Transforming Medical Assessment: Integrating Uncertainty Into the Evaluation of Clinical Reasoning in Medical Education

Pathology discovered in the "first patient" can be the silent teacher of self-directed learning

Pathology found during cadaveric dissection has been used to model integrative teaching methods for medical students at several institutions. Recent evidence has shown that pathology found during dissection can be used in the design of self-directed learning (SDL) activities with standards that are difficult to meet. This study presents a novel method for providing formative feedback, one of the most challenging aspects for LCME accreditation of SDL activities. Three practitioners (two board certified pathologists and one board certified family physician) reviewed and rated pathological findings during routine dissection by first year medical students in the gross anatomy laboratory in New Orleans, Louisiana. The students also rated the findings, and a comparative score was given that provided quick, individualized formative feedback with no additional faculty time burden. The inter-rater reliability (IRR) among the clinical expert panel (n = 3) was adequate (IRR = 0.85). The students' percentage agreement with the expert panel was just under 57%. There was no significant correlation between the score on the Gift formative feedback instrument (FFI) and the students' performances in their gross anatomy course (p > 0.05). This study describes a FFI that allows for the variety of clinical presentations in cadavers dissected in the gross anatomy laboratory, while protecting faculty time that would otherwise be used for scoring individuals in large cohorts of medical students. This instrument can be used to integrate pathology and gross anatomy and provide a practical way of implementing self-directed learning.

Validity and reliability of Brier scoring for assessment of probabilistic diagnostic reasoning

OBJECTIVES

Educators need tools for the assessment of clinical reasoning that reflect the ambiguity of real-world practice and measure learners' ability to determine diagnostic likelihood. In this study, the authors describe the use of the Brier score to assess and provide feedback on the quality of probabilistic diagnostic reasoning.

METHODS

The authors describe a novel format called Diagnostic Forecasting (DxF), in which participants read a brief clinical case and assign a probability to each item on a differential diagnosis, order tests and select a final diagnosis. DxF was piloted in a cohort of senior medical students. DxF evaluated students' answers with Brier scores, which compare probabilistic forecasts with case outcomes. The validity of Brier scores in DxF was assessed by comparison to subsequent decision-making in the game environment of DxF, as well as external criteria including medical knowledge tests and performance on clinical rotations.

RESULTS

Brier scores were statistically significantly correlated with diagnostic accuracy (95 % CI -4.4 to -0.44) and with mean scores on the National Board of Medical Examiners (NBME) shelf exams (95 % CI -474.6 to -225.1). Brier scores did not correlate with clerkship grades or performance on a structured clinical skills exam. Reliability as measured by within-student correlation was low.

CONCLUSIONS

Brier scoring showed evidence for validity as a measurement of medical knowledge and predictor of clinical decision-making. Further work must evaluated the ability of Brier scores to predict clinical and workplace-based outcomes, and develop reliable approaches to measuring probabilistic reasoning.

Exploring Differences in Clinical Decisions Between Medical Students and Expert Clinicians

Background

Numerous challenges exist in effectively bridging theory and practice in the teaching and assessment of clinical reasoning, despite an abundance of theoretical models. This study compares clinical reasoning practices and decisions between medical students and expert clinicians using a problem-solving framework from the learning sciences, which identifies clinical reasoning as distinct, observable actions in clinical case solving. We examined students at various training stages against expert clinicians to address the research question: How do expert clinicians and medical students differ in their practices and decisions during the diagnostic process?.

Methods

We developed a questionnaire about a pediatric infectious disease case based on the problem-solving framework from the learning sciences to probe clinical reasoning decisions. The questionnaire had four sections: medical history, physical examination, medical tests, and working diagnosis. The questionnaire was administered at Stanford University between January 2019 and June 2023 to collect data from 10 experts and 74 medical students. We recruited participants through maximum variation sampling. We applied deductive content analysis to systematically code responses to identify patterns in the execution of the practices and decisions across the questionnaire.

Results

This research introduces a highly detailed, empirically developed framework that holds potential to bridge theory and practice, offering practical insights for medical instructors in teaching clinical reasoning to students across various stages of their training. This framework involves nine practices, with a total of twenty-nine decisions that need to be made when carrying out these practices. Differences between experts and students centered on ten decisions across the practices: Differential diagnosis formulation, Diagnostic plan and execution, Clinical data reassessment, and Clinical solution review.

Conclusion

We were able to identify nuanced differences in clinical reasoning between students and expert physicians under one comprehensive problem-solving framework from the learning sciences. Identifying key clinical reasoning practices and decision differences could help develop targeted instructional materials and assessment tools, aiding instructors in fostering clinical reasoning in students.

Beliefs and experiences of educators when involved in the design of a Learning-by-concordance tool: A qualitative interpretative study

BACKGROUND

Based on the involvement of qualified educators in its design, the Learning-by-Concordance tool aims to promote the learning of reasoning in contexts of uncertainty. However, data are still scarce on the experience of educators in terms of sharing and exposing their reasoning processes using this tool.

PURPOSE

This study sought to explore the beliefs and experiences of educators when involved in the design of a Learning-by-Concordance tool.

METHOD

This research used a descriptive qualitative design. Four dialogue groups were conducted with educators with different roles and responsibilities while designing a Learning-by-Concordance tool. A descriptive interpretative analysis of educators' verbatim quotes was done.

FINDINGS

A total of 14 participants took part in the study. The results show the discomfort of educators despite their recognized expertise. Three themes emerged: 1- the need to be reassured by the opinions of colleagues; 2-feeling like impostors; and 3- concerns for the quality of instructional supports.

CONCLUSIONS

The role taken by educators for teaching reasoning in contexts of uncertainty is to draw on practical experience where different types of knowledge intersect and are mobilized, to overcome feelings of insecurity, and to engage in close and authentic conversation with learners.

Reliability, validity and acceptability of an online clinical reasoning simulator for medical students: An international pilot

INTRODUCTION

Clinical reasoning skills are essential for decision-making. Current assessment methods are limited when testing clinical reasoning and management of uncertainty. This study evaluates the reliability, validity and acceptability of Practicum Script, an online simulation-based programme, for developing medical students' clinical reasoning skills using real-life cases.

METHODS

In 2020, we conducted an international, multicentre pilot study using 20 clinical cases with 2457 final-year medical students from 21 schools worldwide. Psychometric analysis was performed (n = 1502 students completing at least 80% of cases). Classical estimates of reliability for three test domains (hypothesis generation, hypothesis argumentation and knowledge application) were calculated using Cronbach's alpha and McDonald's omega coefficients. Validity evidence was obtained by confirmatory factor analysis (CFA) and measurement alignment (MA). Items from the knowledge application domain were analysed using cognitive diagnostic modelling (CDM). Acceptability was evaluated by an anonymous student survey.

