Cognitive dissonance: how self-protective distortions can undermine clinical judgement.

CONTEXT: When errors occur in clinical settings, it is important that they are recognised without defensiveness so that prompt corrective action can be taken and learning can occur. Cognitive dissonance - the uncomfortable tension we experience when we hold two or more inconsistent beliefs - can hinder our ability to respond optimally to error. OBJECTIVES: The aim of this paper is to describe the effects of cognitive dissonance, a construct developed and tested in social psychology. We discuss the circumstances under which dissonance is most likely to occur, provide examples of how it may influence clinical practice, discuss potential remedies and suggest future research to test these remedies in the clinical context. METHODS: We apply research on cognitive dissonance from social psychology to clinical settings. We examine the factors that make dissonance most likely to occur. We illustrate the power of cognitive dissonance through two medical examples: one from history and one that is ongoing. Finally, we explore moderators at various stages of the dissonance process to identify potential remedies. RESULTS: We show that there is great opportunity for cognitive dissonance to distort judgements, delay optimal responses and hinder learning in clinical settings. We present a model of the phases of cognitive dissonance, and suggestions for preventing dissonance, reducing the distortions that can arise from dissonance and inhibiting dissonance-induced escalation of commitment. CONCLUSIONS: Cognitive dissonance has been studied for decades in social psychology but has not had much influence on medical education research. We argue that the construct of cognitive dissonance is very relevant to the clinical context and to medical education. Dissonance has the potential to interfere with learning, to hinder the process of coping effectively with error, and to make the accepting of change difficult. Fortunately, there is the potential to reduce the negative impact of cognitive dissonance in clinical practice.

Measuring medical students' reflection on their learning: modification and validation of the motivated strategies for learning questionnaire (MSLQ).

BACKGROUND: Reflection on learning is an essential component of effective learning. Deconstructing the components of reflection on learning using a self-regulated learning (SRL) framework, allows the assessment of students' ability to reflect on their learning. The aim of this study was to validate an instrument to measure medical students' reflection on their learning. METHODS: A systematic search was conducted to identify the most suitable instrument to measure students' reflection on their learning based on the theoretical framework of SRL. The search identified the Motivated Strategies for Learning Questionnaire (MSLQ) which contained five subscales: internal goal orientation, self-efficacy, critical thinking, metacognitive/self-regulation, help seeking and peer learning. Using the original MSLQ as the foundation, we carried out three phases of a research program to develop a useful set of items: an expert panel's review of items, a substantial pilot study, and a factor analysis of ratings of a modified set of items by preclinical and final year medical students. RESULTS: The factor analysis of the Modified MSLQ extracted four subscales with reasonable internal consistency: self-orientation, critical thinking, self-regulation and feedback-seeking. Each subscale correlates highly with the Modified MSLQ score, with modest inter-correlations between the subscales suggesting that they are measuring different components of the total score. CONCLUSION: Medical students and their educators need to be able to monitor their learning in their complex academic and clinical environments. The Modified MSLQ provides a means of investigating and tracking individual medical students' reflections on their learning.

Novice students navigating the clinical environment in an early medical clerkship.

CONTEXT: The black box that is student learning in clinical environments is an ongoing research project. Our previous research showed that despite the time that students are given to learn with, about and from patients, some lack confidence for those encounters and see few patients. The study reported here investigated individual and environmental factors affecting medical students' self-directed learning time in hospital. METHODS: We studied second year students in the four-year postgraduate Melbourne Medical School programme as they undertook the first of their four 9-week hospital placements in medical wards. Each week approximately 10 hours of structured teaching is offered; the remaining time is spent in self-directed learning. Over six weeks, we observed 31 medical students and interviewed 17 of them. The interviews were subjected to content analysis procedures and the observation notes added contextual information to what was said in interviews. We considered the findings through the Experience-based Learning framework. RESULTS: We found four main themes in the data: finding and contacting patients challenges all students and overwhelms some; the educational design of the placement is a flawed navigational device providing inadequate clarity and security; the physical and social terrain of a large tertiary hospital is replete with obstacles making it easy for some students to stumble and retreat; finally, any positive connection with peers, staff and patients is empowering. CONCLUSIONS: This study throws light on to the uncertain path of the novice clinical learner illuminating both the intractable aspects of hospital environments and opportunities for pedagogical and affective supports that can compensate. The processes and conditions for self-directed learning time need attention in order to provide for a safe, efficient or successful clerkship experience for all students. Particular effort is needed to sensitively identify those individuals who struggle and suffer on the journey, and provide appropriate support.

