Diagnostic reasoning in cardiovascular medicine

ABSTRACT Research in cognitive psychology shows that expert clinicians make a medical diagnosis through a two step process of hypothesis generation and hypothesis testing. Experts generate a list of possible diagnoses quickly and intuitively, drawing on previous experience. Experts remember specific examples of various disease categories as exemplars, which enables rapid access to diagnostic possibilities and gives them an intuitive sense of the base rates of various diagnoses. After generating diagnostic hypotheses, clinicians then test the hypotheses and subjectively estimate the probability of each diagnostic possibility by using a heuristic called anchoring and adjusting. Although both novices and experts use this two step diagnostic process, experts distinguish themselves as better diagnosticians through their ability to mobilize experiential knowledge in a manner that is content specific. Experience is clearly the best teacher, but some educational strategies have been shown to modestly improve diagnostic accuracy. Increased knowledge about the cognitive psychology of the diagnostic process and the pitfalls inherent in the process may inform clinical teachers and help learners and clinicians to improve the accuracy of diagnostic reasoning. This article reviews the literature on the cognitive psychology of diagnostic reasoning in the context of cardiovascular disease.

Investigación-acción en las prácticas pedagógicas sobre la enseñanza del cuidado: Experiencia docente

Introduction: The teaching of care requires special attention, as well as recognizing its representational nature, what is its dynamics and what are its relationships with the practice itself. Objective: To intervene in the training of teachers for the teaching of care, through the interpretation and awareness of their pedagogical practices that transcend the academic performance of the students of the Nursing Degree. Methodology: Action research with a qualitative-interpretive approach. The intervention was carried out through a course workshop on the teaching of care, given by the researchers to 30 practice and clinical teachers in undergraduate Nursing. The course was structured using the Charles Maguerez Arc methodology in its five stages. The meetings of the sessions were observed in a participatory way, recorded in a field diary and audio-recorded, for later transcription and content analysis. Categories of analysis were formed from the reflections and participation of the teachers: a) Meaning of the teaching of care, b) Pedagogical practices based on the example (hidden curriculum) and, c) Identification of needs to improve pedagogical practices. Results: Among the professors' speeches it was identified that the meaning of the teaching of care transcends in the human relationship; those pedagogical practices must promote the relationship and accompaniment of the student, as well as empowerment, security, and self-confidence, and that there are pedagogical and didactic needs to favor learning and link theory and practice. Conclusions: It is necessary to strengthen work teams and continuous training in the teaching of care, distinguishing that there are opportunities for improvement in the development of pedagogical practices. Introducción: La enseñanza del cuidado requiere especial atención, así como reconocer su naturaleza representacional, cuál es su dinámica y cuáles son sus relaciones con la propia práctica. Objetivo: Intervenir en la capacitación de profesores para la enseñanza del cuidado, mediante la interpretación y concientización de sus prácticas pedagógicas que trasciendan en el desempeño académico de los estudiantes de la Licenciatura en Enfermería. Metodología: Investigación-acción con enfoque cualitativo-interpretativo. La intervención se llevó a cabo mediante un curso-taller sobre la enseñanza del cuidado, impartido por las investigadoras a 30 docentes de práctica y clínica en el pregrado de Enfermería. El curso se estructuró mediante la metodología del Arco de Charles Maguerez, en sus cinco etapas. Los encuentros de las sesiones fueron observados de forma participante, registrados en un diario de campo y audio-grabados, para posterior transcripción y análisis de contenido. Se conformaron categorías de análisis a partir de las reflexiones y participaciones de los docentes: a) Significado de la enseñanza del cuidado, b) Prácticas pedagógicas a partir del ejemplo (currículum oculto) y c) Identificación de necesidades para mejorar las prácticas pedagógicas. Resultados: Entre los discursos de los profesores se identificó que el significado de la enseñanza del cuidado trasciende en la relación humana; que las prácticas pedagógicas tienen que promover la relación y acompañamiento al estudiante, así como el empoderamiento, la seguridad y confianza en sí mismo y que existen necesidades pedagógicas y didácticas para favorecer el aprendizaje y vincular la teoría y la práctica. Conclusiones: Se requiere fortalecer los equipos de trabajo y la capacitación continua en la enseñanza del cuidado, distinguiendo que existen oportunidades de mejora en el desarrollo de las prácticas pedagógicas. Resumo:O ensino do cuidado requer atenção especial, além de reconhecer seu caráter representacional, quais são suas dinâmicas e quais são suas relações com a própria prática. Objetivo: Intervir na formação de professores para o ensino do cuidado, por meio da interpretação e conscientização de suas práticas pedagógicas que transcendem o desempenho acadêmico dos alunos do Curso de Enfermagem.Metodologia: Pesquisa-ação com abordagem qualitativa-interpretativa. A intervenção foi realizada por meio de um curso-oficina sobre ensino do cuidado, ministrado pelas pesquisadoras a 30 professores de prática e clínica do curso de graduação em Enfermagem. O curso foi estruturado utilizando a metodologia do Arco de Charles Maguerez, em suas cinco etapas. Os encontros das sessões foram observados de forma participativa, registrados em diário de campo e audiogravados, para posterior transcrição e análise de conteúdo. As categorias de análise foram formadas a partir das reflexões e da participação dos professores: a) Sentido do ensino do cuidado, b) Práticas pedagógicas baseadas no exemplo (currículo oculto) e, c) Identificação de necessidades de aprimoramento das práticas pedagógicas.Resultados: Dentre as falas dos professores, identificou-se que o sentido do ensino do cuidado transcende na relação humana; que as práticas pedagógicas devem promover a relação e o acompanhamento do aluno, bem como o empoderamento, a segurança e a autoconfiança e que existem necessidades pedagógicas e didáticas que favoreçam a aprendizagem e vinculem teoria e prática.Conclusões: É necessário o fortalecimento das equipes de trabalho e a formação continuada no ensino do cuidado, destacando que há oportunidades de melhoria no desenvolvimento das práticas pedagógicas.

