Measuring Emotions in Medical Education: Methodological and Technological Advances Within Authentic Medical Learning Environments

Relinquishing control? Supervisor co-regulation may disrupt students' self-regulated learning during simulation-based training

When uncertain, medical trainees often seek to co-regulate their learning with supervisors and peers. Evidence suggests they may enact self-regulated learning (SRL) strategies differently when engaged in self- versus co-regulated learning (Co-RL). We compared the impacts of SRL and Co-RL on trainees' acquisition, retention, and preparation for future learning (PFL) of cardiac auscultation skills during simulation-based training. In our two-arm, prospective, non-inferiority trial, we randomly assigned first- and second-year medical students to the SRL (N = 16) or Co-RL conditions (N = 16). Across two learning sessions separated by two-weeks, participants practiced and were assessed in diagnosing simulated cardiac murmurs. We examined diagnostic accuracy and learning trace data across sessions, and conducted semi-structured interviews to explore participants' understandings of their underlying choices and learning strategies. SRL participants' outcomes were non-inferior to Co-RL participants on the immediate post-test and retention test, but not on the PFL assessment (i.e., inconclusive). Analyzing interview transcripts (N = 31) generated three themes: perceived utility of initial learning supports for future learning; SRL strategies and sequencing of murmurs; and perceived control over learning across sessions. Co-RL participants regularly described relinquishing control of learning to supervisors and regaining it when on their own. For some trainees, Co-RL seemed to interfere with their situated and future SRL. We posit that transient clinical training sessions, typical in simulation-based and workplace-based settings, may not allow the ideal processes of Co-RL to unfold between supervisor and trainee. Future research must examine how supervisors and trainees can share accountability to develop the shared mental models that underlie effective Co-RL.

Emotion in remediation: A scoping review of the medical education literature

OBJECTIVES

Remediation can be crucial and high stakes for medical learners, and experts agree it is often not optimally conducted. Research from other fields indicates that explicit incorporation of emotion improves education because of emotion's documented impacts on learning. Because this could present an important opportunity for improving remediation, we aimed to investigate how the literature on remediation interventions in medical education discusses emotion.

METHODS

The authors used Arksey and O'Malley's framework to conduct a scoping literature review of records describing remediation interventions in medical education, using PubMed, CINAHL Complete, ERIC, Web of Science and APA PsycInfo databases, including all English-language publications through 1 May 2020 meeting search criteria. They included publications discussing remediation interventions either empirically or theoretically, pertaining to physicians or physician trainees of any level. Two independent reviewers used a standardised data extraction form to report descriptive information; they reviewed included records for the presence of mentions of emotion, described the mentions and analysed results thematically.

RESULTS

Of 1644 records, 199 met inclusion criteria and were reviewed in full. Of those, 112 (56%) mentioned emotion in some way; others focused solely on cognitive aspects of remediation. The mentions of emotion fell into three themes based on when the emotion was cited as present: during regular coursework or practice, upon referral for remediation and during remediation. One-quarter of records (50) indicated potential intentional incorporation of emotion into remediation programme design, but they were non-specific as to how emotions related to the learning process itself.

CONCLUSION

Even though emotion is omnipresent in remediation, medical educators frequently do not factor emotion into the design of remediation approaches and rarely explicitly utilise emotion to improve the learning process. Applications from other fields may help medical educators leverage emotion to improve learning in remediation, including strategies to frame and design remediation.

Exploring the relationship between emotion and cognitive load types during patient handovers

Cognitive Load Theory has emerged as an important approach to improving instruction in the health professions workplace, including patient handovers. At the same time, there is growing recognition that emotion influences learning through numerous cognitive processes including motivation, attention, working memory, and long-term memory. This study explores how emotion influences the cognitive load experienced by trainees performing patient handovers. From January to March 2019, 693 (38.7%) of 1807 residents and fellows from a 24-hospital health system in New York city completed a survey after performing a handover. Participants rated their emotional state and cognitive load. The survey included questions about features of the learner, task, and instructional environment. The authors used factor analysis to identify the core dimensions of emotion. Regression analyses explored the relationship between the emotion factors and cognitive load types. Two emotion dimensions were identified representing invigoration and tranquility. In regression analyses, higher levels of invigoration, tranquility, and their interaction were independently associated with lower intrinsic load and extraneous load. The interaction of invigoration and tranquility predicted lower germane load. The addition of the emotion variables to multivariate models including other predictors of cognitive load types significantly increased the amount of variance explained. The study provides a model for measuring emotions in workplace learning. Because emotion appears to have a significant influence on cognitive load types, instructional designers should consider strategies that help trainees regulate emotion in order to reduce cognitive load and improve learning and performance.

