Teaching Clinical Reasoning and Critical Thinking: From Cognitive Theory to Practical Application

A thematic content analysis of the structure and effects of good doctor abilities in China

BACKGROUND

The efforts to explore and build the structure of good doctor abilities are important because they help improve the quality of education for medical students and better standardize the working performance of doctors. However, at present, no worldwide standards for such a structure have been established. In this study, we endeavoured to map the structure of good doctor abilities and identify their effects.

METHODS

With a focus on China, a thematic content analysis was adopted in this study to analyse the personal profiles of 50 widely recognized good doctors. NVivo11 software was used.

RESULTS

The Structure and Effects of Good Doctor Abilities in China model was proposed, and interpretations were made based on AMO theory. Good doctor abilities fall within six categories: rigorous clinical thinking, skilled in diagnosis and therapy, clinical empathy, continuous learning and innovation, enhancing and sharing experiences, and communication and coordination. These abilities have positive impacts on doctors' work performances and social benefits by encouraging good behaviours, ultimately promoting the sustainable development of the hospitals where they serve.

CONCLUSIONS

In this study, we established a model of the structure and effects of good-doctor abilities in China and interpreted its mechanism, innovation and theory diversification in "good-doctor" research. Moreover, this study has practical significance because it provides systematic and well-targeted criteria for improving the professionalism of doctors, promoting more good doctor behaviours, providing guidance for regulating doctors' conduct and providing a reference for medical education and working performance reviews worldwide.

The 1-minute preceptor to improve diagnostic reasoning in a primary care nurse practitioner residency program

BACKGROUND

The One-Minute Preceptor (OMP) model to teach diagnostic reasoning and Reporter, Interpreter, Manager, and Educator (RIME) framework to measure progress are used in physician training. Little is known about the use of these tools in nurse practitioner (NP) training.

LOCAL PROBLEM

Precepting NP trainees at the Veterans Affairs (VA) is not standardized. A standardized approach to precepting NP residency trainees using the OMP model and RIME scoring was evaluated for improvement and helpfulness.

METHODS

A quality-improvement project with two Plan-Do-Study-Act (PDSA) cycles were conducted over a 12-week period. Mean RIME scores, preceptor self-efficacy, and use of teaching skills were measured preintervention and postintervention. Data were analyzed using a paired sample t-test and descriptive statistics.

INTERVENTIONS

A convenience sample of preceptors and trainees was recruited from a large VA medical center. A 1-hour workshop educated preceptors with role playing and return demonstrations on OMP techniques and RIME scoring. The teachings were applied to standardize precepting and assess diagnostic reasoning. Trainee self-scoring and results triggered conversations to fulfil the identified gaps.

RESULTS

Mean RIME scores improved (1.62 [0.17] vs. 2.23 [0.38], p < .001) post 12-week intervention. Mean RIME scores improved between PDSA cycle 1 and cycle 2 (2.07 [0.25] vs. 2.48 [0.39], p < .001). Preceptors (91%) and trainees (100%) found the OMP model and RIME framework helpful.

CONCLUSION

Use of the OMP improved diagnostic reasoning in NP trainees. The OMP and RIME framework provided standardization of precepting and trainee discussions on improvements.

Exploring clinical judgment ability in second-degree baccalaureate of science nursing students: A mixed methods study

BACKGROUND

As they have not yet embarked on clinical practice, most students who already have a bachelor's degree but require a bachelor's degree in nursing occasionally perceive the educator's instruction on clinical situations as abstract and challenging for making accurate clinical judgments.

OBJECTIVES

This study aims to implement a clinical judgment model and case scenarios in classroom teaching to evaluate improvements in students' clinical judgment and critical thinking abilities.

DESIGN

A mixed-method design.

SETTING

A second-degree Bachelor of Science in Nursing at a university in Taiwan.

PARTICIPANTS

First-year undergraduate nursing students.

METHODS

This mixed-methods study featured a survey at the beginning and end of a course, followed by one-on-one online interviews. A purposive sample of sophomore nursing students was recruited from a university in northern Taiwan between March 2020 and May 2021. Semi-structured interviews were conducted after a preliminary analysis of the collected quantitative data.

RESULTS

In total, 48 participants completed the study questionnaire, and 20 were interviewed. The results show that the students' ability to make clinical judgment and identify individual health problems from case scenarios significantly improved after completing the course. However, critical thinking did not differ significantly after the course. Qualitative data analysis revealed three key themes relevant to the participants' learning experiences: (1) establishing the context of clinical judgment, (2) building a bridge between basic medical science and clinical nursing, and (3) having a broader perspective.

CONCLUSIONS

Incorporating clinical judgment measurement model and case scenarios in the curriculum may benefit second-degree Bachelor of Science in Nursing students who have not yet begun their clinical practice. Additionally, the result provides educators with valuable learning goals and evaluation strategies in the classroom and clinical practice.