How clinical reasoning is taught and learned: Cultural perspectives from the University of Melbourne and Universitas Indonesia.

BACKGROUND: The majority of schools in the Asia-Pacific region have adopted medical curricula based on western pedagogy. However to date there has been minimal exploration of the influence of the culture of learning on the teaching and learning process. This paper explores this issue in relation to clinical reasoning. METHOD: A comparative case study was conducted in 2 medical schools in Australia (University of Melbourne) and Asia (Universitas Indonesia). It involved assessment of medical students' attitudes to clinical reasoning through administration of the Diagnostic Thinking Inventory (DTI), followed by qualitative interviews which explored related cultural issues. A total of 11 student focus group discussions (45 students) and 24 individual medical teacher interviews were conducted, followed by thematic analysis. RESULTS: Students from Universitas Indonesia were found to score lower on the Flexibility in Thinking subscale of the DTI. Qualitative data analysis based on Hofstede's theoretical constructs concerning the culture of learning also highlighted clear differences in relation to attitudes to authority and uncertainty avoidance, with potential impacts on attitudes to teaching and learning of clinical reasoning in undergraduate medical education. CONCLUSIONS: Different attitudes to teaching and learning clinical reasoning reflecting western and Asian cultures of learning were identified in this study. The potential impact of cultural differences should be understood when planning how clinical reasoning can be best taught and learned in the changing global contexts of medical education, especially when the western medical education approach is implemented in Asian contexts.

'It was serendipity': a qualitative study of academic careers in medical education.

CONTEXT: Despite a demand for educational expertise in medical universities, little is known of the roles of medical educators and the sustainability of academic careers in medical education. We examined the experiences and career paths of medical educators from diverse professional backgrounds seeking to establish, maintain and strengthen their careers in medical schools. METHODS: Semi-structured interviews were conducted with 44 lead and early-career medical educators from all 21 Australian and New Zealand medical schools. Questions explored career beginnings, rewards and challenges. Transcripts underwent systematic coding and independent thematic analysis. Final themes were confirmed by iterative review and member checking. Analysis was informed by Bourdieu's concepts of field (a social space for hierarchical interactions), habitus (individual dispositions which influence social interactions) and capital (economic, symbolic, social and cultural forms of power). RESULTS: Participants provided diverse accounts of what constitutes the practice of medical education. Serendipitous career entry and little commonality of professional backgrounds and responsibilities suggest an ambiguous habitus with ill-defined career pathways. Within the field of medicine as enacted in medical schools, educators have invisible yet essential roles, experiencing tension between service expectations, a lesser form of capital, and demands for more highly valued forms of scholarship. Participants reported increasing expectations to produce research and obtain postgraduate qualifications to enter and maintain their careers. Unable to draw upon cultural capital accrued from clinical work, non-clinician educators faced additional challenges. To strengthen their position, educators consciously built social capital through essential service relationships, capitalising on times when education takes precedence, such as curriculum renewal and accreditation. CONCLUSIONS: Bourdieu's theory provides insight into medical educator career paths and the positioning of medical education within medical schools. Medical educators have an indistinct practice, and limited cultural capital in the form of research outputs. In order to maintain and strengthen their careers, educators must create alternative sources of capital, through fostering collaborative alliances.

What counts as effective communication in nursing? Evidence from nurse educators' and clinicians' feedback on nurse interactions with simulated patients.

AIM: To examine the feedback given by nurse educators and clinicians on the quality of communication skills of nurses in interactions with simulated patients. BACKGROUND: The quality of communication in interactions between nurses and patients has a major influence on patient outcomes. To support the development of effective nursing communication in clinical practice, a good understanding of what constitutes effective communication is helpful. DESIGN: An exploratory design was used involving individual interviews, focus groups and written notes from participants and field notes from researchers to investigate perspectives on nurse-patient communication. METHODS: Focus groups and individual interviews were held between August 2010-September 2011 with a purposive sample of 15 nurse educators and clinicians who observed videos of interactions between nurses and simulated patients. These participants were asked to give oral feedback on the quality and content of these interactions. Verbatim transcriptions were undertaken of all data collected. All written notes and field notes were also transcribed. Thematic analysis of the data was undertaken. FINDINGS: Four major themes related to nurse-patient communication were derived from the educators' and clinicians' feedback: approach to patients and patient care, manner towards patients, techniques used for interacting with patients and generic aspects of communication. CONCLUSION: This study has added to previous research by contributing grounded evidence from a group of nurse educators and clinicians on the aspects of communication that are relevant for effective nurse-patient interactions in clinical practice.

