heures durant un mois. MÉTHODES: Nous avons mesuré la perception des résidents du climat de travail lié à la sécurité des patients lors de la mise en place de stages de nuit dans cinq hôpitaux universitaires. Nous avons interrogé 267 résidents ayant terminé le stage en 2015-2016 avec une version numérique du Safety Attitudes Questionnaire. Les résidents de première année provenaient de la plupart des programmes de résidence, les résidents de deuxième et troisième années provenaient du programme de médecine interne. RÉSULTATS: 130 résidents ont complété le questionnaire. Les scores ne différaient pas entre les hôpitaux et les années de formation des résidents pour les six facteurs liés à la sécurité des patients: climat de travail en équipe, satisfaction au travail, perceptions des supérieurs, climat de sécurité, conditions de travail et reconnaissance du stress. CONCLUSIONS: La mise en place simultanée, dans cinq hôpitaux, de stages cliniques de nuit réunissant des résidents juniors de la majorité des programmes de résidence fut logistiquement possible et a montré des résultats similaires et rassurants sur le climat de travail lié à la sécurité des patients.

Acute infectious aortitis presenting as pyelonephritis.

A 65-years-old man with poorly controlled type 2 diabetes presented to the emergency department in sepsis with a 2-week history of new-onset fever, abdominal pain and pyuria. A Computed Tomography without contrast ruled out nephrolithiasis and hydronephrosis, but showed infiltration around the infra-renal aorta (5 x 1 cm) and several retroperitoneal lymph nodes. The periaortic infiltration raised suspicion for acute infectious aortitis. Aortic CT angiography confirmed an aortic pseudo-aneurysm in the infra-renal aorta without signs of impending aortic rupture. A Positron Emission Tomography-Computed Tomography confirmed abnormal 18F-FDG uptake adjacent to the right posterolateral aortic wall. The patient underwent abdominal aortic reconstruction with cryopreserved arterial allograft. Infectious aortitis is a rare but lethal cause of sepsis. Males over 50 years old with diabetes mellitus and peripheral vascular atherosclerotic disease are considered at higher risk. The diagnosis should be considered when a septic patient has vascular risk factors, abdominal pain, bacteremia and suggestive imaging. A CT without contrast showing infiltration around the aorta should, in some context, be promptly followed by Aortic CTA to search for acute aortitis among other less urgent differentials. Antibiotic therapy and involvement of vascular surgeons should be initiated in the emergency department.

Twelve tips for efficient procedural simulation.

Procedural simulation (PS) is increasingly being used worldwide in healthcare for training caregivers in psychomotor competencies. It has been demonstrated to improve learners' confidence and competence in technical procedures, with consequent positive impacts on patient outcomes and safety. Several frameworks can guide healthcare educators in using PS as an educational tool. However, no theory-informed practical framework exists to guide them in including PS in their training programs. We present 12 practical tips for efficient PS training that translates educational concepts from theory to practice, based on the existing literature. In doing this, we aim to help healthcare educators to adequately incorporate and use PS both for optimal learning and for transfer into professional practice.

Task Demands in OSCEs Influence Learning Strategies.

THEORY: Models on pre-assessment learning effects confirmed that task demands stand out among the factors assessors can modify in an assessment to influence learning. However, little is known about which tasks in objective structured clinical examinations (OSCEs) improve students' cognitive and metacognitive processes. Research is needed to support OSCE designs that benefit students' metacognitive strategies when they are studying, reinforcing a hypothesis-driven approach. With that intent, hypothesis-driven physical examination (HDPE) assessments ask students to elicit and interpret findings of the physical exam to reach a diagnosis ("Examine this patient with a painful shoulder to reach a diagnosis"). HYPOTHESES: When studying for HDPE, students will dedicate more time to hypothesis-driven discussions and practice than when studying for a part-task OSCE ("Perform the shoulder exam"). It is expected that the whole-task nature of HDPE will lead to a hypothesis-oriented use of the learning resources, a frequent use of adjustment strategies, and persistence with learning. METHOD: In a mixed-methods study, 40 medical students were randomly paired and filmed while studying together for two hypothetical OSCE stations. Each 25-min study period began with video cues asking to study for either a part-task OSCE or an HDPE. In a crossover design, sequences were randomized for OSCEs and contents (shoulder or spine). Time-on-task for discussions or practice were categorized as "hypothesis-driven" or "sequence of signs and maneuvers." Content analysis of focus group interviews summarized students' perception of learning resources, adjustment strategies, and persistence with learning. RESULTS: When studying for HDPE, students allocate significantly more time for hypothesis-driven discussions and practice. Students use resources contrasting diagnoses and report persistence with learning. When studying for part-task OSCEs, time-on-task is reversed, spent on rehearsing a sequence of signs and maneuvers. CONCLUSIONS: OSCEs with similar contents but different task demands lead to opposite learning strategies regarding how students manage their study time. Measuring pre-assessment effects from a metacognitive perspective provides empirical evidence to redesign assessments for learning.

The simulated clinical environment: Cognitive and emotional impact among undergraduates.

CONTEXT: Simulated clinical immersion (SCI) is used in undergraduate healthcare programs to expose the learner to real-life situations in authentic simulated clinical environments. For novices, the environment in which the simulation occurs can be distracting and stressful, hence potentially compromising learning. OBJECTIVES: This study aims to determine whether SCI (with environment) imposes greater extraneous cognitive load and stress on undergraduate pharmacy students than simulated patients (SP) (without environment). It also aims to explore how features of the simulated environment influence students' perception of learning. METHODS: In this mixed-methods study, 143 undergraduate pharmacy students experienced both SCI and SP in a crossover design. After the simulations, participants rated their cognitive load and emotions. Thirty-five students met in focus groups to explore their perception of learning in simulation. RESULTS: Intrinsic and extraneous cognitive load and stress scores in SCI were significantly but modestly higher compared to SP. Qualitative findings reveal that the physical environment in SCI generated more stress and affected students? focus. In SP, students concentrated on clinical reasoning. SCI stimulated a focus on data collection but impeded in-depth problem solving processes. CONCLUSION: The physical environment in simulation influences what and how students learn. SCI was reported as more cognitively demanding than SP. Our findings emphasize the need for the development of adapted instructional design guidelines in simulation for novices.