Medical students' awareness of overdiagnosis and implications for preventing overdiagnosis

Overdiagnosis is a growing health issue, yet our understanding of medical students' exposure to this concept within medical education is limited. Our aim was to explore students' experience of diagnostic learning to identify how overdiagnosis may be understood by students. During in-person and online semi-structured interviews throughout 2021, we explored the education experience of twelve Western Sydney University medical students in years 3-5. Through inductive thematic analysis we identified four themes. These themes encompassed student commitment to learning about diagnosis, lack of certainty surrounding diagnosis and emotional factors of medical care, overdiagnosis as seen through the lens of high and low-value care during clinical placements and student-identified missed learning opportunities related to overdiagnosis. This study found that medical students develop inherent knowledge of overdiagnosis through an interplay of personal factors, medical school curriculum and the setting in which their training takes place. Our findings allow insight for future improvement of medical curriculum to produce exceptional medical graduates.

Employment of Small-Group Discussions to Ensure the Effective Delivery of Medical Education

The changing landscape of medical education has made small-group discussions crucial components. These sessions, including problem-based learning (PBL), case-based learning (CBL), and team-based learning (TBL), revolutionize learning by fostering active participation, critical thinking, and practical skills application. They bridge theory with practice, preparing future healthcare professionals for the dynamic challenges of modern healthcare. Despite their transformative potential, there are challenges in faculty preparation, resource allocation, and effective evaluation. The best practices include aligning discussions with curriculum goals, skilled facilitation, promoting active participation, and robust assessment strategies. Looking ahead, adapting to emerging health trends, ongoing research, and evolving healthcare demands will ensure the continued relevance and effectiveness of small-group discussions, shaping competent and adaptable healthcare providers equipped for the ever-evolving healthcare landscape.

Clinical Reasoning: Perspectives of Expert Clinicians on Reasoning Through Complex Clinical Cases

Introduction Clinical reasoning is a core skill for physicians; most doctors do not attain the level of expertise associated with that of an expert clinician (EC). The purpose of this study is to identify the clinical reasoning strategies ECs prioritize when reasoning through complex cases. Methods We interviewed 14 ECs and performed a thematic analysis to identify strategies ECs prioritize when reasoning through complex clinical cases. The authors chose ECs based on the recognition of clinical and teaching expertise by trainees and other faculty members (ECs within our institution) and institutional recognition of high achievement in medicine and medical education (ECs outside our institution). We used a semi-structured guide to interview each EC, then reviewed and coded the interview transcriptions. We developed themes based on agreements between all transcript reviewers.  Results We interviewed 11 male and three female ECs, one from outside the study institution. Two (14%) ECs were primary care physicians, and the remaining were sub-specialists. The authors organized strategies for clinical reasoning through complex cases around four themes, which were as follows: (1) connecting clinical reasoning to patient context; (2) embracing uncertainty, then reducing it; (3) returning to the patient's bedside; and (4) remaining humble to limit diagnostic errors. Conclusion Clinical reasoning is a core clinical skill of physicians, and this article describes clinical reasoning strategies prioritized by ECs for complex clinical cases. Recognition and integration of these strategies into medical training and clinical educator practice may facilitate the evolution of clinical reasoning skills and reduce diagnostic errors.

Virtual reality in simulation-based emergency skills training: A systematic review with a narrative synthesis

Objective

An important role is predicted for virtual reality (VR) in the future of medical education. We performed a systematic review of the literature with a narrative synthesis, to examine the current evidence for VR in simulation-based emergency skills training. We broadly define emergency skills as any clinical skill used in the emergency care of patients across all clinical settings.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The data sources accessed during this study included: PubMed, CINAHL, EMBASE, AMED, EMCARE, HMIC, BNI, PsychINFO, Medline, CENTRAL, SCOPUS, Web of Science, BIOSIS Citation Index, ERIC, ACM Digital Library, IEEE Xplore, and ProQuest Dissertations and Thesis Global. Cochrane's Rob 2 and ROBVIS tools were used during study quality assessment. No ethical review was required for this work.

Results

Thirty-four articles published between 14th March 1998 and 1st March 2022 were included in this review. Studies were predominantly conducted in the USA and Europe and focussed on a variety of healthcare disciplines including medical, nursing, and allied health. VR education was delivered using head-mounted displays, Cave Automatic Virtual Environment systems, and bespoke setups. These systems delivered education in a variety of areas (emergency medicine, equipment training, obstetrics, and basic/advanced life support). Subjective potential advantages of this technology included realism, replayability, and time-effectiveness. Reports of adverse events were low in frequency across the included studies. Whilst clear educational benefit was generally noted, this was not reflected in changes to patient-based outcomes.

Conclusion

There may be educational benefit to using VR in the context of simulation-based emergency skills training including knowledge gain and retention, skill performance, acceptability, usability, and validity. Currently, there is insufficient evidence to demonstrate clear cost-effectiveness, or direct improvement of patient or institutional outcomes, at this stage.

Tool to assess recognition and understanding of elements in Summary of Findings Table for health evidence synthesis: a cross-sectional study

of Findings (SoF) tables concisely present the main findings of evidence synthesis of health evidence, but how users navigate it to understand and interpret the presented information is not clear. We quantified the interaction of medical students with an SoF table while answering a knowledge quiz. Read&Learn tool was used to measure the number of target and non-target table cells visited for each question and the time spent on these cells. Students positively identified target elements for quiz questions and answered simpler questions, but struggled with critical thinking and understanding study outcomes. The question on outcomes with the largest improvement post-intervention had the fewest correct answers, the longest interaction with table cells and the most opened cells before answering. Students spent a median of 72% of the time reading target table cells. A heatmap of the interactions showed that they were mostly answer-oriented. Further development of the tool and metrics is needed to use the tool and the metrics to study the cognitive processes during the assessment of health evidence.

