The relationship between time to diagnose and diagnostic accuracy among internal medicine residents: a randomized experiment.

BACKGROUND: Diagnostic errors have been attributed to cognitive biases (reasoning shortcuts), which are thought to result from fast reasoning. Suggested solutions include slowing down the reasoning process. However, slower reasoning is not necessarily more accurate than faster reasoning. In this study, we studied the relationship between time to diagnose and diagnostic accuracy. METHODS: We conducted a multi-center within-subjects experiment where we prospectively induced availability bias (using Mamede et al.'s methodology) in 117 internal medicine residents. Subsequently, residents diagnosed cases that resembled those bias cases but had another correct diagnosis. We determined whether residents were correct, incorrect due to bias (i.e. they provided the diagnosis induced by availability bias) or due to other causes (i.e. they provided another incorrect diagnosis) and compared time to diagnose. RESULTS: We did not successfully induce bias: no significant effect of availability bias was found. Therefore, we compared correct diagnoses to all incorrect diagnoses. Residents reached correct diagnoses faster than incorrect diagnoses (115 s vs. 129 s, p < .001). Exploratory analyses of cases where bias was induced showed a trend of time to diagnose for bias diagnoses to be more similar to correct diagnoses (115 s vs 115 s, p = .971) than to other errors (115 s vs 136 s, p = .082). CONCLUSIONS: We showed that correct diagnoses were made faster than incorrect diagnoses, even within subjects. Errors due to availability bias may be different: exploratory analyses suggest a trend that biased cases were diagnosed faster than incorrect diagnoses. The hypothesis that fast reasoning leads to diagnostic errors should be revisited, but more research into the characteristics of cognitive biases is important because they may be different from other causes of diagnostic errors.

Does providing the correct diagnosis as feedback after self-explanation improve medical students diagnostic performance?

BACKGROUND: Self-explanation without feedback has been shown to improve medical students' diagnostic reasoning. While feedback is generally seen as beneficial for learning, available evidence of the value of its combination with self-explanation is conflicting. This study investigated the effect on medical students' diagnostic performance of adding immediate or delayed content-feedback to self-explanation while solving cases. METHODS: Ninety-four 3rd-year students from a Canadian medical school were randomly assigned to three experimental conditions (immediate-feedback, delayed-feedback, control). In the learning phase, all students solved four clinical cases by giving i) the most likely diagnosis, ii) two main arguments supporting this diagnosis, and iii) two plausible alternative diagnoses, while using self-explanation. The immediate-feedback group was given the correct diagnosis after each case; delayed-feedback group received the correct diagnoses only after the four cases; control group received no feedback. One week later, all students solved four near-transfer (i.e., same final diagnosis as the learning cases but different scenarios) and four far-transfer cases (i.e., different final diagnosis from the learning cases and different scenarios) by answering the same three questions. Students' diagnostic accuracy (score for the response to the first question only) and diagnostic performance (combined score of responses to the three questions) scores were assessed in each phase. Four one-way ANOVAs were performed on each of the two scores for near and far-transfer cases. RESULTS: There was a significant effect of experimental condition on diagnostic accuracy on near-transfer cases (p < .05). The immediate-feedback and delayed-feedback groups performed equally well, both better than control (respectively, mean = 90.73, standard deviation =10.69; mean = 89.92, standard deviation = 13.85; mean = 82.03, standard deviation = 17.66). The experimental conditions did not significantly differ on far-transfer cases. CONCLUSIONS: Providing feedback to students in the form of the correct diagnosis after using self-explanation with clinical cases is potentially beneficial to improve their diagnostic accuracy but this effect is limited to similar cases. Further studies should explore how more elaborated feedback combined with self-explanation may impact students' diagnostic performance on different cases.

Introduced species in the Pantanal: implications for conservation.

Land use and human occupation within the natural habitats of the Pantanal have facilitated introduction of invasive species of plants and animals, including domestic species. Exotic species threaten regional biodiversity because they modify ecological community structure, alter natural habitats and affect local biodiversity. An international organisation, the International Union for Conservation of Nature (IUCN), and the Brazilian government, identify invasive species as the third most important threat to biodiversity, following habitat loss and direct effect on species. In addition, exotic species carry pathogens or may function as vectors or reservoirs for diseases that affect regional biota.

