Point-of-Care Ultrasound training in undergraduate education in the European Union: current situation and perspectives.

BACKGROUND: Given the widespread use of Point-of-Care UltraSound (PoCUS) in clinical practice, with ultrasound machines becoming more portable and affordable, recommendations and position statements from ultrasound societies now promote teaching PoCUS in the undergraduate curriculum. Nevertheless, surveys about PoCUS teaching in European medical schools are lacking. This survey aims to overview the current and future undergraduate PoCUS courses in the European Union (EU). RESULTS: A questionnaire was sent to medical schools in 26 of the 27 countries of the EU; Luxembourg is the only country without a medical school. The survey was completed by the dean or a member of the medical school with knowledge of the medical curriculum. Of the 58 medical schools from 19 countries that responded to the survey, 18 (31.0%) from 13 (68.4%) EU countries reported the existence of an undergraduate PoCUS curriculum and a further 16 (27.6%) from 12 (41.4%) EU countries intended to offer it in the future. No significant difference was observed between the current and future PoCUS curricula regarding its content and purpose. Less than 40 h of theoretical teaching is provided in all the medical schools and less than 40 h of practical training is provided in 12 (75%) of the 16 medical schools which answered this specific question. Of the 40 (69%) surveyed medical schools that do not currently teach PoCUS, 20 (50%) intend to offer PoCUS courses in the future. CONCLUSION: Although the lack of teaching hours in curricula suggests that most PoCUS courses are introductory in nature and that medical students are possibly not trained to become autonomous in clinical practice, evaluating the feasibility and impact of PoCUS teaching on clinical practice should be promoted. The medical schools that intend to develop this curriculum should be encouraged to implement validated tools to objectively assess their programs and students' performances.

Evaluation of point-of-care ultrasound use in the diagnostic approach for right upper quadrant abdominal pain management in the emergency department: a prospective study.

Point-of-care ultrasound (PoCUS) is commonly used at the bedside in the emergency department (ED) as part of clinical examinations. Studies frequently investigate PoCUS diagnostic accuracy, although its contribution to the overall diagnostic approach is less often evaluated. The primary objective of this prospective, multicenter, cohort study was to assess the contribution of PoCUS to the overall diagnostic approach of patients with right upper quadrant abdominal pain. Two independent members of an adjudication committee, who were blind to the intervention, independently evaluated the diagnostic approaches before and after PoCUS for the same patient. The study included 62 patients admitted to the ED with non-traumatic right upper quadrant abdominal pain from September 1, 2022, to March 6, 2023. The contribution of PoCUS to the diagnostic approach was evaluated using a proportion test assuming that 75% of diagnostic approaches would be better or comparable with PoCUS. Wilcoxon signed-rank tests evaluated the impact of PoCUS on the mean number of differential diagnoses, planned treatments, and complementary diagnostic tests. Overall, 60 (97%) diagnostic approaches were comparable or better with PoCUS (χ2 = 15.9, p < 0.01). With PoCUS, the mean number of differential diagnoses significantly decreased by 2.3 (95% CI - 2.7 to - 1.5) (p < 0.01), proposed treatments by 1.3 (95% CI - 1.8 to - 0.9) (p < 0.01), and complementary diagnostic tests by 1.3 (95% CI - 1.7 to - 1.0) (p < 0.01). These findings show that PoCUS positively impacts the diagnostic approach and significantly decreases the mean number of differential diagnoses, treatments, and complementary tests.

Effect of the Nicotine Replacement Therapy on Biomarkers of Inflammation, Endothelial Dysfunction, Oxidative Stress, and Lipids in Smokers Who Quit Smoking.