A Team-based Learning Approach During Pediatric Clerkship to Promote Clinical Reasoning

BACKGROUND

Clinical reasoning skills are essential to medical practice. The problem lies in assuming junior medical students with limited experience develop clinical reasoning and decision-making skills passively and solely through clinical exposure. To prepare learners for independent practice and care for future patients, explicit teaching and assessment of clinical reasoning in low-stakes, collaborative learning environments are needed.

METHODS

The key-feature question (KFQs) format is an assessment approach that focuses on the reasoning and decision-making aspects of medical problems rather than knowledge recall. This report describes the development, implementation, and evaluation of a team-based learning (TBL) approach using KFQs to foster clinical reasoning in the third-year pediatric clerkship at our institution.

RESULTS

Over the first 2 years of implementation (2017-18, 2018-19), 278 students participated in TBL sessions. Mean individual student scores significantly improved in the group setting for both academic years (P < .001). Individual scores were moderately positively correlated with their total summative Objective Structured Clinical Examination score (r[275] = 0.51; P < .001). The correlation between individual score and their multiple-choice question examination was weaker at 0.29 (P < .001) but remained positive.

CONCLUSIONS

A TBL session using KFQs to both teach and assess clinical reasoning in clerkship students may help educators identify students with gaps in knowledge and/or reasoning. The next steps include developing and implementing individualized coaching opportunities, and expanding this approach within the undergraduate medical curriculum. Outcome measures to assess clinical reasoning in authentic patient encounters require further research and development.

Clinical Instability Is a Sign of Severity of Illness: A Cohort Study

OBJECTIVES

Test the hypothesis that within patient clinical instability measured by deterioration and improvement in mortality risk over 3-, 6-, 9-, and 12-hour time intervals is indicative of increasing severity of illness.

DESIGN

Analysis of electronic health data from January 1, 2018, to February 29, 2020.

SETTING

PICU and cardiac ICU at an academic children's hospital.

PATIENTS

All PICU patients. Data included descriptive information, outcome, and independent variables used in the Criticality Index-Mortality.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 8,399 admissions with 312 deaths (3.7%). Mortality risk determined every three hours using the Criticality Index-Mortality, a machine learning algorithm calibrated to this hospital. Since the sample sizes were sufficiently large to expect statical differences, we also used two measures of effect size, the proportion of time deaths had greater instability than survivors, and the rank-biserial correlation, to assess the magnitude of the effect and complement our hypothesis tests. Within patient changes were compared for survivors and deaths. All comparisons of survivors versus deaths were less than 0.001. For all time intervals, two measures of effect size indicated that the differences between deaths and survivors were not clinically important. However, the within-patient maximum risk increase (clinical deterioration) and maximum risk decrease (clinical improvement) were both substantially greater in deaths than survivors for all time intervals. For deaths, the maximum risk increase ranged from 11.1% to 16.1% and the maximum decrease ranged from -7.3% to -10.0%, while the median maximum increases and decreases for survivors were all less than ± 0.1%. Both measures of effect size indicated moderate to high clinical importance. The within-patient volatility was greater than 4.5-fold greater in deaths than survivors during the first ICU day, plateauing at ICU days 4-5 at 2.5 greater volatility.

CONCLUSIONS

Episodic clinical instability measured with mortality risk is a reliable sign of increasing severity of illness. Mortality risk changes during four time intervals demonstrated deaths have greater maximum and within-patient clinical instability than survivors. This observation confirms the clinical teaching that clinical instability is a sign of severity of illness.

Breathing, Obstruction, Restriction, and Gas Exchange: A Pulmonary Function Testing Interpretation Framework for Novice Learners

Pulmonary function testing (PFT) is a common method of assessing patients with respiratory symptoms, yet exposure to PFT is variable throughout medical training. Therefore, incorporating a dedicated approach to teaching PFT into the formal medical education curriculum can ensure that trainees become familiar with both the relevant physiologic principles involved in interpreting PFT results and the indications for performing PFT in clinical practice. In this "How I Teach" article, we present breathing, obstruction, restriction, and gas exchange (BORG), a novel, small-group workshop designed to teach novice learners a sequential framework for PFT interpretation. The BORG workshop comprises two segments: a whiteboard minilecture that illustrates the BORG framework and a case-based worksheet whereby learners apply this approach to sets of PFTs with increasing difficulty. Our workshop is grounded in two cognitive psychology frameworks: the cognitive theory of multimedia learning and the dual-process theory. We provide three figures and four supplementary videos to illustrate our workshop's design and delivery, as well as both learner and instructor versions of our BORG worksheet. Last, we address three PFT concepts that have challenged us as instructors and provide evidence-based teaching scripts. The BORG workshop can be used by medical educators working with medical students and residents as a means of helping learners progress along the continuum from a basic understanding of spirometry to independent analysis and interpretation of PFTs to application of PFT results to medical decision making.

Pharmacy students' perceptions of clinical reasoning development through a foundational thinking application framework

BACKGROUND AND PURPOSE

Pharmacy students must learn to integrate the foundational and clinical sciences to make therapeutic decisions. There is a need for a developmental framework and scaffolding tools to bridge foundational knowledge with clinical reasoning among novice learners in pharmacy education. Our purpose is to describe the development and student perceptions of a framework designed to integrate foundational knowledge and clinical reasoning in second-year pharmacy students.