“To obey or not to obey” - Medical students’ response towards professional dilemmas in a hierarchical and collectivist culture

Background Clinical clerkship programme in medical schools were developed to provide students with direct interactions with patients and observe clinical teachers in practice. However, professional dilemmas are prone to occur due to the nature of experiential learning. Several studies across different cultures showed that medical students responded differently towards professional dilemma. Aims This study aims to explore how medical students respond to professional dilemmas occurred during their clinical clerkships and to what extent culture influences the responses. Method A qualitative descriptive approach was used in this study. We conducted four focus group discussions with final year medical students who were selected using maximum variety sampling method. Thematic analysis was conducted following the transcription of the focus groups. Results We identified the impact of dilemmas on students’ emotions and concerns, students’ responses towards professional dilemmas, and factors affecting responses to dilemmas in clinical clerkship, which confirmed that cultures played roles in how students responded towards professional dilemmas. Conclusion This study has identified that culture, to some extent, influenced the way students responded to professional dilemmas. Therefore, it is paramount to develop a conducive and culturally sensitive educational environment and students’ ability to learn from professional dilemma experienced in the workplace for developing their professional identity.

Teaching Radiology Courses: How to Address Learning Needs of Medical Students Through Interacting in Radiology

Radiologists in radiology courses (RC) at teaching and university hospitals train medical students in competent image interpreting and reporting (IIR). Information extracted from imaging is crucial for clinical decisions and therapies. This article attempted to explore a teaching approach adapted from adult education for clinical teachers in radiology to address learning needs (LN) in radiology by interacting and tailoring teaching content to LN. The following conclusions were drawn: Addressing LN could encourage students to learn about IIR; Integrating students to negotiate teaching content should take place if feasible, despite high workload and little teaching time in clinical routine; Negotiating with students and co-teachers of other imaging disciplines would help to tailor course specifics to LN and avoid redundancies; Interacting with medical students could be efficient and effective for clinical teaching and learning in RC.

