Subjective awareness of ultrasound expertise development: individual experience as a determinant of overconfidence

Confidence and Utilization are Poorly Associated with Point-of-Care Ultrasound Competency among Internal Medicine Trainees

INTRODUCTION

Point-of-Care Ultrasound (POCUS) is the utilization of bedside ultrasound by clinicians. Its portable and rapid diagnostic capabilities make it an excellent tool for deployment and mobile military settings. However, formal and uniform POCUS training is lacking. Furthermore, the evaluation of these curricula often relies on confidence assessment. Our objective was to assess the relationships between confidence, frequency of utilization, and image interpretation knowledge among our Internal Medicine residents before and after the implementation of a formal curriculum.

MATERIALS AND METHODS

In November 2020, we implemented a longitudinal, flipped-classroom, academic half-day curriculum, conducting a prospective before-after cohort evaluation of its implementation. The POCUS curriculum was implemented as a longitudinal, asynchronous, flipped-classroom activity with workshop sessions during one academic half-day per month. We measured confidence via a Likert scale and utilization frequency via a five-point scale. Six multiple-choice questions (MCQ) with ultrasound videos assessed image interpretation competency. The image interpretation score was reported as percent correct. We related confidence and utilization to the image interpretation score.

RESULTS

Ninety-nine residents were eligible for participation. Fifty-four (55%) completed a pre-curriculum assessment and 45 (45%) completed a post-curriculum assessment. Average image interpretation scores were 41% pre-curriculum and 51% post-curriculum (P =0.02). Pre-curriculum residents were on average unconfident (mean=2.56), and post-curriculum residents were on average confident (mean=3.62). Pre-curriculum residents used POCUS occasionally (mean=2.02, count 13 (24%) never utilizing). Post-curriculum residents used POCUS occasionally (mean=2.42, count 4 (9%) never utilizing). Pre- and post-curriculum confidence were not significantly associated with image interpretation scores (pre-curriculum: r=-0.10, P =0.50; post-curriculum: r=0.24, P =0.11). Pre- and post-curriculum utilization were not significantly associated with image interpretation scores (pre-curriculum: r=0.15, P =0.28; post-curriculum: r=0.02, P =0.90). The number of curriculum sessions attended was significantly associated with higher image interpretation scores (r=0.30, P =0.003).

CONCLUSIONS

Our study suggests that POCUS confidence and informal utilization do not correlate with image interpretation knowledge on MCQs among Internal Medicine residents. These findings support assessing direct measures of knowledge, rather than confidence, as an endpoint in evaluating POCUS curricula among Internal Medicine residents.

The Effect of Chief Executive Officer and Board Prior Corporate Social Responsibility Experiences on Their Focal Firm’s Corporate Social Responsibility: The Moderating Effect of Chief Executive Officer Overconfidence

This research aims to examine how the prior experiences of the chief executive officer (CEO) and board influence the focal firm’s Corporate Social Responsibility (CSR) activities. Further, the present study examines how CEO overconfidence influences the diffusion of CSR activities. The authors theorize that overconfident CEOs are influenced more by the corporate strategies they experienced on other boards and less by the corporate strategies experienced by other directors. Through longitudinal analyses of the CSR profiles a sample of S&P 500 companies for the period 2006-2013, the study shows that CEO and board prior CSR experience are positively related to the firm’s current CSR activities. The authors find a significant positive moderating effect of CEO overconfidence on the relationship between CEO prior CSR and the focal firm’s CSR. The theory and results highlight how CEO and board prior CSR exposure may influence the focal firm’s stances toward CSR and that CEO overconfidence may have differential effects on these relationships.

Physicians' cognitive strategies for avoiding overconfidence

BACKGROUND

Physicians' overconfidence damages the quality of medical care. Due to their high social status and intense impact on people lives, physicians need to develop strategies to avoid overconfidence. Yet until now, the strategies physicians use to avoid overconfidence have not been explored. This study aimed to identify strategies physicians use to minimize potential overconfidence.

METHODS

This qualitative study relied on face-to-face semi-structured interviews. Participants were 22 physicians specializing in ophthalmology, gynaecology, rheumatology, cardiology, anaesthesiology, paediatrics, radiology, orthopaedics, otolaryngology, gastroenterology, family and paediatrics. The interviews were analyzed with the grounded theory approach.

RESULTS

Analysis of the interviews revealed three prominent strategies physicians use to minimize overconfidence: awareness of the risks of overconfidence, framing a mundane professional identity, and cultivation of a positive self-view through pride based on effort rather than skills.

CONCLUSIONS

The study demonstrates the on-going nature of establishing physicians' professional identity and implies that it is shaped by a motivation to adapt their identity to fundamental requirements of medical practice. Medical training and education might promote strategies for minimization of potential overconfidence among physicians.

Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study

OBJECTIVES

To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality.

DESIGN

Multicenter prospective cohort study between September 2017 and February 2018.

SETTINGS

Thirty-four hospitals in the United States and Jordan.

PATIENTS

Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18).

CONCLUSIONS

The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.

Confidence Level and Ability of Medical Students to Identify Abdominal Structures After Integrated Ultrasound Sessions

Purpose

Determine the confidence level and ability of first year medical students to identify abdominal structures using a wireless portable ultrasound scanner.

Methods

The students were assessed for their confidence and ability to perform abdominal ultrasound. The 5-point Likert survey included questions on their perception about ultrasound as a resource for learning anatomy, physical examination skills, and the quality of the pre-session instructions. Data was also recorded by the faculty about the students’ ultrasound skills and confidence. Goodman and Kruskal's gamma was used to demonstrate an association between the students’ ability to identify the structures and the self-reported student confidence level.

Results

Most of the students had confidence and were able to identify the liver, kidney, and urinary bladder, while almost half of them needed faculty help them to identify the inferior vena cava and aorta. The spleen and gall bladder were the most difficult to locate even for the very confident students. The perception of supervising faculty was that the confidence level was low in most of the students and only 13–20% of students felt “very confident” about performing ultrasound. Almost 37% needed encouragement and support and almost 10% of the students were not willing to try to locate difficult organs. Some students started locating the ureteric jet and portal vein. Most of the students agreed that ultrasound is an excellent resource for learning anatomy and physical examination skills. All students suggested having more ultrasound sessions.

Conclusion

Most of the students feel confident about performing ultrasound and they perceive that ultrasound can enhance their basic sciences and physical examination skills.

Balancing confidence and humility in the diagnostic process

Humility in medicine can be difficult to achieve, yet arguably is one of the most important competencies to master. Overconfidence, on the contrary, is a natural tendency, having established its roots in evolution where quicker and more confident decisions likely conferred a selective advantage. Moreover, humility may evoke an image of weakness and vulnerability, antithetical to contemporary medicine, whose culture is dominated by overconfidence. Nevertheless, humility can be learned, and is important because overconfident behavior can be detrimental to our patients medically, psychosocially and legally, when it results in delayed or missed diagnoses. To achieve humility requires a great deal of metacognition, normalizing doubt and not being afraid to utilize tools that may feel beneath us. To practice humility requires strength and emotional resilience. In this paper we explore the definitions, roles and implications of humility in medicine, and we pose suggestions of how to accomplish this in the diagnostic process.