EDUCATIONAL ACTIVITY AND SETTING

Using script theory as a conceptual model, a Foundational Thinking Application Framework (FTAF) was designed around a four-credit Pharmacotherapy of Nervous Systems Disorders course at the beginning of the second year of the doctor of pharmacy curriculum. The framework was implemented as two structured learning guides known as a unit plan and a pharmacologically based therapeutic evaluation. A total of 71 students in the course were asked to complete a 15-question online survey assessing perceptions towards specific components of the FTAF.

FINDINGS

Of 39 survey respondents, 37 (95%) described the unit plan as a useful organizer for the course. Thirty-five (80%) students agreed or strongly agreed that the unit plan helped organize instructional material for a given topic. Students (n = 32, 82%) preferred the pharmacologically based therapeutic evaluation format, with text comments highlighting that it provided good practice for clinical experiences and helped to organize critical thinking.

SUMMARY

Our study found that students had positive perceptions of FTAF's implementation within a pharmacotherapy course. Pharmacy education can benefit by adapting script-based strategies that have been successful in other health professions.

Concept mapping: An aid to teaching and learning: AMEE Guide No. 157

Concept maps are graphic representations that learners draw to depict their understanding of the meaning of a set of concepts. Concept maps can be a useful learning strategy in medical education. The purpose of this guide is to provide an understanding of the theoretical basis and instructional use of concept mapping in health professions education. The guide describes the key elements of a concept map and underscores the critical components of the implementation process, from the introduction of the activity to the use of different mapping techniques, based on purpose and context. This guide also examines the learning opportunities offered by collaborative concept mapping, including co-construction of knowledge, and provides suggestions for the use of concept mapping as an assessment for learning. Implications for the use of concept mapping as a tool for remediation are mentioned. Finally, the guide describes some of the challenges related to the implementation of this strategy.

The mediating effect of psychological empowerment on the relationship between work environment and clinical decision-making among midwives: a multicentre cross-sectional study

BACKGROUND

Clinical decision-making is considered an essential behaviour in clinical practice. However, no research has been done to examine the associations among midwives' clinical decision-making, work environment and psychological empowerment. Thus, this study aimed to determine the influence of work environment on midwives' clinical decision-making and confirm the mediating role of psychological empowerment.

METHOD

This study was designed as a multicentre cross-sectional study, and included 602 registered midwives from 25 public hospitals in China. A sociodemographic questionnaire, Work Environment Scale, Psychological Empowerment Scale and Clinical decision-making Scale were applied. A structural equation model was conducted to estimate the hypothesis model of the clinical decision-making among midwives and explore the potential mediating mechanism of midwives' clinical decision-making. This model was employed maximum likelihood estimation method and bootstrapping to examine the statistical significance.

RESULTS

The mean score of clinical decision-making among midwives was 143.03 ± 14.22, at an intermediate level. The data of this hypothesis model fitted well, and the results showed that work environment positively affected psychological empowerment, which in turn positively affected clinical decision-making; psychological empowerment partly mediated the relationship between work environment and clinical decision-making among midwives.

CONCLUSIONS

Midwives' clinical decision-making could be promoted directly or indirectly by providing a healthy work environment and improving psychological empowerment. It is essential for hospital managers to pay attention to the assessment of the midwives' work environment and actively improve it, such as establishing a supportive, fair and just workplace, and maintaining effective communication with midwives. Furthermore, managers can also promote midwives' clinical decision-making behaviour by enhancing their psychological empowerment via enhancing job autonomy.

Investigating preceptor experiences with cultural intelligence in pharmacy education

BACKGROUND

A culturally intelligent pharmacy workforce is critical for addressing health disparities and ensuring that healthcare teams are equipped to support the medication needs of patients. Despite the critical role of preceptors in developing aspiring pharmacists, little is known about how they create or manage cross-cultural situations for students.

OBJECTIVE

The objective of this study was to explore preceptor experiences teaching cultural intelligence within experiential pharmacy settings.

METHODS

A convergent parallel mixed methods approach was used with a 10-item survey measuring preceptor teaching self-efficacy (measured from 0-cannot do at all to 10-highly certain can do) and interviews/focus groups to further understand cultural intelligence teaching experiences. Data were analyzed according to the 4 domains of the cultural intelligence framework (i.e., cultural awareness, cultural knowledge, cultural practice, and cultural desire). Survey data were analyzed descriptively and qualitative data were analyzed deductively.

RESULTS

Participants (n = 24) were most confident Discussing factors underlying health and healthcare disparities (e.g., access, socioeconomic status, environment, racial/ethnic) (7.54 ± 2.04) and least confident in Understanding the importance of cultural desire in teaching students to be culturally intelligent healthcare practitioners (5.21 ± 2.72). All four cultural intelligence domains were identified in the qualitative data (n = 315 codes), with preceptors providing evidence of cultural awareness (n = 38, 12.1%), cultural knowledge (n = 54, 17.1%), cultural practice (n = 183 codes, 58.1%), and cultural desire (n = 40, 12.7%). Preceptors described various pedagogical strategies, such as case discussions, reflection, and simulation.