Two-year longitudinal observational study of junior doctors as clinical teachers: the Associate Clinical Teaching Fellow Program

Introduction: Most clinical teachers are not trained to teach, though they are critical to determining the quality of clinical learning environment. The General Medical Council, United Kingdom, recognises that being a good teacher is not innate, but that skills and attributes can usually be acquired. Clinical teaching is part of training of junior doctors in the United Kingdom, and from learners’ perspectives, junior doctors are effective clinical teachers, but there are few structured opportunities to learn how to teach during clinical training. The Associate Clinical Teaching Fellow (ACTF) program was developed to provide such structured platform for clinical trainees. The aim of this paper is to evaluate the quality of teaching by the trainees against the current-standard of clinical teaching in the first 2 years of its inception, and to adapt validated feedback questionnaires for practical use. Methods: A prospective longitudinal observational study was done over 2 years in a large 1,215 bed tertiary hospital. Multiple cross-sectional assessments of teachings by ACTFs and consultant teachers were done using two validated questionnaires, the Stanford Faculty Development Program-26 (SFDP-26) and the Clinical Teaching Effectiveness questionnaire (CTEQ), and an in-house global (IHG) feedback form prepared by third- and fifth-year students. Both trainees and consultants were unaware of the timing of the SFDP-26 and CTEQ feedbacks. A graphical representation of all responses was used to create a grading system for practical feedbacks. Results: A total of 507 of 765 (66%) of SFPD-26 and CTEQ and 224 of 286 (78%) of IHG questionnaires were returned for 26 trainees and 31 consultants by 266 medical students. There was a statistically significant higher ratings of trainees in seven of eight domains of SFDP-26, and the median (interquartile ranges [IQR]) overall score was 115 (105–126) and 108 (99–121) for trainees and consultants, respectively (P < 0.0001). Similarly, trainees were rated significantly higher in seven of nine CTEQ domains, and this was reflected in the overall score. The patterns were similar for third- and fifth-year students, and the type of learning exposure did not make a difference. With these students, the overall teaching effectiveness correlated (Spearman Correlation Coefficient [SCC]) the most with enthusiastic and stimulating (SCC 0.711; P < 0.0001), establishes rapport (SCC 0.69; P < 0.0001) and is accessible (SCC 0.67; P < 0.0001) in CTEQ, and with learning climate (SCC 0.62; P < 0.0001), communication of goals (SCC 0.54; P < 0.0001) and evaluation (SCC 0.52; P < 0.0001) in SFDP-26. At the end of their rotations, 30% of both groups of students were neutral or disagreed that consultants were essential to their clinical programs compared to 15% (P = 0.001) and 11% (P < 0.0001) of third- and fifth-year students, respectively, felt about trainees. By applying a new grading system derived from the full database of responses, the trainees would be graded 1 and consultants 7 out of 10 possible grades. Conclusions: Teaching delivered by doctors in training within a formal teaching program is of good quality and well received by medical students. There is a need for an equivalent program for trainee clinical educationalists like the Integrated Academic Training scheme of the National Institute of Health Research (NIHR), UK, for trainee academics. More qualitative studies are needed to analyse some of the findings in this study.

Moving from Basic to More Advanced: Is there an Increase Over Time in the Complexity of Teacher Questions and Student Responses in Case Based Clinical Seminars?

Introduction: Case-based group discussions (CBGD) are a specific, interaction-focused form of case based medical education dedicated to foster medical students’ skills of applying basic biomedical knowledge to patient cases. In such seminars, teacher question-student response patters are a crucial aspect. We empirically investigate to which degree clinical teachers progress from more basic, knowledge-oriented towards more advanced, elaboration-oriented questions in CBGD-seminars. Methods We video recorded 32 case-based seminars in the areas of surgery and internal medicine. 21 different clinical teachers had taught and 398 medical students had attended these seminars. We coded closed-reproductive and open-elaborative teacher questions as well as reproductive and elaborative student responses to these questions. Interrater reliability was satisfactory. For determining trends regarding the teacher questions / student responses, we compared eight equally long time-segments per seminar. Results Overall, clinical teachers posed more closed-reproductive than open-elaborative questions to students and the latter gave more reproductive than elaborative responses. Regarding the frequencies of these forms of teacher questions / student responses, we found no significant differences over time. Discussion We found that clinical teachers did not deliberately modify the types of questions they posed over time to push their students towards more elaborative responses. Generally, this raises the critical question to which degree promising didactic concepts are actually put into clinical teaching practice. In our sample, we observed substantial heterogeneity regarding the variables in focus of our study. We conclude that medical education researchers should more thoroughly take different starting conditions and teaching approaches of different teachers into account.