INTRODUCTION: Our previous study showed major changes in biomarkers on quitting compared to the smoking state. They reflected a decrease in inflammation, endothelial activation, and oxidative stress, as well as an improved lipid profile. Nicotine replacement therapy (NRT) is effective to increase the rate of successful quitting, but healthcare professionals may have concerns to prescribe this first-line smoking cessation treatment because its effect on inflammation and related processes is controversial. AIMS AND METHODS: The present study assessed the influence of NRT on biomarkers of inflammation, endothelial function, oxidative stress, and lipids, in people who quit smoking. Sixty-five subjects who daily smoke cigarettes were recruited and followed on quitting. Thirty-five quit using NRT and thirty quit without NRT. Biomarkers of inflammation, endothelial function, oxidative stress, and lipids were quantified at baseline when actively smoking and after cessation in the presence of NRT or not. RESULTS: Changes in biomarkers on quitting did not differ according to the treatment used. No difference was found when comparing participants who were exposed to NRT and those who were not. CONCLUSIONS: These results may indicate that NRT has no effect on inflammation, endothelial function, oxidative stress, and lipids, when used as a medication aid for quitting smoking. IMPLICATIONS: This study provides new evidence to support the safety profile of NRT products regarding the biomarkers of endothelial function, oxidative stress, inflammation, and lipids.

Novel proposed cutoff values for anatabine and anabasine in differentiating smokers from non-smokers.

OBJECTIVES: Anatabine and anabasine are two tobacco alkaloids used to differentiate between tobacco users and abstainers, including users of nicotine replacement therapy. Cutoff values (>2 ng/mL for both alkaloids) have not been revised since their implementation in 2002. These values may be too high, leading to increased likelihood of misclassification between smokers and abstainers. This results in major consequences, especially adverse outcomes of transplantation when smokers were incorrectly identified as being abstinent. This study proposes that a lower threshold for anatabine and anabasine will better distinguish tobacco users from non-users and thereby improve patients' care. DESIGN AND METHODS: A new and more sensitive analytical method by liquid chromatography-mass detection was developed to allow the quantification of low concentrations. Anatabine and anabasine were measured in urine samples of 116 self-reported daily smokers and 47 long-term non-smokers (confirmed by the analysis of nicotine and its metabolites). The best compromise between sensitivity and specificity allowed us to determine new cutoff values. RESULTS: The thresholds >0.097 ng/mL for anatabine and >0.236 ng/mL for anabasine were associated with a sensitivity of 97% (anatabine) and 89% (anabasine) and a specificity of 98% for both alkaloids. These cutoff values greatly increased the sensitivity given that it dropped to 75% (anatabine) and 47% (anabasine) when using the reference value (>2 ng/mL). CONCLUSIONS: The cutoff values >0.097 ng/mL for anatabine and >0.236 ng/mL for anabasine appear to better differentiate tobacco users from abstainers than the current reference threshold (>2 ng/mL for both alkaloids). It may considerably impact patients' care, especially in transplantation settings in which smoking abstinence is essential to avoid adverse outcomes of transplantation.

Changes in biomarkers of endothelial function, oxidative stress, inflammation and lipids after smoking cessation: A cohort study.

BACKGROUND: Tobacco use is known to be involved in the development of cardiovascular diseases, which leads to premature mortality. Endothelial dysfunction, the first step in this process, was shown induced by smoking. It is reported that quitting smoking could reduce the risk of diseases, but the implied mechanisms are still unclear. This study aimed to evaluate the biological markers of endothelial function in smokers when actively smoking and after cessation. METHODS: Quantification of several biomarkers reflecting inflammation, endothelium activation, oxidative stress, and lipids was performed in 65 smokers when actively smoking and after cessation (median abstinence duration of 70 days). RESULTS: A possible decrease of inflammation was observed through the concentration reduction of a proinflammatory cytokine (interleukine-6) on quitting. A decrease of endothelium activation was visible by the reduced level of the soluble intercellular adhesion molecule. Two antioxidants, uric acid and vitamin C, were found at higher concentration than before the cessation, potentially reflecting the decrease of oxidative stress on quitting. Lipid profile was improved post-quit since HDL level was increased and LDL level was decreased. All these effects were visible at short term with abstinence duration less than 70 days. No sex-specific difference was observed and no additional changes were observed for longer abstinence duration. CONCLUSION: These observations suggest that some adverse effects of smoking on endothelial function could be reversible on quitting smoking. It could encourage smokers to enter a cessation program to reduce the risk for cardiovascular diseases development.

Development of an Ultra-High Performance Liquid Chromatography method for the simultaneous mass detection of tobacco biomarkers in urine.