CONCLUSIONS

Participants provided insight into pedagogical strategies for cultural intelligence that could promote student learning in experiential settings and help explicate curricular gaps. Further research regarding applicability of the cultural intelligence framework is needed, including application of these strategies and opportunities for preceptor development.

Comparison of PRISM and numeric scale for self-assessment of learning progress during a clinical course in undergraduate dental students

OBJECTIVES

To compare Pictorial Representation of Illness and Self-Measure (PRISM) and a numeric scale for self-reflection in dental students.

METHODS

Fourth year dental students were randomly assigned to each receive one interview based on PRISM or a numeric scale to self-assess their competencies at the beginning (t1), the middle (t2) and the end (t3) of integrated clinical course. Questionnaires were used to assess self-perceived benefit of the interviews at each time points.

RESULTS

Students in PRISM group perceived a higher benefit regarding the self-assessment of their practical skills at all time points (P < 0.05), for theoretical knowledge at t2 and t3 (P < 0.05) and reaching the course objectives at t3 (P = 0.04). At all time points, PRISM group rated their interview (P = 0.04), the applied instrument (PRISM, P = 0.01) and the benefit of the combination of both higher than numeric scale group (P < 0.05).

CONCLUSION

In this preliminary study, PRISM was superior against a numeric scale and can be recommended for dental education to facilitate self-assessment.

A concept for adapting medical education to the next generations via three-staged digital peer teaching key feature cases

While the core principles of medical education remain the same, the students' socioecological backgrounds, values and learning requirements are constantly changing. Bridging the generation gap between teachers and students is a key challenge of medical didactics. To meet the demands of today's classroom, we piloted a novel three-stage peer teaching and key feature concept. First, an on-demand key feature video case was presented. Second a background video was launched, followed by a self-assessment tool. Third, a live case discussion webinar focusing on clinical reasoning was held. The contents were created by near-peers experienced in medical didactics and checked by clinical experts. The elective format resonated with 652 participating graduate students and 1250 interactions per webinar, suggesting that students' strengths and weaknesses were addressed adequately. We aim to provide educators with input for creating a flexible and integrative learning environment utilising modern technological and didactic tools that shape the healthcare workers of tomorrow.

Educational priorities and programs for the development of research competencies in science-based medical education

The active development of technology since the middle of the 20th century has changed the requirements for education in view of the demand for knowledge-intensive specialties. The current approach is focused on the intersubjectivity and complexity of problem solving, the project organization of training and the practical orientation of learning courses. The training of specialists capable of solving qualitatively new tasks is possible only in a special environment where personal and professional competencies are formed. The transformation of education in medicine has led to the active integration of research and clinical experience. A significant impetus for the transition to a new level is provided by the development of cognitive competencies, critical thinking, which is closely interrelated with evidence-based medicine. Novel training programs make it possible to receive research, management, entrepreneurial and communication competencies inaddition to classical clinical education. At present, the future belongs to interdisciplinary teams based on developed clusters.

Hemodynamic analysis of the frontal cortex using multi-task fNIRS in major depressive disorder

BACKGROUND

Appropriate task selection is the key to fNIRS-based major depressive disorder (MDD) diagnosis and treatment; however, there exists no unified rule for task selection, which limits its clinical application.

METHODS

Four tasks were employed to investigate the hemodynamic characteristics of MDD during motor, emotional, cognitive, and combinational tasks. A total of 69 subjects were studied: 50 with MDD and 19 healthy controls. The integral value of oxy-hemoglobin and the asymmetric characteristics of the bilateral frontal lobe were used to demonstrate the hemodynamic changes in MDD during different tasks. A detailed analysis and comparison among different tasks were conducted.

RESULTS

Compared with deoxy-hemoglobin (deoxy-Hb), oxy-Hb was more significant to differentiate between MDD subjects and healthy controls. In subjects with MDD, lower activation of the frontal lobe and smaller integral values of oxy-Hb were observed. In most task paradigms, MDD subjects and healthy controls exhibited diametrically opposite left-right frontal asymmetry. For the integral value of oxy-Hb and the asymmetric characteristics of the bilateral frontal lobe, the differences between MDD subjects and healthy controls under the combinational task were more significant than that under the single tasks.

LIMITATIONS

Brain fatigue patterns over time and their effect on the hemodynamic analysis of MDD should be studied further.

CONCLUSIONS

The difference in hemodynamic characteristics between MDD subjects and healthy controls is closely related to the choice of task, and the combinational task showed better discrimination than the single tasks. It provides guidance for the appropriate task design for MDD in clinics.

Medical Students and the Drive for a Single Right Answer: Teaching Complexity and Uncertainty

The arrival of Generation Z, the next generation of medical learners, has been accompanied by efforts to adapt teaching practices for this new group of students. Many have identified challenges associated with addressing the needs of modern medical learners. One particular trend we have observed is that medical students are increasingly requesting an “answer key” for all aspects of their medical education. Students often expect to have the correct answers readily available to them to ensure they have reached the correct conclusion and to determine the precise knowledge they need to master. Yet, for much of medicine, and particularly in the care of critically ill patients with multisystem disease in intensive care units, answers are uncertain, and the body of knowledge is ever-growing. Students’ regular requests for solutions to be provided to them threaten to undermine their development into critically thinking, self-sufficient physicians. We outline three potential contributors to this multifactorial problem and offer corresponding pedagogical solutions. Specifically, we address how prioritizing outcomes over process, discomfort with uncertainty, and fear of faltering can cause students to seek excessive levels of support that may ultimately do more harm than good. Addressing students’ concerns in these three key areas will not only serve students well during their undergraduate medical training but will also equip them with the skills needed to succeed in the clinical realm. To produce physicians capable of navigating an increasingly uncertain world, medical educators will need to help students appreciate that finding the answer is more complex than being provided an answer key.

