Influence of tutor interventions and group process on medical students' engagement in problem-based learning.

INTRODUCTION: Student engagement is influenced by several variables, among which are the teaching styles employed by faculty. In problem-based learning (PBL), the role of faculty is to facilitate the learning of the tutorial group as they work through clinical problems. However, the influence of tutor intervention styles and group process on engagement of students in PBL tutorials is unclear. METHODS: The study was conducted with year 2 and 3 medical students (n = 176) in PBL tutorial groups at the end of an integrated PBL course. Students evaluated their behavioural, cognitive and emotional engagement in PBL tutorials using a pre-validated 11-item questionnaire. Students also filled in a modified version of a previously published tutor intervention profile (TIP) questionnaire. The modified TIP questionnaire represents three constructs (1) steering the learning process (6 items), (2) stimulating student autonomy (4 items) and (3) establishing relatedness with students (3 items). In addition, PBL group process was evaluated using a 5-item nominal scale: (1) tutorial atmosphere, (2) listening and information sharing, (3) group performance, (4) decision making and (5) reaction to leadership. RESULTS: Establishing sense of relatedness in the group by PBL tutors was the most important predictor of emotional engagement (F = 41.213, ΔR2 = 0.191, ß = 0.438, P = 0.000). On the other hand, steering the learning process was a significant predictor of behavioural engagement (F = 19.0, ΔR2=0.098, ß = 0.314, P = 0.000). However, stimulating student autonomy was not a significant predictor of student engagement in PBL tutorials. On the other hand, enhancing the group process in PBL tutorials significantly predicts student engagement with strong impact on emotional and cognitive engagement of students. CONCLUSIONS: Establishing the sense of relatedness in the group and steering the learning process by PBL tutors as well as improving PBL group process are significant predictors of student engagement in PBL tutorials with emotional and cognitive engagement being the most sensitive variables affected.

The influence of context on diagnostic reasoning: A narrative synthesis of experimental findings.

AIMS AND OBJECTIVES: Contextual information which is implicitly available to physicians during clinical encounters has been shown to influence diagnostic reasoning. To better understand the psychological mechanisms underlying the influence of context on diagnostic accuracy, we conducted a review of experimental research on this topic. METHOD: We searched Web of Science, PubMed, and Scopus for relevant articles and looked for additional records by reading the references and approaching experts. We limited the review to true experiments involving physicians in which the outcome variable was the accuracy of the diagnosis. RESULTS: The 43 studies reviewed examined two categories of contextual variables: (a) case-intrinsic contextual information and (b) case-extrinsic contextual information. Case-intrinsic information includes implicit misleading diagnostic suggestions in the disease history of the patient, or emotional volatility of the patient. Case-extrinsic or situational information includes a similar (but different) case seen previously, perceived case difficulty, or external digital diagnostic support. Time pressure and interruptions are other extrinsic influences that may affect the accuracy of a diagnosis but have produced conflicting findings. CONCLUSION: We propose two tentative hypotheses explaining the role of context in diagnostic accuracy. According to the negative-affect hypothesis, diagnostic errors emerge when the physician's attention shifts from the relevant clinical findings to the (irrelevant) source of negative affect (for instance patient aggression) raised in a clinical encounter. The early-diagnosis-primacy hypothesis attributes errors to the extraordinary influence of the initial hypothesis that comes to the physician's mind on the subsequent collecting and interpretation of case information. Future research should test these mechanisms explicitly. Possible alternative mechanisms such as premature closure or increased production of (irrelevant) rival diagnoses in response to context deserve further scrutiny. Implications for medical education and practice are discussed.

Promoting Longitudinal and Developmental Computer-Based Assessments of Clinical Reasoning: Validity Evidence for a Clinical Reasoning Mapping Exercise.