The quantification of tobacco exposure biomarkers is relevant to follow the patients' tobacco use. They allow to discriminate between tobacco users, non-users, passive smokers, and nicotine products users, such as in nicotine replacement therapy. The aim of this study was to develop and validate a quantification method of tobacco biomarkers of choice - nicotine, cotinine, trans-3'-hydroxycotinine, anatabine and anabasine - in urine. The challenge was to develop an easy and rapid liquid chromatography method requiring only one extraction step and allowing simultaneous detections. Some methods are described in the literature but need specific investment in terms of instrumentation and users training. Here, the developed method had to be carried out with instrumentation easily accessible for medical laboratories. The extraction of the analytes was performed by Supported Liquid Extraction (SLE), which consists in liquid-liquid extraction but supported by a sorbent. It allows to insure efficient neutrals extraction with less organic solvent and without any emulsion formation. 200 µl of basified urine - analytes of interest are neutral in this condition - were loaded on Novum SLE 96-Well Plates (Phenomenex) and analytes were eluted with 1 % formic acid in dichloromethane/propan-2-ol (95/5). After solvent evaporation, samples were reconstituted with 100 µl of water for injection. A mass detector (QDa, Waters) was used to detect analytes, this pre-optimised quadrupole mass analyser being less expensive and requiring less adjustments than traditional mass spectrometers while benefiting of the reliability of mass spectral data. This detector was integrated after an Ultra-high performance liquid chromatography (UHPLC) separation on a BEH C18 column (Waters) at a flow rate of 0.5 ml/min. A gradient elution of H2O (pH 10 with NH4OH) and CH3CN was used. Finally, the developed method was validated. This new method is conclusive to assess the patients' tobacco exposure and is easy to implement in medical laboratories.

Agreement of emergency physician-performed ultrasound versus RADiology-performed UltraSound for cholelithiasis or cholecystitis: a systematic review.

Cholecystitis secondary to gallstone migration is the most common suspected diagnosis for right upper quadrant pain in emergency departments, with radiology-performed ultrasound (RADUS) being the main diagnostic tool. The primary aim of this review was to assess the ability of emergency physicians to perform emergency ultrasound (EUS) compared to RADUS to diagnose cholelithiasis and cholecystitis. A systematic search was performed using Embase, Central (Cochrane library), Web of Science, MEDLINE, Google Scholar, prospective trial registries, and OpenSIGLE databases as well as hand-search of articles. Two physicians independently selected the articles. Assessment of methodological quality was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Clinical and methodological heterogeneity were qualitatively reported and discussed. Seven prospective studies were selected involving a total of 1061 subjects undergoing EUS. The included studies all used RADUS as the reference standard and emergency physician-performed EUS as the index test. Included studies mostly reported diagnostic accuracy for cholelithiasis diagnosis whereas only one study mentioned diagnostic accuracy for cholecystitis. Clinical and methodological heterogeneity between included studies prevented a meta-analysis. This review shows there is good agreement between EUS and RADUS to assess the gallbladder for cholelithiasis and therefore supports its use by emergency physicians for that matter. Nevertheless, this work identified clinical and methodological heterogeneity along with a poor description EUS operators' experience. In the future, larger studies should include a larger population of EUS operators, specify their background, and compare EUS to the final diagnosis to evaluate performances for gallbladder diagnostic accuracy.

Interventional radiology and artificial intelligence in radiology: Is it time to enhance the vision of our medical students?

OBJECTIVES: To assess awareness and knowledge of Interventional Radiology (IR) in a large population of medical students in 2019. METHODS: An anonymous survey was distributed electronically to 9546 medical students from first to sixth year at three European medical schools. The survey contained 14 questions, including two general questions on diagnostic radiology (DR) and artificial intelligence (AI), and 11 on IR. Responses were analyzed for all students and compared between preclinical (PCs) (first to third year) and clinical phase (Cs) (fourth to sixth year) of medical school. Of 9546 students, 1459 students (15.3%) answered the survey. RESULTS: On DR questions, 34.8% answered that AI is a threat for radiologists (PCs: 246/725 (33.9%); Cs: 248/734 (36%)) and 91.1% thought that radiology has a future (PCs: 668/725 (92.1%); Cs: 657/734 (89.5%)). On IR questions, 80.8% (1179/1459) students had already heard of IR; 75.7% (1104/1459) stated that their knowledge of IR wasn't as good as the other specialties and 80% would like more lectures on IR. Finally, 24.2% (353/1459) indicated an interest in a career in IR with a majority of women in preclinical phase, but this trend reverses in clinical phase. CONCLUSIONS: Development of new technology supporting advances in artificial intelligence will likely continue to change the landscape of radiology; however, medical students remain confident in the need for specialty-trained human physicians in the future of radiology as a clinical practice. A large majority of medical students would like more information about IR in their medical curriculum; almost a quarter of students would be interested in a career in IR.