Introduced species in the Pantanal: implications for conservation

Land use and human occupation within the natural habitats of the Pantanal have facilitated introduction of invasive species of plants and animals, including domestic species. Exotic species threaten regional biodiversity because they modify ecological community structure, alter natural habitats and affect local biodiversity. An international organisation, the International Union for Conservation of Nature (IUCN), and the Brazilian government, identify invasive species as the third most important threat to biodiversity, following habitat loss and direct effect on species. In addition, exotic species carry pathogens or may function as vectors or reservoirs for diseases that affect regional biota.

O uso da terra e a ocupação humana nos hábitats naturais do Pantanal têm facilitado a introdução de espécies invasivas de plantas e animais, incluindo espécies domésticas. As espécies exóticas ameaçam a biodiversidade regional porque modificam a estrutura das comunidades ecológicas, alteram hábitats e afetam a biodiversidade. A organização internacional União Internacional para a Conservação da Natureza (IUCN) e o Governo brasileiro identificam as espécies invasoras como a terceira maior ameaça para a biodiversidade, seguida da perda de hábitat e do efeito direto sobre espécies. Além disso, espécies exóticas são portadoras de patógenos ou podem funcionar como vetores ou reservatórios de doenças que afetam a biota.

Innovations in medical internship: benchmarking and application within the King Saud bin Abdulaziz University for Health Sciences.

INTRODUCTION: While the medical internship (MI) has evolved in some countries into competency-based training with innovative tools for assessment and feedback, the traditional MI is still the norm in many countries. AIM: To describe recent advances in the MI in several countries, to discuss the current MI situation in Saudi Arabia as an example of a country that applies a traditional MI, and to present a Framework for Medical Interns' Competencies (FMIC) implemented within the King Saud bin Abdulaziz University for Health Sciences (KSAU-HS). METHODS: Common electronic databases were searched for the years 1990 to 2008 under keywords related to medical internship education. Information on curricula designed for medical interns or junior doctors in selected countries was obtained by searching relevant websites. At the KSAU-HS, the FMIC was created by first building the case for the urgent need for revising the MI and adapting international approaches to the KSA's needs, followed by dialogue among faculty and leaders, planning, coordination and execution of the framework. RESULTS: Two trends were identified in the recent evolution of the MI. In North America, the first postgraduate year now serves the traditional purpose of the MI. Australia and the United Kingdom have embedded the MI within junior doctor training. These innovative curricula have in common a focus on the domains of medical knowledge, clinical practice, professionalism and communication skills. The FMIC applies innovative principles during the MI years customized to the local medical education setting. CONCLUSION: The evolution in medical education and healthcare systems worldwide has necessitated innovations in the MI. The FMIC is a model whereby innovative curriculum was introduced to enhance the outcomes of the MI in a country that has applied a traditional MI.

Response of wild mammals to seasonal shrinking-and-expansion of habitats due to flooding regime of the Pantanal, Brazil

The Pantanal is a large savanna wetland (138,183 km² in Brazil), important for its wildlife, fed by tributaries of the upper Paraguay River, center of South America (Brazil, touching Bolivia and Paraguay). Uplands are plateaus (250-1,200 m high, 215,000 km² in Brazil) and flatland is the Pantanal (80-150 m high, 147,574 km² in Brazil). Rivers are slow moving when they meet the flatland (slope 0.3-0.5 m/km east-west; 0.03-0.15 m/km north-south), periodically overflowing their banks, creating a complex seasonal habitat range. Recurrent shallow flooding occupies 80 percent of the Pantanal; during the dry season flooded areas dry up. Fluctuating water levels, nutrients and wildlife form a dynamic ecosystem. A flooding regime forms distinct sub-regions within the Pantanal. A mammal survey was carried out in the sub-region of the Rio Negro from April, 2003 through March, 2004 to study the diversity and abundance of terrestrial mammals during the dry and flooding seasons. A total of 36 species were observed in the field. The capybara Hydrochaeris hydrochaeris was the most frequent species, followed by the crab-eating-fox Cerdocyon thous and the marsh deer Blastocerus dichotomus. The highest abundance of species was observed during the dry season (August and September), when there is a considerable expansion of terrestrial habitats, mainly seasonally flooded grassland. Animal abundance (in terms of observed individual frequencies) varied during the dry and wet seasons and the seasonally flooded grassland was the most utilized habitat by mammals in the dry season.