RESULTS

Reliability estimates were high with narrow confidence intervals. CFA revealed acceptable goodness-of-fit indices for the proposed three-factor model. CDM analysis demonstrated good absolute test fit and high classification accuracy estimates. Student survey responses showed high levels of acceptability.

CONCLUSION

Our findings suggest that Practicum Script is a useful resource for strengthening students' clinical reasoning skills and ability to manage uncertainty.

Stakeholders' priorities in the development of evidence-based practice competencies in rehabilitation students: a nominal group technique study

PURPOSE

Clinically integrated teaching (CIT) is an effective approach for promoting evidence-based practice (EBP) competencies among medical students. Challenges towards the implementation of CIT in rehabilitation curricula include educators' different conceptualizations of EBP, the perceived complexity of EBP and the boundaries between the academic and the clinical setting. This study aimed to identify tailored strategies to implement in rehabilitation programs and their affiliated clinical sites to support the development of EBP competencies among students in occupational therapy (OT), physical therapy (PT) and speech-language pathology (S-LP).

MATERIALS AND METHODS

Nominal group technique (NGT) with stakeholders from three rehabilitation programs in Canada, offering the professional master's in OT and PT (n = 35 participants) and in S-LP (n = 8).

RESULTS

The top two strategies identified in the OT/PT NGT were: 1) Developing a flexible definition of EBP that recognizes its complexity; 2) Providing clinicians with more access to the teaching content by pairing faculty with preceptors. The top two strategies identified in the S-LP NGT were: 1) Providing students with opportunities for decision-making with experienced clinicians; 2) Increasing interactions between faculty and preceptors using formal group meetings.

CONCLUSION

Findings laid foundations for future integrated knowledge translation projects to collaboratively implement, and test identified strategies.

Impact of an online learning by concordance program on reflection

BACKGROUND

Learning by concordance (LbC) is a recent approach that introduces learners to the complexity and uncertainty of clinical practice. Some data on LbC suggest that it stimulates reflection in future clinicians. We developed an online LbC training program on electrocardiogram (ECG) interpretation in general practice at the University of Strasbourg, France, and conducted an exploratory qualitative study to document the impact of this ECG learning-by-concordance training program on reflection in participants.

METHODS

We created 18 clinical vignettes on ECG interpretation based on a review of the literature on frequent and serious cardiovascular diseases that can be identified using an ECG in general practice. The training program was delivered online to postgraduate general practice students in two faculties of medicine. We conducted a qualitative study based on thematic analysis of two focus groups and six individual interviews. Inductive and deductive coding were performed. The five major components of reflection in the Nguyen model were used in the deductive coding: (i) thoughts and actions, (ii) attentive, critical, exploratory, and iterative processes (ACEI), (iii) underlying conceptual frame, (iv) change and (v) self.

RESULTS

Two focus groups and six individual interviews were conducted. The qualitative analysis indicated 203 codes in the focus groups and 206 codes in the individual interviews, which were divided into five groups based on the components of reflection in the Nguyen model: (i) the self; (ii) attentive, critical, exploratory, and iterative interactions with (iii) one's thoughts and actions; and (iv) a view on both the change itself and (v) the underlying conceptual frame. Inductive coding revealed interesting insights into the impact of the identity of the panel members, the absence of a scoring system and the question of uncertainty in ECG reading.

CONCLUSIONS

This study supports the claim that the use of LbC in the context of ECG interpretation could foster reflection in future general practitioners. We discuss future research avenues on instructional design of LbC and reflection.

Is there ever a single best answer (SBA): assessment driving certainty in the uncertain world of GP?

Uncertainty is inherent in all areas of medical practice, not least in primary care, which is defined by its acceptance of uncertainty and complexity. Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical assessments; however clinical practice, particularly in primary care, challenges the supposition that a single best answer exists for all clinical encounters and dilemmas. In this article, we seek to highlight several aspects of the relationship between this assessment format and clinical uncertainty by considering its influence on medical students' views of uncertainty in the contexts of their medical education, personal epistemology, and clinical expectations.

Teaching the science of uncertainty

As we increasingly acknowledge the ubiquitous nature of uncertainty in clinical practice (Meyer AN, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Counsel 2021;104:2606-15; Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011;31:828-38) and strive to better define this entity (Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2020; Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med 2018;33:103-15), as educators we should also design, implement, and evaluate curricula addressing clinical uncertainty. Although frequently encountered, uncertainty is often implicitly referred to rather than explicitly discussed (Gärtner J, Berberat PO, Kadmon M, Harendza S. Implicit expression of uncertainty - suggestion of an empirically derived framework. BMC Med Educ 2020;20:83). Increasing explicit discussion of - and comfort with -uncertainty has the potential to improve diagnostic reasoning and accuracy and improve patient care (Dunlop M, Schwartzstein RM. Reducing diagnostic error in the intensive care unit. Engaging. Uncertainty when teaching clinical reasoning. Scholar;1:364-71). Discussion of both diagnostic and prognostic uncertainty with patients is central to shared decision-making in many contexts as well, (Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med 2019;34:2586-91) from the outpatient setting to the inpatient setting, and from undergraduate medical education (UME) trainees to graduate medical education (GME) trainees. In this article, we will explore the current status of how the science of uncertainty is taught from the UME curriculum to the GME curriculum, and describe strategies how uncertainty can be explicitly discussed for all levels of trainees.

Fostering uncertainty tolerance in anatomy education: Lessons learned from how humanities, arts and social science (HASS) educators develop learners' uncertainty tolerance

Uncertainty tolerance, individuals' perceptions/responses to uncertain stimuli, is increasingly recognized as critical to effective healthcare practice. While the Covid-19 pandemic generated collective uncertainty, healthcare-related uncertainty is omnipresent. Correspondingly, there is increasing focus on uncertainty tolerance as a health professional graduate "competency," and a concomitant interest in identifying pedagogy fostering learners' uncertainty tolerance. Despite these calls, practical guidelines for educators are lacking. There is some initial evidence that anatomy education can foster medical students' uncertainty tolerance (e.g., anatomical variation and dissection novelty), however, there remains a knowledge gap regarding robust curriculum-wide uncertainty tolerance teaching strategies. Drawing upon humanities, arts and social sciences (HASS) educators' established uncertainty tolerance pedagogies, this study sought to learn from HASS academics' experiences with, and teaching practices related to, uncertainty pedagogy using a qualitative, exploratory study design. Framework analysis was undertaken using an abductive approach, wherein researchers oscillate between inductive and deductive coding (comparing to the uncertainty tolerance conceptual model). During this analysis, the authors analyzed ~386 min of data from purposively sampled HASS academics' (n = 14) discussions to address the following research questions: (1) What teaching practices do HASS academics' perceive as impacting learners' uncertainty tolerance, and (2) How do HASS academics execute these teaching practices? The results extend current understanding of the moderating effects of education on uncertainty tolerance and supports prior findings that the anatomy learning environment is ripe for supporting learner uncertainty tolerance development. This study adds to growing literature on the powerful moderating effect education has on uncertainty tolerance and proposes translation of HASS uncertainty tolerance teaching practices to enhance anatomy education.

Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study

BACKGROUND

Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors.

METHODS

We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more.

RESULTS

We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit.

INTERPRETATION

Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.

Internists’ ambivalence toward their role in health counseling and promotion: A qualitative study on the internists’ beliefs and attitudes

Crucial to its success is that physicians enhance their competence in Lifestyle Medicine and take on their role as Health Advocates in Health Counseling and Promotion (HC&P). However, studies on patients’ views of lifestyle counseling in clinical practice demonstrate that many patients neither perceived a need to adopt a healthy lifestyle nor having had any discussion with their physician about their lifestyle. This study is part of a participatory action research project focusing on identifying areas of improvement for health promotion in the practice of internists. Within this project, we interviewed 28 internists from six different subspecialties of an academic medical center in the Netherlands. This study aims to gain insight into how internists understand their role in HC&P by a qualitative analysis of their beliefs and attitudes in the interview data. Participants claimed that promoting a healthy lifestyle is important. However, they also reflected a whole system of beliefs that led to an ambivalent attitude toward their role in HC&P. We demonstrate that little belief in the success of HC&P nurtured ambivalence about the internists’ role and their tasks and responsibilities. Ambivalence appeared to be reinforced by beliefs about the ability and motivation of patients, the internists’ motivational skills, and the patient-doctor relationship, and by barriers such as lack of time and collaboration with General Practitioners. When participants viewed HC&P as a part of their treatment and believed patients were motivated, they were less ambivalent about their role in HC&P. Based on our data we developed a conceptual framework that may inform the development of the competences of the Health Advocate role of internists in education and practice.

Diagnostic Reasoning of Resident Physicians in the Age of Clinical Pathways

BACKGROUND

Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described.

OBJECTIVE

To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning.

METHODS

We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework.

RESULTS

Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process.

CONCLUSIONS

This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.

The chicken and the egg: Clinical reasoning and uncertainty tolerance

Richmond aruges that clinical reasoning and uncertainty tolerance development occur simultaneously and that deficit in either domain will affect the development of the other. Implications for curriculum design are offered.

Educators and practitioners' perspectives in the development of a learning by concordance tool for medical clerkship in the context of the COVID pandemic

BACKGROUND

The COVID-19 pandemic has forced medical schools to create educational material to palliate the anticipated and observed decrease in clinical experiences during clerkships. An online learning by concordance (LbC) tool was developed to overcome the limitation of students' experiences with clinical cases. However, knowledge about the instructional design of an LbC tool is scarce, especially the perspectives of collaborators involved in its design: 1- educators who wrote the vignettes' questions and 2- practitioners who constitute the reference panel by answering the LbC questions. The aim of this study was to describe the key elements that supported the pedagogical design of an LbC tool from the perspectives of educators and practitioners.

METHODS

A descriptive qualitative research design has been used. Online questionnaires were used, and descriptive analysis was conducted.

RESULTS

Six educators and 19 practitioners participated in the study. Important to the educators in designing the LbC tool were prevalent or high-stake situations, theoretical knowledge, professional situations experienced and perceived difficulties among students, and that the previous workshop promoted peer discussion and helped solidify the writing process. Important for practitioners was standards of practice and consensus among experts. However, they were uncertain of the educational value of their feedback, considering the ambiguity of the situations included in the LbC tool.

CONCLUSIONS

The LbC tool is a relatively new training tool in medical education. Further research is needed to refine our understanding of the design of such a tool and ensure its content validity to meet the pedagogical objectives of the clerkship.

Towards a medical school curriculum for uncertainty in clinical practice

Uncertainty abounds in the clinical environment. Medical students, however, are not explicitly prepared for situations of uncertainty in clinical practice, which can cause anxiety and impact well-being. To address this gap, we sought to capture how students felt in various clinical scenarios and identify programs they found helpful as they worked through uncertainty in their clerkships to better inform curriculum that prepares them to acknowledge and navigate this uncertainty. This is an observational cross-sectional study of third-year medical students surveyed at the end of core clerkships. The survey consisted of the General Self-Efficacy (GSE) Scale and Intolerance of Uncertainty Scale (IUS). Items asked students to rate preparedness, confidence, and comfort with uncertainty in clinical practice. Items on curricular programs asked students to identify training that prepared them for uncertainty in clerkships, and examined correlations with specific clinical practice uncertainty domains (CPUDs). Spearman's rank-order correlation, Chi-Square, and ANOVA were used to analyze quantitative data. Open responses were analyzed using Braun and Clarke's Framework. Response rate was 98.9% (287/290). GSE was inversely correlated with IUS (p < 0.001). GSE was positively correlated with all CPUDs (p < 0.005). IUS had an inverse correlation with all CPUDs (p < 0.005). Pedagogies with statistically-significant relationships with preparing students for uncertainty, communicating and building relationships with patients during times of uncertainty, and overall well-being included: team debriefs, role plays, case- and team-based learning, story slams, and sharing narratives with peers and faculty (p < 0.05). Qualitatively, students appreciated storytelling, role-modeling of communication strategies, debriefing, and simulations. Strategically immersing specific educational formats into formal curriculum may help cultivate skills needed to prepare students for uncertainty. Clinical debriefs, interprofessional role plays, simulations, communications skills training, instructor emotional vulnerability, storytelling, and peer-to-peer conversations may have the most impact. Further study is required to evaluate their longitudinal impact.

Building evidence-based practice competencies among rehabilitation students: a qualitative exploration of faculty and preceptors' perspectives

Medical education literature suggests clinically-integrated teaching may be the most effective approach to teach evidence-based practice (EBP). Before implementing this educational best practice in rehabilitation curricula, it is imperative to better understand the current context, barriers and facilitators to teach EBP in rehabilitation from the academic to the clinical setting. The aim of this study was to explore faculty and preceptors' experiences and perceptions of teaching EBP in rehabilitation professions, namely occupational therapy, physical therapy and speech-language pathology. We gathered data from seven focus groups and an individual interview with a sample of 24 faculty and 15 preceptors, i.e., clinical supervisors. Data collected were subjected to inductive thematic content analysis. We identified three overarching themes and corresponding strategies. First, "Recognizing EBP as a multifaceted concept" denoted participants' lack of consensus regarding the meaning and scope of EBP, and their awareness of such discrepancies. Second, "Complexity of EBP is at the core of teaching practices and experiences" referred to participants' perception of EBP as a complex process involving high-level cognitive skills, which influenced their teaching practices and challenged students and themselves. Third, "Connections and divides between research and practice" represented the limited and delicate connection between faculty and preceptors, the factors either bridging or maintaining the gap between them, and the impacts of such connections and divides on teaching. Improving collaboration between faculty and preceptors constitutes an essential first step towards more effective EBP training programs in rehabilitation that could be facilitated through online communities of practice or integrated knowledge translation research projects.