In Brief: Validity of Case Summaries in Written Examinations of Clinical Reasoning.

Construct: The purpose of this study was to provide initial evidence of the validity of written case summaries as assessments of clinical problem representation in a classroom setting. BACKGROUND: To solve clinical problems, clinicians must gain a clear representation of the issues. In the clinical setting, oral case presentations-or summaries-are used to assess learners' ability to gather, synthesize, and "translate" pertinent case information. This ability can be assessed in Objective Structured Clinical Examination and Virtual Patient settings using oral or written case summaries. Evidence of their validity in these settings includes adequate interrater agreement and moderate correlation with other assessments of clinical reasoning. We examined the use of written case summaries in a classroom setting as part of an examination designed to assess clinical reasoning. APPROACH: We developed and implemented written examinations for 2 preclerkship general practice courses in Years 4 and 5 of a 7-year curriculum. Examinations included 8 case summary questions in Year 4 and 5 in Year 5. Seven hundred students participated. Cases were scored using 3 criteria: extraction of pertinent findings, semantic quality, and global ratings. We examined the item parameters (using classical test theory) and generalizability of case summary items. We computed correlations between case summary scores and scores on other questions within the examination. RESULTS: Item parameters were acceptable (average item difficulty = 0.49-0.73 and 0.59-0.68 in Years 4 and 5; average point-biserials = 0.21-0.24 and 0.18-0.21). Scores were moderately generalizable (G coefficients = 0.40-0.50), with case-specificity a substantial source of measurement error (10.2%-19.5% of variance). Scoring and rater had small effects. Correlations with related constructs were low to moderate. CONCLUSIONS: There is good evidence regarding the scoring and generalizability of written case summaries for assessment of clinical problem representation. Further evidence regarding the extrapolation and implications of these assessments is warranted.

Activity confrontation methods: A reflexive and metacognitive approach for interprofessional collaboration training.

Integration of interprofessional collaboration into healthcare education and training programmes has become a fundamental issue. Its objective is to learn how to collectively build collaborative care practice that addresses the uniqueness of each context and the specific situation of the patient. It is also about understanding the process of collectively building collaborative care practice in order to be able to apply it in different contexts. This article describes a study that aimed to examine the value of relying on activity confrontation methods to develop training. These methods consist of filming practitioners during an activity and encouraging them to analyse it. It was found that these methods encourage reflexive analysis of the motives for pursuing interprofessional action (identifying constitutive factors) but also a metacognitive approach on the conditions of learning (p < 0.01). In addition to the educational dimensions (methods and leadership positions) and organisational dimensions (frameworks), it was found that the patient's role is essential in developing interprofessional care practice and training (p < 0.01). Given the nature of these findings, this article goes on to suggest that the patient must be considered a "partner" in development and delivery of interprofessional learning and care.

Multifaceted assessment in a family medicine clerkship: a pilot study.