The Student-Generated Reasoning Tool (SGRT): Linking medical knowledge and clinical reasoning in preclinical education

INTRODUCTION

The simultaneous integration of knowledge acquisition and development of clinical reasoning in preclinical medical education remains a challenge. To help address this challenge, the authors developed and implemented the Student-Generated Reasoning Tool (SGRT)-a tool asking students to propose and justify pathophysiological hypotheses, generate findings, and critically appraise information.

METHODS

In 2019, students in a first-year preclinical course (n = 171; SGRT group) were assigned to one of 20 teams. Students used the SGRT individually, then in teams, and faculty provided feedback. The control group (n = 168) consisted of students from 2018 who did not use SGRT. Outcomes included academic performance, effectiveness of collaborative environments using the SGRT, and student feedback.

RESULTS

Students were five times more likely to get questions correct if they were in the SGRT group versus control group. Accuracy of pathophysiological hypotheses was significantly lower for individuals than teams. Qualitative analysis indicated students benefited from generating their own data, justifying their reasoning, and working individually as well as in teams.

CONCLUSIONS

This study introduces the SGRT as a potentially engaging, case-based, and collaborative learning method that may help preclinical medical students become aware of their knowledge gaps and integrate their knowledge in basic and clinical sciences in the context of clinical reasoning.

Teaching Culturally Safe Care in Simulated Cultural Communication Scenarios During the COVID-19 Pandemic: Virtual Visits with Indigenous Animators

Clinical learning activities involving Indigenous patient actors that specifically address the development of culturally safe care skills among medical students are important in order to improve health care for Indigenous people. In 2020, the COVID-19 pandemic led to strict physical distancing regulations and regional lockdowns that made the in-person delivery of Simulated Cultural Communication Scenarios (SCCS) with Indigenous patient actors impossible due to the disproportionate risk that public health emergencies pose for Indigenous communities. As the pandemic continued in 2021, we co-created a Virtual Visit approach to SCCS for the education of culturally safe care to pre-clerkship medical students. We report on student and tutor evaluation of these virtual sessions and contextualize our findings with our previous results delivering In-Person SCCSs. We found that Virtual Visit SCCS were highly effective in providing authentic exposure to and feedback from Indigenous patients. However, students rated their learning outcomes with Virtual Visit lower than the In-person approach to SCCS. We recommend formal training on interacting with patients in virtual care scenarios prior to Virtual Visit SCCS. We also found that exposure to SCCS with Indigenous animators has the potential to conjure up a diverse spectrum of sometimes unresolved negative feelings related to colonialism among students and tutors including discomfort, embarrassment, and anxiety. Our findings underscore the importance of resolving these sentiments within the safe environment of a classroom. To prepare Indigenous as well as non-Indigenous students and tutors adequately, it is important to acknowledge and critically deconstruct the embodiment of colonialism and Indigenous-settler relations when teaching physicians, as well as future physicians, preparedness for culturally safe care of Indigenous peoples.

"Sick or not sick?" A mixed methods study evaluating the rapid determination of illness severity in a pediatric emergency department

OBJECTIVES

Experienced physicians must rapidly identify ill pediatric patients. We evaluated the ability of an illness rating score (IRS) to predict admission to a pediatric hospital and explored the underlying clinical reasoning of the gestalt assessment of illness.

METHODS

We used mixed-methods to study pediatric emergency medicine physicians at an academic children's hospital emergency department (ED). Physicians rated patients' illness severity with the IRS, anchored by 0 (totally well) and 10 (critically ill), and shared their rationale with concurrent think-aloud responses. The association between IRS and need for hospitalization, respiratory support, parenteral antibiotics, and resuscitative intravenous (IV) fluids were analyzed with mixed effects linear regression. Area under the curve (AUC) receiver operator characteristic (ROC) curve and test characteristics at different cut-points were calculated for IRS as a predictor of admission. Think-aloud responses were qualitatively analyzed via inductive process.

RESULTS

A total of 141 IRS were analyzed (mean 3.56, SD 2.30, range 0-9). Mean IRS were significantly higher for patients requiring admission (4.32 vs. 3.13, p<0.001), respiratory support (6.15 vs. 3.98, p = 0.033), IV fluids (4.53 vs. 3.14, p < 0.001), and parenteral antibiotics (4.68 vs. 3.32, p = 0.009). AUC for IRS as a predictor of admission was 0.635 (95% CI: 0.534-0.737). Analysis of 95 think-aloud responses yielded eight categories that describe the underlying clinical reasoning.

CONCLUSIONS

Rapid assessments as captured by the IRS differentiated pediatric patients who required admission and medical interventions. Think-aloud responses for the rationale for rapid assessments may form the basis for teaching the skill of identifying ill pediatric patients.