Analysing clinical reasoning characteristics using a combined methods approach.

BACKGROUND: Despite a major research focus on clinical reasoning over the last several decades, a method of evaluating the clinical reasoning process that is both objective and comprehensive is yet to be developed.The aim of this study was to test whether a dual approach, using two measures of clinical reasoning, the Clinical Reasoning Problem (CRP) and the Script Concordance Test (SCT), provides a valid, reliable and targeted analysis of clinical reasoning characteristics to facilitate the development of diagnostic thinking in medical students. METHODS: Three groups of participants, general practitioners, and third and fourth (final) year medical students completed 20 on-line clinical scenarios -10 in CRP and 10 in SCT format. Scores for each format were analysed for reliability, correlation between the two formats and differences between subject-groups. RESULTS: Cronbach's alpha coefficient ranged from 0.36 for SCT 1 to 0.61 for CRP 2, Statistically significant correlations were found between the mean f-score of the CRP 2 and total SCT 2 score (0.69); and between the mean f-score for all CRPs and all mean SCT scores (0.57 and 0.47 respectively). The pass/fail rates of the SCT and CRP f-score are in keeping with the findings from the correlation analysis (i.e. 31% of students (11/35) passed both, 26% failed both, and 43% (15/35) of students passed one but not the other test), and suggest that the two formats measure overlapping but not identical characteristics. One-way ANOVA showed consistent differences in scores between levels of expertise with these differences being significant or approaching significance for the CRPs. CONCLUSION: SCTs and CRPs are overlapping and complementary measures of clinical reasoning. Whilst SCTs are more efficient to administer, the use of both measures provides a more comprehensive appraisal of clinical skills than either single measure alone, and as such could potentially facilitate the customised teaching of clinical reasoning for individuals. The modest reliability of SCTs and CRPs in this study suggests the need for an increased number of items for testing. Further work is needed to determine the suitability of a combined approach for assessment purposes.

Revisiting the hypothesis-driven interview in a contemporary context.

OBJECTIVE: The "hypothesis-driven interview" was articulated by George Engel as a method of raising and testing hypotheses in the process of building a biopsychosocial formulation and determining the most likely diagnosis. This interview was a forerunner of the modern medical interview as well as the contemporary psychiatric assessment. The objective of this article is to describe the hypothesis-driven interview and to explore its relationship with the contemporary medical interview. METHOD: The literature on the medical and hypothesis-driven interview was reviewed. Key features of each were identified. RESULTS: The hypothesis-driven interview shares much with the contemporary medical interview. In addition, it enhances the application of communication skills and allows the interviewer to develop a formulation during the course of the assessment. CONCLUSION: The hypothesis-driven interview is well suited to the aims of a contemporary psychiatric assessment.

A student-centred electronic health record system for clinical education.

INTRODUCTION: Electronic Health Record (EHR) systems are an increasingly important feature of the national healthcare system [1]. However, little research has investigated the impact this will have on medical students' learning. As part of an innovative technology platform for a new masters level program in medicine, we are developing a student-centred EHR system for clinical education. A prototype was trialed with medical students over several weeks during 2010. This paper reports on the findings of the trial, which had the overall aim of assisting our understanding of how trainee doctors might use an EHR system for learning and communication in a clinical setting. BACKGROUND: In primary care and hospital settings, EHR systems offer potential benefits to medical students' learning: Longitudinal tracking of clinical progress towards established learning objectives [2]; Capacity to search across a substantial body of records [3]; Integration with online medical databases [3]; Development of expertise in creating, accessing and managing high quality EHRs [4]. While concerns have been raised that EHR systems may alter the interaction between teachers and students [3], and may negatively influence physician-patient communication [6], there is general consensus that the EHR is changing the current practice environment and teaching practice needs to respond. METHODS: Final year medical students on clinical placement at a large university teaching hospital were recruited for the trial. Following a four-week period of use, semi-structured interviews were conducted with 10 participants. Audio-recorded interviews were transcribed and data analysed for emerging themes. Study participants were also surveyed about the importance of EHR systems in general, their familiarity with them, and general perceptions of sharing patient records. CONCLUSIONS: Medical students in this pilot study identified a number of educational, practical and administrative advantages that the student-centred EHR system offered over their existing ad-hoc procedures for recording patient encounters. Findings from this preliminary study point to the need to introduce and instruct students' on the use of EHR systems from their earliest clinical encounters, and to closely integrate learning activities based on the EHR system with established learning objectives. Further research is required to evaluate the impact of student-centred EHR systems on learning outcomes.