Towards a new understanding of uncertainty in medical education

RATIONALE, AIMS, AND OBJECTIVES

Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education.

METHOD

A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty.

RESULTS

Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education.

CONCLUSION

The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.

Script Concordance Approach in Nursing Education

BACKGROUND

The script concordance approach aims at triggering judgments in simulated contexts of uncertainty.

PROBLEM

Nursing students need to be prepared to manage the uncertainty of clinical practice.

APPROACH

The purpose of this article is to describe the theoretical foundation and the pedagogical use of the script concordance approach, as well as to present the current state of nursing evidence on the subject. The script concordance approach includes (1) script concordance testing, which is a quantitative examination that evaluates clinical reasoning; (2) a face-to-face script concordance activity; and (3) a digital educational strategy based on script concordance delivered via an online teaching/learning platform that aims to support clinical reasoning development.

CONCLUSIONS

Relying on questioning and experts' modeling, the script concordance offers an innovative pedagogical approach that approximates the uncertainty of clinical practice.

The ubiquity of uncertainty: a scoping review on how undergraduate health professions' students engage with uncertainty

Although the evidence base around uncertainty and education has expanded in recent years, a lack of clarity around conceptual terms and a heterogeneity of study designs means that this landscape remains indistinct. This scoping review explores how undergraduate health professions' students learn to engage with uncertainty related to their academic practice. To our knowledge, this is the first scoping review which examines teaching and learning related to uncertainty across multiple health professions. The scoping review is underpinned by the five-stage framework of (Arksey and O'Malley in Scoping studies: Towards a methodological framework International Journal of Social Research Methodology 8(1) 19-32, 2005). We searched MEDLINE, Embase, PsychINFO, ISI Web of Science, and CINAHL and hand-searched selected health professions' education journals. The search strategy yielded a total of 5,017 articles, of which 97 were included in the final review. Four major themes were identified: "Learners' interactions with uncertainty"; "Factors that influence learner experiences"; "Educational outcomes"; and, "Teaching and learning approaches". Our findings highlight that uncertainty is a ubiquitous concern in health professions' education, with students experiencing different forms of uncertainty at many stages of their training. These experiences are influenced by both individual and system-related factors. Formal teaching strategies that directly support learning around uncertainty were infrequent, and included arts-based teaching, and clinical case presentations. Students also met with uncertainty indirectly through problem-based learning, clinical teaching, humanities teaching, simulation, team-based learning, small group learning, tactical games, online discussion of anatomy topics, and virtual patients. Reflection and reflective practice are also mentioned as strategies within the literature.

The Impact of Surgeon Experience on Script Concordance Test Scoring

OBJECTIVE

The Script Concordance Test (SCT) is a test of clinical decision-making that relies on an expert panel to create its scoring key. Existing literature demonstrates the value of specialty-specific experts, but the effect of experience among the expert panel is unknown. The purpose of this study was to explore the role of surgeon experience in SCT scoring.

DESIGN

An SCT was administered to 29 general surgery residents and 14 staff surgeons. Staff surgeons were stratified as either junior or senior experts based on years since completing residency training (<15 versus >25 years). The SCT was scored using the full expert panel, the senior panel, the junior panel, and a subgroup junior panel in practice <5 years. A one-way ANOVA was used to compare the scores of first (R1) and fifth (R5) year residents using each scoring scheme. Cognitive interviews were analyzed for differences between junior and senior expert panelist responses.

RESULTS

There was no statistically significant difference between the mean score of six R1s and five R5s using the full expert panel (R1 69.08 versus R5 67.06, F_1,9 = 0.10, P = 0.76), the junior panel (R1 66.73 versus R5 62.50, F_1,9 = 0.35, P = 0.57), or the subgroup panel in practice <5 years (R1 61.07 versus R5 58.79, F_1,9 = 0.18, P = 0.75). However, the average score of R1s was significantly lower than R5s when using the senior faculty panel (R1 52.04 versus R5 63.26, F_1,9 = 26.90, P = 0.001). Cognitive interview data suggests that some responses of junior experts demonstrate less confidence than those of senior experts.

CONCLUSIONS

SCT scores are significantly affected by the responses of the expert panel. Expert differences between first and fifth year residents were only demonstrated when using an expert panel consisting of senior faculty members. Confidence may play a role in the response selections of junior experts. When constructing an SCT expert panel, consideration must be given to the experience of panel members.

How do cognitive processes influence script concordance test responses?

INTRODUCTION

The script concordance test (SCT) is a test of clinical decision-making (CDM) that compares the thought process of learners to that of experts to determine to what extent their cognitive 'scripts' align. Without understanding test-takers' cognitive process, however, it is unclear what influences their responses. The objective of this study was to gather response process validity evidence by studying the cognitive process of test-takers to determine whether the SCT tests CDM and what cognitive processes may influence SCT responses.

METHODS

Cases from an SCT used in a national validation study were administered and semi-structured cognitive interviews were conducted with ten residents and five staff surgeons. A retrospective verbal probing technique was used. Data was independently analysed and coded by two analysts. Themes were identified as factors that influence SCT responses during the cognitive interview.

RESULTS

Cognitive interviews demonstrated variability in CDM among test-takers. Consistent with dual process theory, test-takers relied on scripts formed through past experiences, when available, to make decisions and used conscious deliberation in the absence of experience. However, test-takers' response process was also influenced by their comprehension of specific terms, desire for additional information, disagreement with the planned management, underlying knowledge gaps and desire to demonstrate confidence or humility.

CONCLUSION

The rationale behind SCT answers may be influenced by comprehension, underlying knowledge and social desirability in addition to formed scripts and/or conscious deliberation. Having test-takers verbalise their rationale for responses provides a depth of assessment that is otherwise lost in the SCT's current format. With the improved ability to standardise CDM assessment using the SCT, consideration of test-makers improving the SCT construction process and combining the SCT question format with verbal responses may improve the use of the SCT for CDM assessment.

Clinical guidelines and the pursuit of reducing epistemic uncertainty. An ethnographic study of guideline development panels in three countries

PURPOSE

To explore, from a philosophy of knowledge perspective, the contribution of the guideline development process to reducing epistemic uncertainty in clinical decision-making - defined as the challenge of applying evidence to patients, dealing with conflicting information and determining the level of confidence in a medical conclusion.