BACKGROUND AND OBJECTIVES: Programs of assessment should reflect the multifaceted nature of medical competence. We experimented with new testing methods, ie, script concordance testing (SCT) and clinical reasoning problems (CRPs), combined with the habitual OSCE for an end of family medicine clerkship. Our aims were to compare students' scores with experts' scores, to determine whether the new tests detected learning over a 3-month period, and to examine whether the tests were redundant. METHODS: We conducted a longitudinal study on one cohort of family medicine clerks. Two formative testing sessions using both SCT and CRPs were held 3 months apart. Students' scores were compared to those of the panel of experts used to score the tests. We examined the difference in students' scores between the two testing sessions. Finally, we computed correlation coefficients between these scores and the summative OSCE. RESULTS: Panelists' scores were significantly higher than students' scores. SCT scores did not change significantly over 3 months whereas CRP scores improved (Wilcoxon z -3.058, effect size 0.461, P=.002). Correlations between the OSCE and the written tests were low or non-significant. There were low correlations between the first CRP and both SCTs (Spearman's rho 0.357 and 0.358) but not between the second CRP and any SCT. CONCLUSIONS: Written tests of clinical reasoning could provide relevant additional information to the evaluation of students' competence over the course of a family medicine clerkship. Further research is needed to determine the potential educational consequences of such programs of assessment.

Assessing clinical reasoning using a script concordance test with electrocardiogram in an emergency medicine clerkship rotation.

OBJECTIVES: Script concordance tests (SCTs) can be used to assess clinical reasoning, especially in situations of uncertainty, by comparing the responses of examinees with those of emergency physicians. The examinee's answers are scored based on the level of agreement with responses provided by a panel of experts. Emergency physicians are frequently uncertain in the interpretation of ECGs. Thus, the aim of this study was to validate an SCT combined with an ECG. METHODS: An SCT-ECG was developed. The test was administered to medical students, residents and emergency physicians. Scoring was based on data from a panel of 12 emergency physicians. The statistical analyses assessed the internal reliability of the SCT (Cronbach's α) and its ability to discriminate between the different groups (ANOVA followed by Tukey's post hoc test). RESULTS: The SCT-ECG was administered to 21 medical students, 19 residents and 12 emergency physicians. The internal reliability was satisfactory (Cronbach's α=0.80). Statistically significant differences were found between the groups (F(0.271)=21.07; p<0.0001). Moreover, significant differences (post hoc test) were detected between students and residents (p<0.001), students and experts (p<0.001), and residents and experts (p=0.017). CONCLUSIONS: This SCT-ECG is a valid tool to assess clinical reasoning in a context of uncertainty due to its high internal reliability and its ability to discriminate between different levels of expertise.

Comparison of five D-dimer reagents and application of an age-adjusted cut-off for the diagnosis of venous thromboembolism in emergency department.

There is still a considerable uncertainty concerning D-dimer cut-off values used in exclusion of venous thromboembolic (venous thromboembolism, VTE) disease, especially among the elderly patients. The objectives were to compare five different D-dimer reagents in the daily practice of an emergency department and to test retrospectively the performances of an age-adjusted cut-off. A total of 473 consecutive ambulatory outpatients suspected of VTE (confirmed VTE = 21) were included in this study. Five commercially available tests were assessed: STA-Liatest D-Di (LI), AxSYMD-Dimer (AX), VIDAS D-Dimer (VI), INNOVANCE D-Dimer (IN), and HemosIL D-Dimer HS (HS). When using a cut-off value of 500 ng/ml fibrinogen equivalent units (FEUs), D-dimer reagents differ in their abilities to avoid further testing. Indeed, LI allowed exclusion of VTE diagnosis in statistically more patients than VI, AX, and IN but not HS. The use of an age-adjusted cut-off is cost-effective without increasing significantly the number of false negative results. The interest of such strategy is more or less pronounced, depending on the type of D-dimer reagent. The application of an age-adjusted cut-off may be useful to reduce differences among D-dimer reagents to lower costly imaging studies. Prospective validation studies on large cohorts of patients are required to determine the safety of such strategy.

[From the pragmatic to pragmatism: what are the stakes for training in ethics?]. / Du pragmatique au pragmatisme : quels enjeux pour la formation à l'éthique?

The contemporary evolution of the request and the recourse for ethics in the health field questions the models of ethics training. Indeed the stake is no more to train actors able of producing a moral speech on the practices but, in a destabilized context, to accompany them in the development of new practices in professional situation. This pragmatic turn in health ethics requires more active, reflective and contextual models of training, needing new links between training places and care practices. This paper is about theoretical foundations of such an ethics pedagogy, and about its stakes in terms of re-institutionalization. Pragmatism, and more particularly the approach of John Dewey, will be mobilized here to found educational practices needed by such an ethics pedagogy (an experiential, reflective and collective learning), but also to consider issues concerning training device linked to such a learning. On this point, the philosophy of integrative block-release training is investigated as a way to develop future professional competences, even if the last part of this text will insist on the reflective governance such an alternation requires and on the "re-institutionalization of the ethics pedagogy" that the latter generates.