Building upon the foundational science curriculum with physiology-based grand rounds: a multi-institutional program evaluation

Introduction: Vertically integrating physiology into patient care has the potential to improve clinical reasoning. Clinical Physiology Grand Rounds (CPGR) is a case-based teaching method that brings together students from all years of medical school to focus on linking clinical presentations to core basic science concepts including anatomy, physiology, and pathophysiology. In this study, we describe the implementation of CPGR at two different institutions in the United States and assess student-reported outcomes.Methods: We survey students who participated in CPGR at Columbia University College of Physicians & Surgeons (P&S) and Medical University of South Carolina (MUSC). Subjects were queried across three domains: the benefits of attending, the impact of concept maps, and the impact of the mixed-learner environment.Results: Despite differences in session leadership and the underlying medical school curricula, conference attendees reported similar benefits at the two schools included in this study. Students overwhelmingly (92.9%) reported that remembering clinical presentations was easier when they understood the underlying physiology. They also reported gaining a true understanding of concepts that were previously memorized (87.5%). Both clinical (92.5%) and preclinical students (93.1%) valued the mixed-learner environment as a component of the conference.Discussion: By assuring a mixed-learner environment with near-peer interactions, using concept maps as a teaching tool, and rigorously linking clinical presentation and management to physiological concepts, we found that the key benefits of CPGR were replicable across different institutions, despite several local differences in how CPGR was implemented, led, and conducted.

Intensive Care Unit Decision-Making in Uncertain and Stressful Conditions Part 2: Cognitive Errors, Debiasing Strategies, and Enhancing Critical Thinking

Diagnostic errors are considered a blind spot of health care delivery and occur in up to 15% of patient cases. Cognitive failures are a leading cause of diagnostic error and often occur as a result of overreliance on system 1 thinking. This narrative review describes why diagnostic errors occur by shedding additional light on systems 1 and 2 forms of thinking, reviews literature on debiasing strategies in medicine, and provides a framework for teaching critical thinking in the intensive care unit as a strategy to promote learner development and minimize cognitive failures.

Effect of educational intervention on clinical reasoning skills in nursing: A quasi-experimental study

This study evaluated the effect of an educational intervention based on virtual clinical simulation and problem-based learning using a mobile application in a clinical nursing education context as a tool to improve clinical reasoning skills of students on the second year of nursing graduation. A prospective quasi-experimental study was conducted in the year 2018, and assessments were performed before and after the educational intervention. A random convenience sample (n = 32) of nursing students in the second year of a public university in Brazil was divided equally into experimental and control groups. The experimental group underwent educational intervention about clinical reasoning skills and measured the quality of the Diagnostician Nurse software by LORI 2.0 instrument. The control group experienced the conventional class on clinical reasoning skills. Four clinical cases were used to assess reasoning skills before and after the educational intervention. The data were analyzed using descriptive and inferential statistics. The experimental group showed a statistically significant difference regarding the prioritization of nursing diagnoses (p = 0.014) and a higher final score. There was a statistically significant difference in performance between the pre- and post-test in the grades of the students who participated in the intervention (p = 0.003). The control group also showed statistical significance in the score attributed to the clinical reasoning process (p = 0.015). In addition, the Diagnostician Nurse software had excellent usability and quality evaluations (SUS 87.81 and LORI 4.66, respectively). It is concluded that educational intervention based on virtual clinical simulation and learning problems using the Diagnostician Nurse software is effective as a tool to improve clinical reasoning skills and can support early detection of patients. The educational intervention developed was of high quality and attractive and improved students' motivation for the teaching-learning process.

Applying digital storytelling in the medical oncology curriculum: Effects on students' achievement and critical thinking

Background

Digital storytelling (DST), which combines traditional storytelling with digital tools, can provide a narrative pedagogy that promotes critical thinking (CT). However, we found no previous study in medical education.

Materials and methods

The aim of the study was to investigate if DST can promote CT and, if so, which CT skills were improved. Thirty-two students participated in a non-equivalent control group pretest-posttest research study, with 16 in each group. The participants were fifth-year medical students on a hematology rotation. We compared the routine instructional method (control group) with DST (intervention group). The measures of CT used for the pre- and post-test in both groups was the Health Science Reasoning Test (HRST) and knowledge test. We also evaluated the satisfaction of the students in DST group. We used Paired and independent t-tests for comparing the mean scores. To eliminate the confounding effect of pre-test on the results of the intervention, the ANCOVA test was used.

Results

There was no significant difference in the overall CT pretest scores (P-value = 0.51) between the control and intervention groupsbut the difference was significant for the post-test scores (P-value = 0.03). Although post-test scores showed a significant increase (P-value = 0.002) compared to pre-test scores in the intervention group, no significant increase was observed in the control group (P-value = 0.26). Most students considered that DST improved their CT, deep learning, communication skills and team-working.

Conclusions

The study demonstrated that DST promoted CT. We recommend the use of DST to promote CT in clinical education placements.

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Critical thinking (CT) is a vital ability for medical students.

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Digital storytelling (DST) is a narrative approach to promote CT.

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DST promote CT as well as analysis skill in clinical setting.

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For medical students who deal with everyday patient's stories, DST is a powerful teaching and learning method in clinical education.