PURPOSE: Clinical reasoning is vitally important for practitioners across the health professions. However, the assessment of clinical reasoning remains a significant challenge. Combined with other assessment methods, non-workplace-based assessment can increase opportunities to address multiple components of clinical reasoning, evaluate growth, and foster learning, but tools with validity evidence to assess clinical reasoning outside the workplace are scare. This study examined validity evidence for a novel clinical reasoning mapping exercise (CResME). METHOD: Data include CResME performance scores from 120 third-year medical students at the University of Central Florida for 3 topics in May 2022. Each CResME was scored by 2 physician raters based on a scoring rubric that included a combined diagnosis and sequence score. Descriptive statistics were used to examine trends in scores. The authors gathered validity evidence for response process, internal structure, and relations to other variables. RESULTS: The overall mean (SD) score across cases was 66 (29). Internal consistency reliability of cases (Cronbach α) ranged from 0.75 to 0.91. The Phi and G coefficients were 0.45 and 0.56, respectively. Students accounted for 10% of the total variance, indicating the ability to differentiate high and low clinical reasoning skills; the interaction between learner and case accounted for 8.1% of the variance, demonstrating case specificity. There was a moderate correlation between the overall CResME scores and the mean overall score of patient encounter notes from an objective structured clinical examination performed at the end of the third year (0.46; P = .001). Significant associations were also found between the CResME scores and subject exam scores. CONCLUSIONS: The CResME can be used to facilitate the assessment of clinical reasoning, supporting the developmental progress of learners throughout the curriculum. Future research is needed to gather validity evidence for CResMEs with different learners across different settings and formats.

Overconfidence, Time-on-Task, and Medical Errors: Is There a Relationship?

Background: Literature suggest that physicians' high level of confidence has a negative impact on medical decisions, and this may lead to medical errors. Experimental research is lacking; however, this study investigated the effects of high confidence on diagnostic accuracy. Methods: Forty internal medicine residents from different hospitals in Saudi Arabia were divided randomly into two groups: A high-confidence group as an experimental and a low-confidence group acting as a control. Both groups solved each of eight written complex clinical vignettes. Before diagnosing these cases, the high-confidence group was led to believe that the task was easy, while the low-confidence group was presented with information from which it could deduce that the diagnostic task was difficult. Level of confidence, response time, and diagnostic accuracy were recorded. Results: The participants in the high-confidence group had a significantly higher confidence level than those in the control group: 0.75 compared to 0.61 (maximum 1.00). However, neither time on task nor diagnostic accuracy significantly differed between the two groups. Conclusion: In the literature, high confidence as one of common cognitive biases has a strong association with medical error. Even though the high-confidence group spent somewhat less time on the cases, suggesting potential premature decision-making, we failed to find differences in diagnostic accuracy. It is suggested that overconfidence should be studied as a personality trait rather than as a malleable characteristic.

Role of knowledge and reasoning processes as predictors of resident physicians' susceptibility to anchoring bias in diagnostic reasoning: a randomised controlled experiment.

BACKGROUND: Diagnostic errors have been attributed to reasoning flaws caused by cognitive biases. While experiments have shown bias to cause errors, physicians of similar expertise differed in susceptibility to bias. Resisting bias is often said to depend on engaging analytical reasoning, disregarding the influence of knowledge. We examined the role of knowledge and reasoning mode, indicated by diagnosis time and confidence, as predictors of susceptibility to anchoring bias. Anchoring bias occurs when physicians stick to an incorrect diagnosis triggered by early salient distracting features (SDF) despite subsequent conflicting information. METHODS: Sixty-eight internal medicine residents from two Dutch university hospitals participated in a two-phase experiment. Phase 1: assessment of knowledge of discriminating features (ie, clinical findings that discriminate between lookalike diseases) for six diseases. Phase 2 (1 week later): diagnosis of six cases of these diseases. Each case had two versions differing exclusively in the presence/absence of SDF. Each participant diagnosed three cases with SDF (SDF+) and three without (SDF-). Participants were randomly allocated to case versions. Based on phase 1 assessment, participants were split into higher knowledge or lower knowledge groups. MAIN OUTCOME MEASUREMENTS: frequency of diagnoses associated with SDF; time to diagnose; and confidence in diagnosis. RESULTS: While both knowledge groups performed similarly on SDF- cases, higher knowledge physicians succumbed to anchoring bias less frequently than their lower knowledge counterparts on SDF+ cases (p=0.02). Overall, physicians spent more time (p<0.001) and had lower confidence (p=0.02) on SDF+ than SDF- cases (p<0.001). However, when diagnosing SDF+ cases, the groups did not differ in time (p=0.88) nor in confidence (p=0.96). CONCLUSIONS: Physicians apparently adopted a more analytical reasoning approach when presented with distracting features, indicated by increased time and lower confidence, trying to combat bias. Yet, extended deliberation alone did not explain the observed performance differences between knowledge groups. Success in mitigating anchoring bias was primarily predicted by knowledge of discriminating features of diagnoses.