Lactic acidosis following intentional overdose by inhalation of salmeterol and fluticasone.

Salmeterol, a long-acting ß2-adrenergic receptor agonist used for the treatment of asthma and chronic obstructive pulmonary disease, has an adverse effects profile that is similar to that of salbutamol and other ß2-agonists. We report a sympathomimetic syndrome with metabolic acidosis and hyperlactatemia after intentional inhalation of salmeterol in a suicide attempt. A 16-year-old female patient was admitted to the emergency department approximately 2 hours after having inhaled 60 puffs of a combination of salmeterol xinafoate 25 µg and fluticasone propionate 50 µg. She presented in an anxious state with complaints of palpitations and chest pain. The electrocardiogram demonstrated sinus tachycardia and ST-segment depression in the inferior and anterolateral leads. Laboratory findings showed hypokalemia, hypophosphatemia, and lactic acidosis. Cardiac troponin I and creatine kinase MB remained within the normal range. Treatment was supportive and included intravenous fluids and cautious potassium supplementation. The next day, electrocardiographic and laboratory findings returned to normal. We hypothesize that stimulation of ß2-adrenergic receptors by inhalation of salmeterol caused this patient's lactic acidosis. This observation is consistent with the hypothesis that the hyperlactatemia observed during asthma attacks is due in part to the administration of high doses of ß2-agonists. Salmeterol overdose by inhalation appears to be sufficient to cause lactic acidosis.

How to construct and implement script concordance tests: insights from a systematic review.

CONTEXT: Programmes of assessment should measure the various components of clinical competence. Clinical reasoning has been traditionally assessed using written tests and performance-based tests. The script concordance test (SCT) was developed to assess clinical data interpretation skills. A recent review of the literature examined the validity argument concerning the SCT. Our aim was to provide potential users with evidence-based recommendations on how to construct and implement an SCT. METHODS: A systematic review of relevant databases (MEDLINE, ERIC [Education Resources Information Centre], PsycINFO, the Research and Development Resource Base [RDRB, University of Toronto]) and Google Scholar, medical education journals and conference proceedings was conducted for references in English or French. It was supplemented by ancestry searching and by additional references provided by experts. RESULTS: The search yielded 848 references, of which 80 were analysed. Studies suggest that tests with around 100 items (25-30 cases), of which 25% are discarded after item analysis, should provide reliable scores. Panels with 10-20 members are needed to reach adequate precision in terms of estimated reliability. Panellists' responses can be analysed by checking for moderate variability among responses. Studies of alternative scoring methods are inconclusive, but the traditional scoring method is satisfactory. There is little evidence on how best to determine a pass/fail threshold for high-stakes examinations. CONCLUSIONS: Our literature search was broad and included references from medical education journals not indexed in the usual databases, conference abstracts and dissertations. There is good evidence on how to construct and implement an SCT for formative purposes or medium-stakes course evaluations. Further avenues for research include examining the impact of various aspects of SCT construction and implementation on issues such as educational impact, correlations with other assessments, and validity of pass/fail decisions, particularly for high-stakes examinations.

How competent do general practice residents feel and why?

BACKGROUND: General practice residency aims to produce competent general practitioners (GPs) who will practice independently, i.e. who demonstrate adequate levels of actual and self-perceived competence. PURPOSES: To measure self-perceived competence in GP residents at our institution and explore potential determinants. METHODS: We conducted a cross-sectional study of our GP residents. Self-perceived competence was measured in four domains. Independent variables included gender, postgraduate year, patient contacts, on-call duties, practice of specific tasks, self-assessed effort and knowledge. RESULTS: Between 1.6 and 37.8% of GP residents assessed their competence as less than average. Self-perceived competence was not consistently linked to any of the hypothesised factors. CONCLUSIONS: A significant proportion of residents reported less than satisfactory levels of self-perceived competence. Longitudinal studies should be conducted as well as qualitative studies focusing on the role of other factors in the development of high levels of self-perceived competence during general practice training.

