Search

Rapidly assessing how ill a patient is based on their immediate presentation-colloquially termed 'eyeballing' in practice-serves a vital role in acute care settings. Yet surprisingly little is known about how this diagnostic skill is learned or how it should be taught. Some authors have pointed to a dual-process model, suggesting that assessments of illness severity are driven by two distinct types of processing: an intuitive, fast, pattern recognition-like process (Type 1) that depends on many prior patient encounters and outcomes being stored in memory; and a deliberate, slow, analytic process (Type 2) characterized by additional data gathering, data scrutiny, or recollection of rules. But prior studies have supported a dual-process model for the assessment of illness severity only insofar as experienced clinicians chiefly displayed what was presumed to be Type 1 processing. Here we further explored a dual-process model by examining whether less experienced clinicians displayed both types of processing when assessing illness severity across a series of cases. Consistent with the model, a dissociation between Type 1 and Type 2 processing was observed through resident reports of deliberation, response times, and three eye tracking metrics associated with diagnostic expertise. We conclude by discussing potential implications for the training of this enigmatic diagnostic skill., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V. part of Springer Nature.)

The paper reviews 50 years of research in health sciences education and identifies several recurring controversies-formative versus summative assessment, high and low fidelity simulation, expertise as knowledge versus skills, and the impact of teaching versus curriculum. I then look at the role these may play in the current situation where COVID has necessitated rapid change to distance learning. I then posit an essential role for research in teaching and learning, using multiple methods from qualitative to neuropsychological to better understand the dimensions of effective teaching. The ultimate goal is to operationalize these findings in creation of distance learning modules.

While multiple theories exist to explain the diagnostic process, there are few available assessments that reliably determine diagnostic competence in trainees. Most methods focus on aspects of the process of diagnostic reasoning, such as the relation between case features and diagnostic hypotheses. Inevitably, detailed elucidation of aspects of the process requires substantial time per case and limits the number of cases that can be examined given a limited testing time. Shifting assessment to the outcome of diagnostic reasoning, accuracy of the diagnosis, may serve as a reliable measure of diagnostic competence and would allow increased sampling across cases. The present study is a retrospective analysis of 7 large studies, conducted by 3 research teams, that all used a series of brief written cases to examine the outcome of diagnostic reasoning-the diagnosis. The studies involved over 600 clinicians ranging from final year medical students to practicing emergency physicians. For 4 studies with usable reliability data, reliability for a 2 h test ranged from .63 to .94. On average speeded tests were more reliable (.85 vs. .73).To achieve a reliability of .75 required an average test time of 1.11 h for speeded tests and 1.99 for unspeeded tests. The measure was shown to be positively correlated with both written knowledge tests and measures of problem solving derived from OSCE performance tests. This retrospective analysis provides evidence to support the implementation of outcome-based assessments of clinical reasoning.

Although educators frequently act as if curricula are as standardized as drug doses (300 mg of PBL t.i.d.), such is not the case. As a case in point, at its inception, Problem Based Learning was hailed as a major curriculum innovation, with the promise of enormous gains in learning outcomes. Very quickly, ecclesiastical debates arose as what was true PBL and what was "modified PBL". Ironically, systematic reviews conducted fairly early in its evolution showed that the gains in learning outcome from PBL were neither large nor uniform (Vernon and Blake in Acad Med 68:550-563, 1993), and the most consistent finding was greater student satisfaction. In this paper, we review five decades of experience with the first PBL curriculum at McMaster. We point out how the curriculum has evolved, both theoretically and practically, in response to external influences, based both on empirical evidence and practical demands. We describe these changes in four broad domains-theoretical rationale, the curriculum, assessment and admissions.

There is an ongoing debate regarding the cause of diagnostic errors. One view is that errors result from unconscious application of cognitive heuristics; the alternative is that errors are a consequence of knowledge deficits. The objective of this study was to compare the effectiveness of checklists that (a) identify and address cognitive biases or (b) promote knowledge retrieval, as a means to reduce errors in ECG interpretation. Novice postgraduate year (PGY) 1 emergency medicine and internal medicine residents (n = 40) and experienced cardiology fellows (PGY 4-6) (n = 21) were randomly allocated to three conditions: a debiasing checklist, a content (knowledge) checklist, or control (no checklist) to be used while interpreting 20 ECGs. Half of the ECGs were deliberately engineered to predispose to bias. Diagnostic performance under either checklist intervention was not significantly better than the control. As expected, more errors occurred when cases were designed to induce bias (F = 96.9, p < 0.0001). There was no significant interaction between the instructional condition and level of learner. Checklists attempting to help learners identify cognitive bias or mobilize domain-specific knowledge did not have an overall effect in reducing diagnostic errors in ECG interpretation, although they may help novices. Even when cognitive biases are deliberately inserted in cases, cognitive debiasing checklists did not improve participants' performance.