METHODS

Longitudinal ethnographic study of national guideline development panels. Fieldnotes were collected from 19 panel meetings in UK, Netherlands and Norway (~120 h of observation) between September 2016 and February 2019. Draft guidelines, review protocols and background material were collated (~200 documents). Data were analyzed thematically to gain familiarity and then theorized using concepts of knowledge development and use and clinical decision-making.

RESULTS

Guideline development panels in all three countries wrestled with epistemic tensions - notably between the desire to "purify" an assumed external truth (for example by limiting included evidence to high-quality randomized controlled trials) and a more pragmatic and pluralist approach that drew on a wider range of evidence including qualitative research, real-world data, clinical experience and patient testimony. Detailed analysis of the process by which particular guideline recommendations were constructed allowed us to draw out the implications of these tensions for guideline users in clinical practice.

CONCLUSION

Guideline development panels apply multiple - often conflicting - understandings of knowledge, inference and truth in an attempt to reduce epistemic uncertainty. Guidelines makers, clinicians, scientists and students should engage critically and reflexively with the philosophical assumptions that underpin guideline development and inductive inference to build capability to deal with clinical complexity.

Does burnout affect clinical reasoning? An observational study among residents in general practice

BACKGROUND

Burnout results from excessive demands at work. Caregivers suffering from burnout show a state of emotional exhaustion, leading them to distance themselves from their patients and to become less efficient in their work. While some studies have shown a negative impact of burnout on physicians' clinical reasoning, others have failed to demonstrate any such impacts. To better understand the link between clinical reasoning and burnout, we carried out a study looking for an association between burnout and clinical reasoning in a population of general practice residents.

METHODS

We conducted a cross-sectional observational study among residents in general practice in 2017 and 2019. Clinical reasoning performance was assessed using a script concordance test (SCT). The Maslach Burnout Inventory for Human Services Survey (MBI-HSS) was used to determine burnout status in both original standards of Maslach's burnout inventory manual (conventional approach) and when individuals reported high emotional exhaustion in combination with high depersonalization or low personal accomplishment compared to a norm group ("emotional exhaustion +1" approach).

RESULTS

One hundred ninety-nine residents were included. The participants' mean SCT score was 76.44% (95% CI: 75.77-77.10). In the conventional approach, 126 residents (63.31%) had no burnout, 37 (18.59%) had mild burnout, 23 (11.56%) had moderate burnout, and 13 (6.53%) had severe burnout. In the "exhaustion + 1" approach, 38 residents had a burnout status (19.10%). We found no significant correlation between burnout status and SCT scores either for conventional or "exhaustion + 1" approaches.

CONCLUSIONS

Our data seem to indicate that burnout status has no significant impact on clinical reasoning. However, one speculation is that SCT mostly examines the clinical reasoning process's analytical dimension, whereas emotions are conventionally associated with the intuitive dimension. We think future research might aim to explore the impact of burnout on intuitive clinical reasoning processes.

Artificial Intelligence and Clinical Decision Making: The New Nature of Medical Uncertainty

Estimates in a 1989 study indicated that physicians in the United States were unable to reach a diagnosis that accounted for their patient's symptoms in up to 90% of outpatient patient encounters. Many proponents of artificial intelligence (AI) see the current process of moving from clinical data gathering to medical diagnosis as being limited by human analytic capability and expect AI to be a valuable tool to refine this process. The use of AI fundamentally calls into question the extent to which uncertainty in medical decision making is tolerated. Uncertainty is perceived by some as fundamentally undesirable and thus, for them, optimal decision making should be based on minimizing uncertainty. However, uncertainty cannot be reduced to zero; thus, relative uncertainty can be used as a metric to weigh the likelihood of various diagnoses being correct and the appropriateness of treatments. Here, the authors make the argument, using as examples the experiences of 2 AI systems, IBM Watson on Jeopardy and Watson for Oncology, that medical decision making based on relative uncertainty provides a better lens for understanding the application of AI to medicine than one that minimizes uncertainty. This approach to uncertainty has significant implications for how health care leaders consider the benefits and trade-offs of AI-assisted and AI-driven decision tools and ultimately integrate AI into medical practice.

Reducing Diagnostic Error in the Intensive Care Unit. Engaging Uncertainty When Teaching Clinical Reasoning

As medicine continues to advance with improvements in technology, factual information has become more easily available at the bedside. Nevertheless, diagnostic error remains a salient concern for the medical community and public. To address this problem, two fundamental characteristics of the physician remain important: curiosity and the ability to apply critical reasoning to solve problems, often in the setting of imperfect knowledge and uncertainty. Historically, the teaching and recall of factual information, illness scripts, and pattern recognition are emphasized early in medical education. Students are often left with the impression that there is a single correct answer for every question; discussions of uncertainty are rare. Consequently, discomfort with uncertainty is common among doctors. As attention to explicit teaching of clinical reasoning increases, one must consider how to incorporate uncertainty into that teaching and to transform the clinical learning environment to embrace uncertainty. The authors propose the use of several simple methods easily employed in the critical care setting to make uncertainty explicit by changing the language used for expressing differential diagnosis, incorporating probabilities into daily sign-outs, and by implementing inductive reasoning when teaching critical thinking to offer learners a strategy for working through unknown problems; these approaches may normalize uncertainty, improve comfort with it, and reduce the impact of cognitive bias in decision-making. Comfort with uncertainty may result not only in improved clinical experiences for learning by transforming a once negative cognitive experience to a positive one but also in reduced susceptibility to thinking errors.

The Utility of Virtual Patient Simulations for Clinical Reasoning Education

Virtual Patient Simulations (VPSs) have been cited as a novel learning strategy, but there is little evidence that VPSs yield improvements in clinical reasoning skills and medical knowledge. This study aimed to clarify the effectiveness of VPSs for improving clinical reasoning skills among medical students, and to compare improvements in knowledge or clinical reasoning skills relevant to specific clinical scenarios. We enrolled 210 fourth-year medical students in March 2017 and March 2018 to participate in a real-time pre-post experimental design conducted in a large lecture hall by using a clicker. A VPS program (^®Body Interact, Portugal) was implemented for one two-hour class session using the same methodology during both years. A pre–post 20-item multiple-choice questionnaire (10 knowledge and 10 clinical reasoning items) was used to evaluate learning outcomes. A total of 169 students completed the program. Participants showed significant increases in average total post-test scores, both on knowledge items (pre-test: median = 5, mean = 4.78, 95% CI (4.55–5.01); post-test: median = 5, mean = 5.12, 95% CI (4.90–5.43); p-value = 0.003) and clinical reasoning items (pre-test: median = 5, mean = 5.3 95%, CI (4.98–5.58); post-test: median = 8, mean = 7.81, 95% CI (7.57–8.05); p-value < 0.001). Thus, VPS programs could help medical students improve their clinical decision-making skills without lecturer supervision.