The individual in the system: The role of affect in recent veterinary graduates' reflective activity

BACKGROUND

The transition to professional practice can be a challenging time. The Royal College of Veterinary Surgeons' (RCVS) Professional Development Phase (PDP) aims to support recent graduates through this transition, with graduates required to reflect on their experiences. This study drew on the concept of "lived experience" to explore the influence of affect (feelings, emotions and mood) on recent graduates' experience of reflective activity.

METHODS

Data comprised semi-structured interviews with 15 recent graduates from one veterinary school. Thematic analysis was used to explore the influence of three aspects of affect on reflective activity: affective valence (whether a chosen action is anticipated to result in positive or negative feelings), tacit aspects (such as tiredness) and perceptions of workplace mood.

RESULTS

Participants preferred to engage in activities associated with positive feelings. Tacit feelings, such as panic or tiredness, and perceptions of workplace mood, influenced how and with whom participants engaged in reflective activity. Participants often made different choices when reflecting primarily on affective compared to clinical aspects of situations.

CONCLUSION

These findings suggest that acknowledging and understanding aspects of affect during the professional development phase has the potential to help the profession improve support for recent graduates.

Examining the role of self-regulation and emotion in clinical reasoning: Implications for developing expertise

This paper explores the role that self-regulation and emotions play in establishing a clinical diagnosis in the context of solving a clinical case in BioWorld, a computer supported learning environment designed for medical students to practice clinical reasoning. Group differences between high and low performers were explored. The results revealed no group differences in overall measures of SRL but high performers spend more time than lows in a subcategory of the reflection phase (reflecting on prioritized evidence and results). A reciprocal role of emotions was demonstrated for clinical reasoning and predicted students' diagnostic performance. High performers showed less negative activating emotions than low performers.

Development and application of a multi-modal task analysis to support intelligent tutoring of complex skills

BACKGROUND

Contemporary work in the design and development of intelligent training systems employs task analysis (TA) methods for gathering knowledge that is subsequently encoded into task models. These task models form the basis of intelligent interpretation of student performance within education and training systems. Also referred to as expert models, they represent the optimal way(s) of performing a training task. Within Intelligent Tutoring Systems (ITSs), real-time comparison of trainee task performance against the task model drives automated assessment and interactive support (such as immediate feedback) functionality. However, previous task analysis (TA) methods, including various forms of cognitive task analysis (CTA), may not be sufficient to support identification of the detailed design specifications required for the development of an ITS for a complex training task incorporating multiple underlying skill components, as well as multi-modal information presentation, assessment, and feedback modalities. Our current work seeks to develop an ITS for training Robotic Assisted Laparoscopic Surgery (RALS), a complex task domain that requires a coordinated utilization of integrated cognitive, psychomotor, and perceptual skills.

RESULTS

In this paper, we describe a methodological extension to CTA, referred to as multi-modal task analysis (MMTA) that elicits and captures the nuances of integrated and isolated cognitive, psychomotor, and perceptual skill modalities as they apply to training and performing complex operational tasks. In the current case, we illustrate the application of the MMTA method described here to RALS training tasks. The products of the analysis are quantitatively summarized, and observations from a preliminary qualitative validation are reported.

CONCLUSIONS

We find that iterative use of the described MMTA method leads to sufficiently complete and robust task models to support encoding of cognitive, psychomotor, and perceptual skills requisite to training and performance of complex skills within ITS task models.

Resonance and dissonance asymmetry in effective physician-patient relationships

This paper examines the proposed asymmetry that should occur between resonance and dissonance in physician-patient relationships in favour of resonance to facilitate an effective relationship. Resonance is represented by the positive emotional attractor, which comprises patients' conscious preferred future or ideal self, and dissonance is expressed by the negative emotional attractor and consists of the gaps between patients' ideal and real self or their fears, problems, and shortfalls. Intentional change theory is reviewed to optimise the physician-patient relationship. Concepts from complexity theory and recent research on emotions are used to explain positive and negative emotional attractors. The role of resonance and dissonance in physician-patient relationships is discussed along with how behaviour can be changed with positive and negative emotional attractors. This paper focuses on the quality and effectiveness of physician-patient relationships for physicians who create high versus low positive emotional attractor/negative emotional attractor ratios. Two theoretical propositions are offered and the research and practice implications are explained.