O que a pesquisa sobre raciocínio clínico tem a dizer a preceptores e professores de áreas clínicas? / What does research on clinical reasoning have to say to clinical teachers?

O raciocínio clínico é um fator determinante da performance do médico, crucial para chegar a um diagnóstico correto e possibilitar decisões terapêuticas adequadas. Ajudar seus estudantes a desenvolver o raciocínio clínico é um desafio diário de muitos professores e, para selecionar estratégias de ensino adequadas, pode ser útil conhecer um pouco dos resultados da pesquisa sobre raciocínio clínico que vem se desenvolvendo já há algumas décadas. Este artigo traz uma síntese de achados desta pesquisa que ajudam a compreender os processos cognitivos envolvidos no raciocínio clínico, a trajetória que leva o estudante de uma condição de "iniciante" `a de "expert" e abordagens instrucionais que têm se mostrado úteis para facilitar esta trajetória. O foco do artigo é o processo diagnóstico, porque é ele que tem sido o objeto central de pesquisa. Esta pesquisa indica que não há estratégias de raciocínio específicas, próprias do médico expert, que possam ser ensinadas ao estudante. É a existência de uma larga base de conhecimentos organizados na memória em scripts de doenças de diversos formatos que explica o melhor desempenho do expert. Quanto mais numerosos, mais ricos e melhor organizados são os scripts que um médico tem na memória, mais apto ele está para fazer diagnósticos acurados. Estes scripts são formados gradualmente ao longo dos anos de formação e para desenvolvê-los o estudante deve ser exposto a uma grande diversidade de problemas clínicos, com os quais ele deve interagir de forma ativa. Abordagens instrucionais que requerem que o estudante reflita de forma sistemática sobre os problemas, analisando diferenças e similaridades entre eles, explicando mecanismos subjacentes, comparando e contrastando diagnósticos alternativos têm se mostrado úteis para ajudar a refinar scripts de doenças e são ferramentas valiosas para os professores interessados no desenvolvimento do raciocínio clínico de seus estudantes.

Clinical reasoning is a crucial determinant of physicians' performance. It is key to arrive at a correct diagnosis, which substantially increases the chance of appropriate therapeutic decisions. Clinical teachers face the daily challenge of helping their students to develop clinical reasoning. To select appropriate teaching strategies, it may be useful to become acquainted with the results of the research on clinical reasoning that has been conducted over the last decades. This article synthesizes the findings of this research that help in particular to understand the cognitive processes involved in clinical reasoning, the trajectory that leads the student from novice to expert, and instructional approaches that have been shown to be useful to facilitating this trajectory. The focus of the article is the diagnostic process, because it is about it that most research has been conducted. This research indicates that there is not a particular reasoning strategy that is specific to expert physicians and could be taught to students. It is the availability of a large knowledge base organized in memory in illness scripts of different formats that explains the expert's better performance. The more, the richer, and the more well-structured are the illness scripts a physician has stored in memory, the more he/she would be able to make accurate diagnoses. These scripts are formed gradually over the years of education. To help develop them, students should be exposed to a wide variety of clinical problems, with which they must interact actively. Instructional approaches that require students to systematically reflect on problems, analyzing differences and similarities between them, explaining underlying mechanisms, comparing and contrasting alternative diagnoses, have proved useful to help refine disease scripts. These approaches are valuable tools for teachers concerned with the development of their students clinical reasoning.