Screening and Prophylaxis to Prevent Hepatitis B Reactivation: Introduction and Immunology.

Current recommendations concerning hepatitis C virus (HBV) reactivation are limited, with nearly all guidelines focused on its occurrence in patients with hematological malignancies or some solid tumors, who are treated with immunosuppressive therapies. Few of the guidelines address reactivation in patients receiving immunosuppression with organ transplants or treatment with any of the many immunosuppressive agents in use today for the treatment of multiple different diseases, or in patients receiving the direct-acting antivirals used in the treatment of hepatitis C virus (HCV). This article covers the immunology of HBV reactivation, mechanisms of viral clearance, and recommendations for screening and prophylaxis.

Screening and Prophylaxis to Prevent Hepatitis B Reactivation: Transplant Recipients.

Organ transplantation is a lifesaving procedure for many patients. To prevent rejection or graft-versus-host disease, recipients require long-term immunosuppression. In patients who have ever been exposed to hepatitis B, it is possible for reactivation to occur; this includes patients who are anti-hepatitis B core antibody-positive only or both anti-hepatitis B core antibody-positive and hepatitis B surface antibody-positive. The susceptibility to this varies with the nature of the transplant. Hepatitis B can be transmitted from donor to recipient. It is important to assess the hepatitis B status and formulate a strategy to prevent transmission and prevent reactivation.

Screening and Prophylaxis to Prevent Hepatitis B Reactivation: Patients with Hematological and Solid Tumor Malignancies.

Patients with malignancies require chemotherapy and other immunosuppressive therapies for treatment. Because of this immunosuppression, in patients who have ever been exposed to hepatitis B it is possible for reactivation to occur. This reactivation can be fatal. Reactivation is particularly likely in patients who receive B cell-active agents such as rituximab. The occurrence of reactivation flares may also delay further chemotherapy, which can negatively affect the outcome of the underlying malignancy. Accordingly, it is important to screen patients for markers of hepatitis B and institute antiviral prophylaxis to prevent reactivation.

Screening and Prophylaxis to Prevent Hepatitis B Reactivation: Other Populations and Newer Agents.

Because of the relatively high prevalence of both hepatitis B infection and various forms of autoimmune inflammatory diseases treated with aggressive immunotherapy, reactivation of hepatitis B occurs in a substantial number of patients. The risk of reactivation depends on the degree and duration of immunosuppression. A large number of drug treatments have resulted in reactivation of hepatitis B virus infection and, based on the mechanisms and extent of immunosuppression, recommendations for some of the newer classes of immunosuppressive drugs are provided.

Examining the nature of feedback within the Mini Clinical Evaluation Exercise (Mini-CEX): an analysis of 1427 Mini-CEX assessment forms.

Background: Despite the growing use, studies have demonstrated some limitations related to the feedback provided in the context of the increasing use of the Mini Clinical Evaluation Exercise (Mini-CEX) in undergraduate medical education. This study examined the written feedback provided on the Mini-CEX form to determine its usefulness as a learning tool for students. Methods: 1427 Mini-CEX assessment forms of final year medical students were collected. Written feedback, both on students' strength and weakness, was categorized and correlated with the variables of clinical case complexity, assessors' clinical position and students' clinical performance rating. Results: The number of general feedback comments for students' strengths and development were 953 (65.3%) and 604 (38.64%) respectively. Less than 30% of the feedback for each domain was categorized as specific feedback. Significant associations were found between feedback on strength and clinical case complexity (Χ2=17.48, p<.01); and also with assessor clinical position (Χ2=37.10, p<.01). There was also an association between feedback for students' development and assessor clinical position (Χ2=27.22, p<.01). Conclusion: Based on the Mini-CEX forms of student cohort this study examined, it can be concluded that the written feedback provided in the Mini-CEX assessment form was general and lacked specificity. This finding leads to the need to train clinical teachers in the provision of feedback.