Conceptualising, evaluating and communicating uncertainty in forensic science: Identifying commonly used tools through an interdisciplinary configurative review

This study provides a set of tools for conceptualising, evaluating and communicating uncertainty in forensic science. Given that the concept of uncertainty is one that transcends disciplinary boundaries, an interdisciplinary configurative review was carried out incorporating the disciplines of medicine, environmental science and economics, in order to identify common themes which could have valuable applications to the discipline of forensic science. Critical Interpretive Synthesis was used to develop sub-synthetic and synthetic constructs which interpreted and synthesised the underlying evidence and codes. This study provides three toolkits, one each for conceptualisation, evaluation and communication. The study identified an underlying theme concerning the obstacles that would need to be overcome for the effective application of these toolkits and achieving effective conceptualisation, evaluation and communication of uncertainty in forensic science to lay-stakeholders. These toolkits offer a starting point for developing the conversation for achieving greater transparency in the communication of uncertainty. They also have the potential to offer stakeholders enhanced understanding of the nuances and limitations of forensic science evidence and enable more transparent evaluation and scrutiny of the reliability, relevance and probative value of forensic materials in a crime reconstruction.

Clinical prioritisation questions: A novel assessment tool to encourage tolerance of uncertainty?

Uncertainty is a common and increasingly acknowledged problem in clinical practice. Current single best answer (SBA) style assessments test areas where there is one correct answer, and as the approach to assessment impacts on the approach to learning, these exams may poorly prepare our future doctors to handle uncertainty. We therefore, need to modify our approach to assessment to emphasize reasoning and introduce the possibility of more than one 'correct' answer. We have developed clinical prioritization questions (CPQs), a novel formative assessment tool in which students prioritize possible responses in order of likelihood. This assessment format was piloted with a group of medical students and evaluated in comparison with the more traditional SBA question format in a team-based learning setting. Students reported that they felt ongoing use would help improve their tolerance of uncertainty (p < 0.01). Furthermore, over 80% of students felt that CPQs were more reflective of real-life clinical practice. Group based discussions were significantly longer when answering CPQs (p < 0.01), suggesting they may promote richer discourse. CPQs may have a role in formative assessment to help equip students with the skills to cope with ambiguity and strengthen clinical reasoning and decision-making. Institutions may find them more practical to implement compared with other clinical reasoning assessment tools.

The cognitive process of test takers when using the script concordance test rating scale

CONTEXT

Clinical decision making (CDM) skills are important to learn and assess in order to establish competence in trainees. A common tool for assessing CDM is the script concordance test (SCT), which asks test takers to indicate how a new clinical finding influences a proposed plan using a Likert-type scale. Most criticisms of the SCT relate to its rating scale but are largely theoretical. The cognitive process of test takers when selecting their responses using the SCT rating scale remains understudied, but is essential to gathering validity evidence for use of the SCT in CDM assessment.

METHODS

Cases from an SCT used in a national validation study were administered to 29 residents and 14 staff surgeons. Semi-structured cognitive interviews were then conducted with 10 residents and five staff surgeons based on the SCT results. Cognitive interview data were independently coded by two data analysts, who specifically sought to elucidate how participants mapped their internally generated responses to any of the rating scale options.

RESULTS

Five major issues were identified with the response matching cognitive process: (a) the meaning of the '0' response option; (b) which response corresponds to agreement with the planned management; (c) the rationale for picking '±1' versus '±2'; (d) which response indicates the desire to undertake the planned management plus an additional procedure, and (e) the influence of time on response selection.

CONCLUSIONS

Studying how test takers (experts and trainees) interpret the SCT rating scale has revealed several issues related to inconsistent and unintended use. Revising the scale to address the variety of interpretations could help to improve the response process validity of the SCT and therefore improve the SCT's ability to be used in CDM skills assessments.

Implicit expression of uncertainty - suggestion of an empirically derived framework

BACKGROUND

Uncertainty occurs in physicians' daily work in almost every clinical context and is also present in the clinical reasoning process. The way physicians communicate uncertainty in their thinking process during handoffs is crucial for patient safety because uncertainty has diverse effects on individuals involved in patient care. Dealing with uncertainty and expressing uncertainty are important processes in the development of professional identity of undergraduate medical students. Many studies focused on how to deal with uncertainty and whether uncertainty is explicitly expressed. Hardly any research has been done regarding implicit expression of uncertainty. Therefore, we studied the ways in which medical students in the role of beginning residents implicitly express uncertainty during simulated handoffs.

METHODS

Sixty-seven advanced undergraduate medical students participated in a simulated first day of residency including a consultation hour, a patient management phase with interprofessional interaction, and a patient handoff. We transcribed the videographed handoffs verbatim and extracted language with respect to expression of uncertainty using a grounded theory approach. Text sequences expressing patient related information were analyzed and coded with respect to language aspects which implicitly modified plain information with respect to increasing or decreasing uncertainty. Concepts and categories were developed and discussed until saturation of all aspects was reached.

RESULTS

We discovered a framework of implicit expressions of uncertainty regarding diagnostic and treatment-related decisions within four categories: "Statement", "Assessment", "Consideration", and "Implication". Each category was related to either the subcategory "Actions" or "Results" within the diagnostic or therapeutic decisions. Within each category and subcategory, we found a subset of expressions, which implicitly attenuated or strengthened plain information thereby increasing uncertainty or certainty, respectively. Language that implicitly attenuated plain information belonged to the categories questionable, incomplete, alterable, and unreliable while we could ascribe implicit strengtheners to the categories assertive, adequate, focused, and reliable.

CONCLUSIONS

Our suggested framework of implicit expression of uncertainty may help to raise the awareness for expression of uncertainty in the clinical reasoning process and provide support for making uncertainty explicit in the teaching process. This may lead to more transparent communication processes among health care professionals and eventually to improved patient safety.

Uncertainty in Decision Making in Medicine: A Scoping Review and Thematic Analysis of Conceptual Models

PURPOSE

The practice of medicine is rarely straightforward. Data used to facilitate medical decision making may be conflicting, ambiguous, or scarce, and providing optimal care requires balancing clinicians' expertise and available evidence with patients' preferences. To explore uncertainty in decision making across disciplines, the authors performed a scoping review and thematic analysis of the literature to formulate a model describing the decision-making process in medicine under uncertain conditions.

METHOD

In 2016, the authors performed a comprehensive search of key databases using a combination of keywords and controlled vocabulary. They identified and reviewed 3,398 records. After applying their inclusion and exclusion criteria to the titles and abstracts and then full texts, 19 articles were selected. The authors applied a qualitative thematic analysis to these articles, using codes to extract themes related to uncertainty in decision making.