Strategies to Improve Bedside Clinical Skills Teaching

The bedside encounter between a patient and physician remains the cornerstone of the practice of medicine. However, physicians and trainees spend less time in direct contact with patients and families in the modern healthcare system. The current pandemic has further threatened time spent with patients. This lack of time has led to a decline in clinical skills, and a decrease in the number of faculty who are confident in teaching at the bedside. In this review we offer several strategies to get physicians and trainees back to the bedside to engage in clinical skills teaching and assessment. We recommend that providers pause before bedside encounters to be present with patients and learners and develop clear goals for a bedside teaching session. We suggest that clinical teachers practice an evidence-based approach, including a hypothesis-driven physical examination. We encourage the use of point-of-care technology to assist in diagnosis and allow learners to calibrate traditional physical exam skills with real-time visualization of pathology. Tools like point-of-care ultrasound can be powerful levers to get learners excited about bedside teaching, and to engage patients in their clinical care. We value telemedicine visits as unique opportunities to engage with patients in their home environment and to participate in patient-directed physical exam maneuvers. Finally, we recommend that educators provide feedback to learners on specific clinical exam skills, whether in the clinic, the wards, or during dedicated clinical skills assessments.

Clinical Reasoning in Forensic Psychiatry: Concepts, Processes, and Pitfalls

Forensic psychiatrists are often sought by the court of law to provide professional opinion on specific legal matters that have a major impact on the evaluee and possibly society at large. The quality of that opinion and recommendations rely on the quality of the analysis from the assessment results conducted by the psychiatrist. However, the definition and scope of a forensic psychiatric analysis is not clear. While existing literature on forensic psychiatric analysis generally includes organizing information, identifying relevant details, and formulating a set of forensic psychiatric opinions as components, there is no explicit and unified definition of these terms and process. This lack of clarity and guidelines may hinder forensic psychiatry from achieving its goal of providing objective information to the court or other relevant parties. Forensic psychiatric analysis exhibits numerous parallels to clinical reasoning in other fields of medicine. Therefore, this review aims to elaborate forensic psychiatric analysis through the lens of clinical reasoning, which has been developed by incorporating advances in cognitive sciences. We describe forensic psychiatric analysis through three prominent clinical reasoning theories: hypothetico-deductive model, illness script theory, and dual process theory. We expand those theories to elucidate how forensic psychiatrists use clinical reasoning not only to diagnose mental disorders, but also to determine mental capacities as requested by law. Cognitive biases are also described as potential threat to the accuracy of the assessment and analysis. Additionally, situated cognition theory helps elucidate how contextual factors influence risk of errors. Understanding the processes involved in forensic psychiatric analysis and their pitfalls can assist forensic psychiatrists to be aware of and try to mitigate their bias. Debiasing strategies that have been implemented in other fields of medicine to mitigate errors in clinical reasoning can be adapted for forensic psychiatry. This may also shape the training program of general psychiatrists and forensic psychiatrists alike.

fNIRS Evaluation of Frontal and Temporal Cortex Activation by Verbal Fluency Task and High-Level Cognition Task for Detecting Anxiety and Depression

Anxiety and depression are widespread psychosis which are believed to affect cerebral metabolism, especially in frontal and temporal cortex. The comorbidity patients of anxiety and depression (A&D) have more serious clinical symptoms. Functional near-infrared spectroscopy (fNIRS) is a noninvasive modality used to monitor human brain oxygenation, and it could be considered as a potential tool to detect psychosis which may lead to abnormal cerebral oxygen status when the brain is activated. However, how sensitive the cerebral oxygenation response to the cortex activation and whether these responses are consistent at different stages of A&D or different regions still remains unclear. In this study, a conventional physiological paradigm for cortex activation, i.e., verbal fluency task (VFT), and a relatively new paradigm, i.e., high-level cognition task (HCT), were compared to detect A&D through a longitudinal measurement of cerebral oxygen status by fNIRS. The A&D patients at the acute, consolidation and maintenance stages as well as the healthy subjects participated in the VFT and HCT paradigms, respectively. For the VTF paradigm, the subject was instructed to answer questions of phrase constructions within 60 s. For the HCT paradigm, the subject was instructed to categorize items, logical reasoning, and comprehensive judgment and write down the answers within 60 s. For most of the subjects, the oxy-Hb is found to increase remarkably, accompanied with a relatively small reduction in deoxy-Hb when subject to both paradigms. The statistical analyses show a relatively large variability within any group, leading to the significant difference that was only found between A&D at the acute stage and healthy subjects in the temporal lobe region (p < 0.001). Nevertheless, HCT would activate more oxygen increment when compared with the VFT, with a large integral value in oxy-Hb. On average, the oxy-Hb integral value of the A&D patients differs substantially at different stages when subject to HCT paradigm. Moreover, the prefrontal lobe and temporal lobe responses were more consistent to the HCT paradigm rather than the VFT paradigm. Under the VFT paradigm, however, no remarkable difference in integral value was found among the three stages, either at the prefrontal lobe or at the temporal lobe. This study indicated that HCT, which is intensively involved in brain function, would activate more oxygenation changes in the cerebral cortex. Additionally, with good performance at distinguishing different stages according to the oxy-Hb criterion, the HCT has the potential to evaluate the therapeutic effects for A&D patients.