Self-regulated learning profiles including test anxiety linked to stress and performance: A latent profile analysis based across multiple cohorts

INTRODUCTION

Medical educators aim to understand why students differ in performance and stress. While performance and stress are associated with student demographics, school factors and aspects of self-regulated learning (SRL), it remains unclear how these elements interact within individuals. This multi-cohort study identified SRL profiles among medical students and explored their associations with performance and stress. Additionally, we examined the identified profiles' associations with gender, migration status and assessment policy.

METHODS

We used latent profile analysis (LPA) to identify profiles on Motivated Strategies for Learning Questionnaire (MSLQ) scores of six cohorts (2014-2019) of Year 1, first semester medical students (n = 1894) in a Dutch medical school. We used nine MSLQ subscales that measure test anxiety (TA), self-efficacy, deep learning, resource management and value. The university's assessment policy varied, demanding students to obtain 100% or 75% of Year 1 credits to remain enrolled. We defined optimal performance as obtaining all credits at the end of Year 1. Two cohorts completed the Perceived Stress Scale (PSS-14, n = 409) in the 2nd semester.

RESULTS

We identified three distinct student profiles: 693/1894(36.6%) were classified as TAhighSRLhigh, 661/1894(34.9%) as TAlowSRLhigh and 540/1894(28.5%) as TAmoderateSRLlow. Females were more likely to belong to TAhighSRLhigh profiles compared to males (effect size [ES] Cramer's V = .13, small). Migration background was not associated with these profiles. The TAhighSRLhigh profile was more prevalent under the 100% assessment policy (ES Cramer's V = .10, negligible). TAlowSRLhigh students demonstrated lower stress levels (PSS = 23.9 out of 56) compared to TAhighSRLhigh students (PSS = 28.7, ES Cohen's d = .62, medium) and TAmoderateSRLlow students (PSS = 28.2, ES Cohen's d = .51, medium). Performance differed among the three profiles (ES Cramer's V = .16, small): 82.5% optimal performance in the TAlowSRLhigh, 71.9% in the TAhighSRLhigh and 65.2% in the TAmoderateSRLlow profile.

DISCUSSION

Three distinct SRL student profiles associated with gender, academic performance and perceived stress were identified. Test anxiety had additional value in distinguishing subgroups with differential academic performance and stress. These profiles may aid educators to inform personalised support strategies for novice learners.

The association between how medical students were selected and their perceived stress levels in Year-1 of medical school

BACKGROUND

The prevalence of medical students' mental distress is high. While schools apply various methods to select a well-performing and diverse student population, little is known about the association between different selection methods and the well-being of these students during medical school. The present retrospective multi-cohort study assessed whether students selected by high grades, assessment, or weighted lottery showed different stress perception levels in Year-1 of medical school.

METHODS

Of 1144 Dutch Year-1 medical students, 650 (57%) of the cohorts 2013, 2014, and 2018 who were selected by high grades, assessment, or weighted lottery completed a stress perception questionnaire (PSS-14). A multilevel regression analysis assessed the association between selection method (independent variable) and stress perception levels (dependent variable) while controlling for gender and cohort. In a post-hoc analysis, academic performance (optimal vs. non-optimal) was included in the multilevel model.

RESULTS

Students selected by assessment (B = 2.25, p < .01, effect size (ES) = small) or weighted lottery (B = 3.95, p < .01, ES = medium) had higher stress perception levels than students selected by high grades. Extending the regression model with optimal academic performance (B=-4.38, p < .001, ES = medium), eliminated the statistically significant difference in stress perception between assessment and high grades and reduced the difference between weighted lottery and high grades from 3.95 to 2.45 (B = 2.45, p < .05, ES = small).

CONCLUSIONS

Selection methods intended to create a diverse student population - assessment and lottery - are associated with higher stress perception levels in Year-1 of medical school. These findings offer medical schools insights into fulfilling their responsibility to take care of their students' well-being.

Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis

Background

Preventable diagnostic errors are a large burden on healthcare. Cognitive reasoning tools, that is, tools that aim to improve clinical reasoning, are commonly suggested interventions. However, quantitative estimates of tool effectiveness have been aggregated over both workplace-oriented and educational-oriented tools, leaving the impact of workplace-oriented cognitive reasoning tools alone unclear. This systematic review and meta-analysis aims to estimate the effect of cognitive reasoning tools on improving diagnostic performance among medical professionals and students, and to identify factors associated with larger improvements.

Methods

Controlled experimental studies that assessed whether cognitive reasoning tools improved the diagnostic accuracy of individual medical students or professionals in a workplace setting were included. Embase.com, Medline ALL via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar were searched from inception to 15 October 2021, supplemented with handsearching. Meta-analysis was performed using a random-effects model.

Results

The literature search resulted in 4546 articles of which 29 studies with data from 2732 participants were included for meta-analysis. The pooled estimate showed considerable heterogeneity (I2=70%). This was reduced to I2=38% by removing three studies that offered training with the tool before the intervention effect was measured. After removing these studies, the pooled estimate indicated that cognitive reasoning tools led to a small improvement in diagnostic accuracy (Hedges’ g=0.20, 95% CI 0.10 to 0.29, p<0.001). There were no significant subgroup differences.

Conclusion

Cognitive reasoning tools resulted in small but clinically important improvements in diagnostic accuracy in medical students and professionals, although no factors could be distinguished that resulted in larger improvements. Cognitive reasoning tools could be routinely implemented to improve diagnosis in practice, but going forward, more large-scale studies and evaluations of these tools in practice are needed to determine how these tools can be effectively implemented.

PROSPERO registration number

CRD42020186994.

Why patients' disruptive behaviours impair diagnostic reasoning: a randomised experiment

BACKGROUND

Patients who display disruptive behaviours in the clinical encounter (the so-called 'difficult patients') may negatively affect doctors' diagnostic reasoning, thereby causing diagnostic errors. The present study aimed at investigating the mechanisms underlying the negative influence of difficult patients' behaviours on doctors' diagnostic performance.

METHODS

A randomised experiment with 74 internal medicine residents. Doctors diagnosed eight written clinical vignettes that were exactly the same except for the patients' behaviours (either difficult or neutral). Each participant diagnosed half of the vignettes in a difficult patient version and the other half in a neutral version in a counterbalanced design. After diagnosing each vignette, participants were asked to recall the patient's clinical findings and behaviours. Main measurements were: diagnostic accuracy scores; time spent on diagnosis, and amount of information recalled from patients' clinical findings and behaviours.

RESULTS

Mean diagnostic accuracy scores (range 0-1) were significantly lower for difficult than neutral patients' vignettes (0.41 vs 0.51; p<0.01). Time spent on diagnosing was similar. Participants recalled fewer clinical findings (mean=29.82% vs mean=32.52%; p<0.001) and more behaviours (mean=25.51% vs mean=17.89%; p<0.001) from difficult than from neutral patients.

CONCLUSIONS

Difficult patients' behaviours induce doctors to make diagnostic errors, apparently because doctors spend part of their mental resources on dealing with the difficult patients' behaviours, impeding adequate processing of clinical findings. Efforts should be made to increase doctors' awareness of the potential negative influence of difficult patients' behaviours on diagnostic decisions and their ability to counteract such influence.