RESULTS

The 19 articles spanned 6 fields of study and 5 disciplines within the health sciences. The thematic analysis revealed 6 main themes: recognition of uncertainty, classification of uncertainty, stakeholder perspectives, knowledge acquisition, decision-making approach, and evaluation of the decision-making process.

CONCLUSIONS

Based on the themes that emerged from their thematic analysis of the literature characterizing the effects of uncertainty and ambiguity on the decision-making process, the authors developed a framework depicting the interplay between these themes with a visual representation of the decision-making process under uncertain conditions. Future research includes further development and validation of this framework to inform medical school curricula.

Medical students' experiences with goals of care discussions and their impact on professional identity formation

CONTEXT

Goals of care (GoC) discussions occur amongst patients, family members and clinicians in order to establish plans of care and are invaluable aspects of end-of-life care. In previous research, medical learners have reported insufficient training and emotional distress about end-of-life decision making, but most studies have focused on postgraduate trainees and have been quantitative or have evaluated specific educational interventions. None have qualitatively explored medical students' experiences with GoC discussions, their perceptions of associated hidden curricula, and the impacts of these on professional identity formation (PIF), the individualised developmental processes by which laypersons evolve to think, act and feel like, and ultimately become, medical professionals.

METHODS

Using purposive sampling at one Canadian medical school, individual semi-structured interviews were conducted with 18 medical students to explore their experiences with GoC discussions during their core internal medicine clerkship. Interviews were audiorecorded, transcribed and anonymised. Concurrently with data collection, transcripts were analysed iteratively and inductively using interpretative phenomenological analysis, a qualitative research approach that allows the rich exploration of subjective experiences.

RESULTS

Participants reported minimal support and supervision in conducting GoC discussions, which were experienced as ethically challenging, emotionally powerful encounters exemplifying tensions between formal and hidden curricula. Role modelling and institutional culture were key mechanisms through which hidden curricula were transmitted, subverting formal curricula in doing so and contributing to participants' emotional distress. Participants' coping responses were generally negative and included symptoms of burnout, the pursuit of standardisation, rationalisation, compartmentalisation and the adaptation of previously held, more idealised professional identities.

CONCLUSIONS

GoC discussions in this study were often led by inexperienced medical students and impacted negatively on their PIF. Through complex emotional processes, they struggled to reconcile earlier concepts of physician identities with newly developing ones and often reluctantly adopted suboptimal professional behaviours and attitudes. Improved education about GoC discussions is necessary for patient care and may represent concrete and specific opportunities to influence students' PIF positively.

'I wish I was someone else': complexities in identity formation and professional wellbeing in veterinary surgeons

BACKGROUND

There is widespread concern surrounding veterinarians' mental health. Upon entering the profession, early career veterinary surgeons encounter colleagues with diverse and conflicting identities, manifesting in their differential prioritisation of definitive clinical treatment, interpersonal interactions or the commercial success of the practice. In other professions, poor wellbeing arises from confusion between these conflicting identity discourses, as new professionals attempt to identify role models aligned with their own identity beliefs. New veterinarians' wellbeing may thus depend on their negotiation of different identities, as they construct their own sets of professional values and determine the type of veterinarian they wish to become.

METHODS

Identity formation was explored narratively using veterinarians' social media stories.

RESULTS

Poor professional wellbeing appeared to arise from identity confusion: failure to consistently commit to either the dominant diagnosis-focused discourse valued by academic role models, or a relational discourse, emphasising working through contextual challenges such as varying client needs. Workplace stress appeared to magnify the dominance of academic priorities in self-identity understanding, worsening identity confusion. Also concerning was the positioning of the client 'as enemy', obstructive to veterinarians' identity goals. Social dialogue, intended to provide support during veterinarian-client conflict, potentially reinforced rejection of the client from the veterinary professional identity, strengthening a context-inappropriate, non-relational identity. This worsened identity confusion between the prized 'diagnostic identity' and the locally valued relational identity and was detrimental to wellbeing.

CONCLUSIONS

Interventions are required, within veterinary education and postgraduate continuing professional development, that encourage reflection on identity and reinforce the value of relational identity attributes.

Evaluation of Validity Evidence for Personality, Emotional Intelligence, and Situational Judgment Tests to Identify Successful Residents

Importance

The ability to identify candidates who will thrive and successfully complete their residency is especially critical for general surgery programs.

Objective

To assess the extent to which 3 screening tools used extensively in industrial selection settings-emotional intelligence (EQ), personality profiles, and situational judgment tests (SJTs)-could identify successful surgery residents.

Design, Setting, and Participants

In this analysis, personality profiles, EQ assessments, and SJTs were administered from July through August 2015 to 51 postgraduate year 1 through 5 general surgery residents in a large general surgery residency program. Associations between these variables and residency performance were investigated through correlation and hierarchical regression analyses.

Interventions

Completion of EQ, personality profiles, and SJT assessments.

Main Outcomes and Measures

Performance in residency as measured by a comprehensive performance metric. A score of zero represented a resident whose performance was consistent with that of their respective cohort's performance; below zero, worse performance; and greater than zero, better performance.

Results

Of the 61 eligible residents, 51 (84%) chose to participate and 22 (43%) were women. US Medical Licensing Examination Step 1 (USMLE1), but not USMLE2, emerged as a significant factor (t2,49 = 1.98; β = 0.30; P = .03) associated with overall performance. Neither EQ facets nor overall EQ offered significant incremental validity over USMLE1 scores. Inclusion of the personality factors did not significantly alter the test statistic and did not explain any additional portion of the variance. By contrast, inclusion of SJT scores accounted for 15% more of the variance than USMLE1 scores alone, resulting in a total of 25% of the variance explained by both USMLE1 and SJT scores (F2,57 = 7.47; P = .002). Both USMLE1 (t = 2.21; P = .03) and SJT scores (t = 2.97; P = .005) were significantly associated with overall resident performance.

Conclusions and Relevance

This study found little support for the use of EQ assessment and only weak support for some distinct personality factors (ie, agreeableness, extraversion, and independence) in surgery resident selection. Performance on the SJT was associated with overall resident performance more than traditional cognitive measures (ie, USMLE scores). These data support further exploration of these 2 screening assessments on a larger scale across specialties and institutions.