Health profession educators have identified auscultation skill as a learning need for health professional students. This article explores the application of cognitive load theory (CLT) to designing cardiac and respiratory auscultation skill instruction for senior-level undergraduate nursing students. Three experiments assessed student auscultation performance following instructional manipulations of the three primary components of cognitive load: intrinsic, extraneous, and germane load. Study 1 evaluated the impact of intrinsic cognitive load by varying the number of diagnoses learned in one instruction session; Study 2 evaluated the impact of extraneous cognitive load by providing students with single or multiple examples of diagnoses during instruction; and Study 3 evaluated the impact of germane cognitive load by employing mixed or blocked sequences of diagnostic examples to students. Each of the three studies presents results that support CLT as explaining the influence of different types of cognitive processing on auscultation skill acquisition. We conclude with a discussion regarding CLT's usefulness as a framework for education and education research in the health professions.

Applying a previously learned concept to a novel problem is an important but difficult process called transfer. Practicing multiple concepts together (mixed practice mode) has been shown superior to practicing concepts separately (blocked practice mode) for transfer. This study examined the effect of single and multiple practice contexts for both mixed and blocked practice modalities on transfer performance. We looked at performance on near transfer (familiar contexts) cases and far transfer (unfamiliar contexts) cases. First year psychology students (n = 42) learned three physiological concepts in a 2 × 2 factorial study (one or two practice contexts and blocked or mixed practice). Each concept was practiced with two clinical cases; practice context was defined as the number of organ systems used (one system per concept vs. two systems). In blocked practice, two practice cases followed each concept; in mixed practice, students learned all concepts before seeing six practice cases. Transfer testing consisted of correctly classifying and explaining 15 clinical cases involving near and far transfer. The outcome was ratings of quality of explanations on a 0-3 scale. The repeated measures analysis showed a significant near versus far by organ system interaction [F(1,38) = 3.4, p < 0.002] with practice with a single context showing lower far transfer scores than near transfer [0.58 (0.37)-0.83 (0.37)] compared to the two contexts which had similar far and near transfer scores [1.19 (0.50)-1.01 (0.38)]. Practicing with two organ contexts had a significant benefit for far transfer regardless of mixed or blocked practice; the single context mixed practice group had the lowest far transfer performance; this was a large effect size (Cohen's d = 0.81). Using only one practice context during practice significantly lowers performance even with the usually superior mixed practice mode. Novices should be exposed to multiple contexts and mixed practice to facilitate transfer.

Applying a previously learned concept to a novel problem is an important but difficult process called transfer. It is suggested that a commonsense analogy aids in transfer by linking novel concepts to familiar ones. How the context of practice affects transfer when learning using analogies is still unclear. This study investigated the effect of a commonsense analogy and context familiarity for transfer of physiological concepts. First year psychology students (n = 24) learned three concepts: Starling's law, Laplace's law, and laminar-turbulent flow. The control group saw standard explanations while the intervention group saw an additional commonsense analogy. The context of learning was the organ system used for two practice clinical cases which differed for all concepts. Testing consisted of 12 new clinical cases. Starling's law cases used the organ system from practice while the other concepts presented in both novel and familiar organ systems. Half of the sample repeated testing after 1 week delay. The outcome was ratings of explanations of cases on a 0-3 scale. The effect of analogy was significant (Mean = 1.24 with, 0.86 without, F(1,22) = 4.26, p < 0.05) but not after delay (means of 1.08 and 0.75 respectively, F = (1,10), p = 0.06) There was significant effect for familiar context (Same = 1.23 (Starling), different = 0.68 (Laplace) and 0.73 (laminar-turbulent flow) (F(2,44) = 5.14, p < 0.01). Laplace's law and laminar turbulent flow cases in the familiar organ system had means of 1.65 and 1.77 respectively compared to novel cases with means of 0.74 and 0.68 (F(1,22) = 35.64, p < 0.0001). Similar effects were observed after delay. There was significant decay in performance after delay for all participants (immediate = 1.17, delayed = 0.91, F = 11.9 (1,10) p < 0.01). Common analogies aid conceptual understanding necessary for transfer. Despite conceptual aids, solving transfer problems is difficult.