What is so difficult about managing clinical reasoning difficulties?

CONTEXT: Clinical reasoning is the cornerstone of medical competence. Difficulties in this area are often identified late in clinical training. Studies point to challenges faced by clinical educators in their dual roles as clinicians and educators. Little is known about the common, yet complex, issue of how they manage clinical reasoning difficulties. We therefore sought to: (i) describe the current state of affairs in various clinical teaching settings, and (ii) explore the factors that determine the behaviour of clinical educators in this respect. METHODS: Four focus groups were conducted with 26 clinical educators in general practice, internal medicine and emergency medicine in Belgium and Switzerland. Two researchers analysed the transcripts of the focus group discussions using Fishbein's integrative model of behaviour prediction in a theory-driven, immersion-crystallisation process. Experienced faculty members validated the findings. RESULTS: Across diverse settings, the process of identifying and remediating clinical reasoning difficulties was unstructured. Consistent with Fishbein's model, clinical educators' underlying beliefs determined their behaviour. They believed in the apprenticeship model of learning in the clinical environment, in which their educational role was limited to role-modelling and in which residents were responsible for assimilating skills. They were sceptical about the potential impact of remediation. A few more knowledgeable supervisors had a stronger sense of their educational role, but did not implement systematic procedures to manage clinical reasoning difficulties. Environmental constraints were symptomatic of a collective paradigm of residency as an apprenticeship, in which the focus is on clinical duties, rather than as an educational programme. CONCLUSIONS: In order to improve the current state of affairs in the management of clinical reasoning difficulties, a collective paradigm shift is required to alter the perception of residency as an apprenticeship to one of residency as a structured educational programme. Faculty development programmes should be designed in an integrated way so that they not only develop clinical educators' skills, but also modify their beliefs.

Usable knowledge, hazardous ignorance - beyond the percentage correct score.

BACKGROUND: Little attention has been paid to the metacognitive ability of medical students. AIM: We used confidence marking to explore certainty of knowledge and ignorance. METHODS: One hundred and twenty-seven of 169 general practice trainees took part. Students sat a written multiple choice question (MCQ) test. Each answer was followed by a degree of certainty judgement. Answers attributed with a high degree of certainty were used to compute overall usable knowledge, hazardous ignorance, proportions of knowledge that is usable and of ignorance that is hazardous. The former variables were analysed according to MCQ score, year of training and gender. RESULTS: At a group level, the mean amount of usable knowledge on the MCQ was 21.13%, mean amount of hazardous ignorance on the MCQ was 5.21%, mean proportion of knowledge that was usable was 36.57%, mean proportion of ignorance that was hazardous was 14.32%. There were neither significant differences between highest and lowest quartiles of MCQ score, nor according to year of training. Men had higher levels of ignorance that is hazardous. CONCLUSION: A third of trainees' knowledge was partial. A sixth of their ignorance was hazardous. Confidence marking can aid formative assessment and could potentially be implemented into summative assessments.

Evaluation of clinical reasoning in basic emergencies using a script concordance test.

OBJECTIVES: To develop and assess the reliability of a script concordance test (SCT) to evaluate pharmacy students' clinical reasoning when facing basic emergency situations. DESIGN: A first aid course was designed that consisted of 8 weekly instructional sessions (4 on internal medicine, including life threatening situations; 2 on pediatrics; and 2 on trauma) in which the instructor presented case studies in a small-group format. In the first and final sessions of the course, a practice SCT was administered to familiarize students with the test format. ASSESSMENT: A 66-question SCT examination was administered to the 68 third-year pharmacy students enrolled in the first aid course. The students' mean score was 68.5% ± 9.8% and panel members' mean score was 86.5% ± 4.2%. Twenty students were selected randomly to complete a course survey and 85% indicated they were satisfied with using the SCT. CONCLUSIONS: A first aid SCT was found to be both a practical and reliable testing instrument for assessing the clinical reasoning of pharmacy students in basic emergency situations.