An Economic Evaluation of Stopping Versus Continuing Tumor Necrosis Factor Inhibitor Treatment in Rheumatoid Arthritis Patients With Disease Remission or Low Disease Activity: Results From a Pragmatic Open-Label Trial.

OBJECTIVE: To evaluate, from a societal perspective, the incremental cost-effectiveness of withdrawing tumor necrosis factor inhibitor (TNFi) treatment compared to continuation of these drugs within a 1-year, randomized trial among rheumatoid arthritis patients with longstanding, stable disease activity or remission. METHODS: Data were collected from a pragmatic, open-label trial. Cost-utility analysis was performed using the nonparametric bootstrapping method, and a cost-effectiveness acceptability curve was constructed using the net-monetary benefit framework, where a willingness-to-accept threshold (WTA) was defined as the minimal cost saved that a patient accepted for each quality-adjusted life year (QALY) lost. RESULTS: A total of 531 patients were randomized to the stop group and 286 patients to the continuation group. Withdrawal of TNFi treatment resulted in a >60% reduction of the total drug cost, but led to an increase of ∼30% in other health care expenditures. Compared to continuation, stopping TNFi resulted in a mean yearly cost saving of €7,133 (95% confidence interval [95% CI] €6,071, €8,234]) and was associated with a mean loss of QALYs of 0.02 (95% CI 0.002, 0.040). Mean saved cost per QALY lost and per extra flare incurred in the stop group compared to the continuation group was €368,269 (95% CI €155,132, €1,675,909) and €17,670 (95% CI €13,650, €22,721), respectively. At a WTA of €98,438 per QALY lost, the probability that stopping TNFi treatment is cost-effective was 100%. CONCLUSION: Although an official WTA is not defined, the mean saved cost of €368,269 per QALY lost seems acceptable in The Netherlands, given existing data on willingness to pay.

If at first you don't succeed adoption of iPad marking for high-stakes assessments.

Large-scale interview and simulation-based assessments such as objective structured clinical examinations (OSCEs) and multiple mini interviews (MMIs) are logistically complex to administer, generate large volumes of assessment data, and are strong candidates for the adoption of computer-based marking systems. Adoption of new technologies can be challenging, and technical failures, which are relatively commonplace, can delay and/or create resistance to ongoing implementation.This paper reports on the adoption process of an electronic marking system for OSCEs and MMIs following an unsuccessful initial trial. It describes how, after the initial setback, a staged implementation, progressing from small to larger-scale assessments, single to multiple assessment types, and lower to higher stakes assessments, was used to successfully adopt and embed iPad-based marking within our medical school.Critical factors in the success of this approach included thorough appraisal and selection of technologies, rigorous assurance of system reliability and security, constant review and refinement, and careful attention to implementation and end-user training. Engagement of stakeholders is also crucial, especially in the case of previous failures or setbacks. The early identification and recruitment of staff to provide specific expertise and support for adoption of an innovation helps to facilitate this process with four key roles proposed; those of innovation advocate, champion, expert and sponsor.

Assessment of the trauma evaluation and management (TEAM) module in Australia.

AIM: To assess the immediate effect on trauma-related knowledge of the trauma evaluation and management (TEAM) program applied to medical students in Australia. METHODS: 73 final year medical students from Melbourne were randomly assigned to two experimental groups (E1 and E2 who completed the TEAM program after a 20 item MCQ pre-test on trauma resuscitation and a second MCQ exam after the TEAM program) and two control groups (C1 and C2 who completed the pre- and post-MCQ exams before completing the TEAM module). All 73 students completed an evaluation questionnaire. Paired and unpaired t-tests were used for within and between groups comparisons. RESULTS: Groups C1 and C2 had similar mean scores in pre- and post-tests ranging from 57.2 to 60.5%. Groups E1 and E2 had similar pre-test scores but increased their post-test scores (pre-test range 53.8-57.1% and post-test 68.8-77.4%, P < 0.05). On a scale of 1-5 with five being the highest, a score of four or greater was assigned by over 74% of the students that the objectives were met, over 80% that trauma knowledge was improved, 25-40% that clinical skills were improved with over 74% overall satisfaction. Over 75% assigned a score of four or greater suggesting the module be mandatory. CONCLUSIONS: After the TEAM program there was significant improvement in cognitive skills. The students strongly supported its introduction in the undergraduate curriculum.