A Philosophical Approach to Addressing Uncertainty in Medical Education

Conveying the uncertainty inherent in clinical practice has rightly become a focus of medical training. To date, much of the emphasis aims to encourage trainees to acknowledge and accept uncertainty. Intolerance of uncertainty is associated with medical student distress and a tendency in clinicians toward overtreatment. The authors argue that a deeper, philosophical understanding of the nature of uncertainty would allow students and clinicians to move beyond simple acceptance to explicating and mitigating uncertainty in practice.Uncertainty in clinical medicine can be categorized philosophically as moral, metaphysical, and epistemic uncertainty. Philosophers of medicine-in a way analogous to ethicists a half century ago-can be brought into medical education and medical practice to help students and physicians explore the epistemic and metaphysical roots of clinical uncertainty. Such an approach does not require medical students to master philosophy and should not involve adding new course work to an already-crowded medical curriculum. Rather, the goal is to provide students with the language and reasoning skills to recognize, evaluate, and mitigate uncertainty as it arises. The authors suggest ways in which philosophical concepts can be introduced in a practical fashion into a variety of currently existing educational formats. Bringing the philosophy of medicine into medical education promises not only to improve the training of physicians but, ultimately, to lead to more mindful clinical practice, to the benefit of physicians and patients alike.

[Uncertainty management and medical skills: A clinical and educational reflexion]

Uncertainty arises when information is not sufficient to predict the prognosis or the outcome following an intervention. It is omnipresent in medical daily practice, and will follow each practitioner all along his career. The communication or merely even the feeling of uncertainty is frequently perceived as a negative experience. Nevertheless, rather than a sign of weakness, feeling uncertain reflects a dynamic state of self-reassessment which should be experienced by each doctor involved in providing his patients with the best care. Furthermore, uncertainty may lead to disastrous consequences for practitioners who have not been properly prepared to it, involving the sphere of emotions (stress, anxiety, burn-out) as well as the behavioral field (misdiagnosis, excessive testing, impaired communication…). A growing number of observations, clinical or educational studies, supports the idea that learning uncertainty should be a critical prerequisite to a valuable medical practice. Through this literature review, we propose herein a conceptual glance on uncertainty. Then, we expose some sources of uncertainty in daily practice and teaching, its consequences, and the main factors that contribute to the wide variety of the individual relationship with uncertainty. We finally aim to prompt a global reflexion, falling within an uncertainty competency-based education approach, assuming that our obligation to professionalize the students necessitates making them skilled in dealing with uncertainty.

Transition to Residency: The Successful Development and Implementation of a Nonclinical Elective in Perioperative Management

OBJECTIVE

Few medical school programs in Canada address challenges related to the significant increase in responsibility for patient care between medical school and residency. This is particularly important in surgery and anesthesia due to the high-acuity care required during the perioperative period. The purpose of this study was to develop and assess a program that would help students transition to surgical and anesthesia residencies, in terms of knowledge acquisition, clinical decision-making skills, and subjective preparedness.

DESIGN

The authors developed a 1-week nonclinical Perioperative Management Elective for students matching to surgical or anesthesia residencies. Clinical decision-making training was incorporated using a simulated pager called the MedsOnCall Pager app. A study was conducted to evaluate knowledge acquisition and development of clinical decision-making skills in students completing the elective. A mixed-effects model analysis of the proportion of pages answered correctly during the elective was used as a marker of their progression. Students were asked to complete entry and exit questionnaires to provide subjective information regarding their elective experience.

SETTING

The study ran for 2 iterations of the elective in 2016 and 2017 at the University of Ottawa.

PARTICIPANTS

A total of 20 University of Ottawa fourth-year medical students completed the elective.

RESULTS

There was a significant increase in the proportion of correctly answered pages over the course of the elective week (p = 0.04). Results from entry and exit questionnaires revealed that students felt more knowledgeable, comfortable, and prepared for residency after completing the elective (p < 0.001).

CONCLUSIONS

The Perioperative Management Elective has completed 2 successful iterations with confirmed knowledge acquisition and improved clinical decision-making skills among elective students. Participating students perceived that the experience was beneficial and fulfilled a gap in their medical school training. We believe that this elective framework could be employed by other schools to help graduating students' transition smoothly into residency.

Beyond "formative": assessments to enrich student learning

Formative assessments can enhance and enrich student learning. Typically, these have been used to provide feedback against end-of-course standards and prepare students for summative assessments of performance or measurement of competence. Here, we present the case for using assessments for learning to encompass a wider range of important outcomes. We discuss 1) the rationale for using assessment for learning; 2) guiding theories of expertise that inform assessment for learning; 3) theoretical and empirical evidence; 4) approaches to rigor and validation; and 5) approaches to implementation at multiple levels of the curriculum. The literature strongly supports the use of assessments as an opportunity to reinforce and enhance learning. Physiology teachers have a wide range of theories, models, and interventions from which to prepare students for retention, application, transfer, and future learning by using assessments.

Implementation of a Clinical Reasoning Course in the Internal Medicine trimester of the final year of undergraduate medical training and its effect on students' case presentation and differential diagnostic skills

Background: Clinical reasoning, comprising the processes of clinical thinking, which form the basis of medical decisions, constitutes a central competence in the clinical routine on which diagnostic and therapeutic steps are based. In medical curricula in Germany, clinical reasoning is currently taught explicitly only to a small extend. Therefore, the aim of this project was to develop and implement a clinical reasoning course in the final year of undergraduate medical training. Project description: A clinical reasoning course with six learning units and 18 learning objectives was developed, which was taught by two to four instructors on the basis of 32 paper cases from the clinical practice of the instructors. In the years 2011 to 2013, the course of eight weeks with two hours per week was taught seven times. Before the first and after the last seminar, the participating students filled out a self-assessment questionnaire with a 6-point Likert scale regarding eight different clinical reasoning skills. At the same times, they received a patient case with the assignment to prepare a case presentation and differential diagnoses. Results: From 128 participating students altogether, 42 complete data sets were available. After the course, participants assessed themselves significantly better than before the course in all eight clinical reasoning skills, for example in "Summarizing and presentation of a paper case" or in the "Skill to enumerate differential diagnoses" (p<0.05). The greatest increase occurred in the skill to recognize typical cognitive errors in medicine and to identify risk situations for their occurrence (pre: 2.98±0.92 and retro-pre: 2.64±1.01, respectively, versus post: 4.38±0.88). Based on the ratio of number of words used per keywords used the problem presentation of the paper case was significantly more focused after the course (p=0.011). A significant increase in the number of gathered differential diagnoses was not detected after the course. Conclusion: The newly developed and established Clinical Reasoning Course leads to a gain in the desired skills from the students' self-assessment perspective and to a more structured case presentation. To establish better options to exercise clinical reasoning, a longitudinal implementation in the medical curriculum seems to be desirable. Faculty training would be useful to implement the concept as standardized as possible.

Developing teaching to improve the wellbeing of future vets

Some people are under the impression that developing the educational experience of students at the Royal Veterinary College doesn't make you a 'real vet'. Here, Elizabeth Armitage-Chan explains how her role helps future vets gain in confidence and competence.