O Pantanal é uma área inundável (138.183 km² no Brasil), importante globalmente por sua biodiversidade, alimentado por tributários da margem esquerda do alto Rio Paraguai, no centro da América do Sul (Brasil, tocando a Bolívia e o Paraguai). As terras altas do entorno são o planalto (250-1200 m de altitude, 215.000 km² no Brasil), e a planície é o Pantanal (80-150 m de altitude, 147.574 km² no Brasil). Os rios movem-se lentamente quando encontram a planície (declividade de 0,3-0,5 m/km leste-oeste; 0,03-0,15 m/km norte-sul), periodicamente transbordando suas margens, criando um complexo de habitats sazonais. Inundação rasa e recorrente ocupa 80 por cento do Pantanal; áreas inundáveis secam na estação seca. Flutuação do nível da água, nutrientes e espécies silvestres formam um ecossistema dinâmico. Diferentes tipos de inundação formam diferentes tipos de pantanais. Um censo de mamíferos silvestres foi feito no Pantanal do Rio Negro, de abril de 2003 até março de 2004, para estudar a diversidade e a abundância de mamíferos terrestres durante as estações seca e cheia. Um total de 36 espécies de mamíferos foi observado no campo. A capivara Hydrochaeris hydrochaeris foi a espécie mais freqüente, seguida do lobinho Cerdocyon thous e do cervo-do-Pantanal Blastocerus dichotomus. A maior freqüência de espécies de mamíferos observada (abundância) foi registrada em agosto e setembro, coincidindo com a época de maior expansão de habitats sazonalmente inundáveis. A abundância de animais (em termos de freqüência de indivíduos observados) varia entre a estação seca e cheia, sendo que os campos sazonalmente inundáveis são os habitats mais utilizados pelos animais na estação seca.

Response of wild mammals to seasonal shrinking-and-expansion of habitats due to flooding regime of the Pantanal, Brazil.

The Pantanal is a large savanna wetland (138,183 km2 in Brazil), important for its wildlife, fed by tributaries of the upper Paraguay River, center of South America (Brazil, touching Bolivia and Paraguay). Uplands are plateaus (250-1,200 m high, 215,000 km2 in Brazil) and flatland is the Pantanal (80-150 m high, 147,574 km2 in Brazil). Rivers are slow moving when they meet the flatland (slope 0.3-0.5 m/km east-west; 0.03-0.15 m/km north-south), periodically overflowing their banks, creating a complex seasonal habitat range. Recurrent shallow flooding occupies 80% of the Pantanal; during the dry season flooded areas dry up. Fluctuating water levels, nutrients and wildlife form a dynamic ecosystem. A flooding regime forms distinct sub-regions within the Pantanal. A mammal survey was carried out in the sub-region of the Rio Negro from April, 2003 through March, 2004 to study the diversity and abundance of terrestrial mammals during the dry and flooding seasons. A total of 36 species were observed in the field. The capybara Hydrochaeris hydrochaeris was the most frequent species, followed by the crab-eating-fox Cerdocyon thous and the marsh deer Blastocerus dichotomus. The highest abundance of species was observed during the dry season (August and September), when there is a considerable expansion of terrestrial habitats, mainly seasonally flooded grassland. Animal abundance (in terms of observed individual frequencies) varied during the dry and wet seasons and the seasonally flooded grassland was the most utilized habitat by mammals in the dry season.

Developing an information system to support the pursuit of decentralization. The perspective of Cearà State in Brazil.

Discusses the national health information system in Brazil which, until very recently, consisted of two main structures of health services with a dichotomy between curative and preventive health care acting in a vertical manner. The autonomy of health authorities and specialized structures created numerous independent health information systems with different methods of data collection. Although the issues of decentralization and a unified health system had been agreed on in 1963, they had not been implemented until the new health policy reform was lunched in 1988. The reform was based on the strengthening of primary health care at national level and accelerating decentralization of health systems. However, in spite of strong political will the new health managers at local level are lacking essential information, data and instruments that only a decentralized health management information system can provide. Based on a study conducted in the Cearà State of the north east of Brazil, explores how the present health information system can support the process of decentralization.

Chicken house as a resting site of sandflies in Rio de Janeiro, Brazil.

During studies on the biology of sandflies in Itaipu, Rio de Janeiro state day catches were performed in a chicken house. Species such Lutzomyia intermedia, L. migonei and L. fischeri use the chicken house as refuge for blood digestion before moving for a better place to lay eggs. There is no evidence that chicken coop is a breeding site for those sandflies in the area.