What is the impact of the COVID-19 pandemic on residency training: a systematic review and analysis

Background The coronavirus disease 2019 (COVID-19) pandemic has greatly affected medical education in addition to clinical systems. Residency training has probably been the most affected aspect of medical education during the pandemic, and research on this topic is crucial for educators and clinical teachers. The aim of this study was to understand the effect of the COVID-19 pandemic comprehensively through a systematic review and analysis of related published articles. Methods A systematic review was conducted based on a predesigned protocol. We searched MEDLINE and EMBASE databases until November 30, 2020, for eligible articles. Two independent reviewers extracted data by using a customized form to record crucial information, and any conflicts between the two reviewers were resolved through discussion with another independent reviewer. The aggregated data were summarized and analyzed. Results In total, 53 original articles that investigated the effect of the COVID-19 pandemic on residency training were included. Studies from various regions were included in the research, with the largest percentage from the United States (n = 25, 47.2%). Most of these original articles were questionnaire-based studies (n = 44, 83%), and the research target groups included residents (79.55%), program directors (13.64%), or both (6.82%). The majority of the articles (n = 37, 84.0%) were published in countries severely affected by the pandemic. Surgery (n = 36, 67.92%) was the most commonly studied field. Conclusions The COVID-19 pandemic has greatly affected residency training globally, particularly surgical and interventional medical fields. Decreased clinical experience, reduced case volume, and disrupted education activities are major concerns. Further studies should be conducted with a focus on the learning outcomes of residency training during the pandemic and the effectiveness of assisted teaching methods.

Hurdles for adopting mobile learning devices at the outset of clinical courses

Background Mobile devices provide medical students with easy access to medical information and educational resources. Since 2013, we have followed the study use of iPads among medical students. In 2016, we observed a notable drop in the mobile device usage in the first cohort of medical students entering their clinical courses. Methods The aim of the study was to identify the hurdles for adopting mobile devices at the beginning of the clinical courses. We examined how students evaluated their own and the clinical teachers’ ability to use the iPad, how the study assignments fit into digital learning, and how students used the mobile device with patients. The data were collected with online surveys among three consecutive student cohorts and the distributions of closed-ended questions analyzed. Results Response rates ranged from 67.5 to 90.8%. Students evaluated their own ability to use the iPad as good or excellent and teachers’ skills as relatively poor and wanted more digitally tailored assignments. They reported negative attitudes towards mobile device use in the clinical setting and were hesitant to use them in patient contact. Teachers seldom communicated suitable quality medical applications to students. Conclusions Clinical teachers need support and training to implement a learning environment and assignments appropriate for mobile devices. Both students and teachers were concerned about using these devices with patients. To achieve the full potential of digitalisation in clinical courses, their use should be developed collectively with students.

Moving from Basic to More Advanced: Is there an Increase Over Time in the Complexity of Teacher Questions and Student Responses in Case Based Clinical Seminars?

Introduction: Case-based group discussions (CBGD) are a specific, interaction-focused form of case based medical education dedicated to foster medical students’ skills of applying basic biomedical knowledge to patient cases. In such seminars, teacher question-student response patters are a crucial aspect. We empirically investigate to which degree clinical teachers progress from more basic, knowledge-oriented towards more advanced, elaboration-oriented questions in CBGD-seminars.Methods: We video recorded 32 case-based seminars in the areas of surgery and internal medicine. 21 different clinical teachers had taught and 398 medical students had attended these seminars. We coded closed-reproductive and open-elaborative teacher questions as well as reproductive and elaborative student responses to these questions. Interrater reliability was satisfactory. For determining trends regarding the teacher questions / student responses, we compared eight equally long time-segments per seminar.Results: Overall, clinical teachers posed more closed-reproductive than open-elaborative questions to students and the latter gave more reproductive than elaborative responses. Regarding the frequencies of these forms of teacher questions / student responses, we found no significant differences over time.Discussion: We found that clinical teachers did not deliberately modify the types of questions they posed over time to push their students towards more elaborative responses. Generally, this raises the critical question to which degree promising didactic concepts are actually put into clinical teaching practice. In our sample, we observed substantial heterogeneity regarding the variables in focus of our study. We conclude that medical education researchers should more thoroughly take different starting conditions and teaching approaches of different teachers into account.