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In the context of a large first-year business course, we explore the value of student contributors, the former students from this course, working with faculty to improve the learning experience of the students enrolled in the course. By describing our study of the roles, impacts, benefits, and challenges of the student contributors' involvement in creating supplemental resources, such as videos and practice problems, intended to augment the teaching process of the faculty and the learning process of the student learners, we contribute to the understanding of this three-party experience. Our study included interviews, survey questions, and resource-engagement analytics. We found that because student contributors can provide unique perspectives, greater inclusivity, and diverse approaches to teaching, there are benefits to the instructors, the student contributors, and the student learners. [ABSTRACT FROM AUTHOR]

Aims: To describe potential sources of bias during an academic assessment reappraisal and ways to mitigate these. Methods: We describe why the typical scenario of an academic assessment reappraisal – where committee members are asked to weigh contrasting accounts of past events that they did not witness, and to rate elusive constructs, such as "fairness" – is prone to multiple types of bias, including attribute substitution, default bias, confirmation bias, and impact bias. We also discuss how increased awareness of sources of bias and of debiasing strategies can improve the validity of decision making. Results: Strategies that can reduce bias in reappraisal include clearly articulating and focusing on the reappraisal question (did bias cause a wrong decision to be made?), educating those involved in the reappraisal of the types of bias that frequently occur in teaching and assessment (including biases that they themselves may introduce to the reappraisal), and ensuring that those involved in the reappraisal contribute equally to making decisions and recommendation. Conclusions: All academic assessments of students, particularly those that involve subjective ratings of performance, are prone to bias, which threatens the integrity of the assessment process. Given the high stakes of academic assessments, we feel that each medical school should have a process for assessment reappraisal that reduces, rather than compounds, the likelihood of wrong assessment decisions. [ABSTRACT FROM AUTHOR]

Prior studies have shown a correlation between the grades students receive and how they rate their teacher in the classroom. In this study, the authors probe this association on clinical rotations and explore potential mechanisms. All In-Training Evaluation Reports (ITERs) for students on mandatory clerkship rotations from April 1, 2013 to January 31, 2015 were matched with the corresponding student's rating of their teacher (SRT). The date and time that ITERs and SRTs were submitted was used to divide SRTs into those submitted before versus after the corresponding ITER was submitted. Multilevel, mixed effects linear regression was used to examine the association between SRT, ITER rating, and whether the ITER was submitted before or after SRT. Of 2373 paired evaluations, 1098 (46.3%) SRT were submitted before the teacher had submitted the ITER. There was a significant interaction between explanatory variables: when ITER ratings had not yet been submitted, the regression coefficient for this association was 0.25 (95% confidence interval [0.17, 0.33], p < 0.001), whereas the regression coefficient was significantly higher when ITER ratings were submitted prior to SRT (0.40 [0.31, 0.49], p < 0.001). Finding an association between SRT and ITER when students do not know their ITER ratings suggests that SRTs can capture attributes of effective teaching, but the effect modification when students have access to their ITER rating supports grade satisfaction bias. Further studies are needed to explain the mechanism of grade satisfaction and to identify other biases that may impact the validity of SRT. [ABSTRACT FROM AUTHOR]

Aim: To be an effective teacher, content expertise is necessary but alone does not guarantee optimal learning outcomes for students. In this article, the authors discuss ways in which medical teachers can shape the learning of their students and enable them to become more efficient and effective learners. Methods: Using Bjork and Bjork's new theory of disuse as their framework, the authors discuss strategies to improve storage strength of to-be-learned information and strategies to improve retrieval strength of learned information. Results: Strategies to improve storage strength include optimizing cognitive load, providing causal explanations, and giving effective feedback. Strategies to improve retrieval strength include situated cognition and various types of retrieval practice. Conclusions: Adopting these teaching strategies should hopefully help teachers improve the learning outcomes of their students, but there is still a need for further research into the science of learning and the science of instruction, including comparative effectiveness of different teaching strategies and how best to translate findings from the psychology literature into medical education. [ABSTRACT FROM AUTHOR]

The flipped classroom model is increasingly being adopted in healthcare education, despite the fact that recent systematic reviews in the nursing and medical education literature suggest that this method of instructional design is not inherently better or worse than the traditional classroom. In this study, we used a sequential, explanatory mixed methods design to assess the impact of flipping the hepatology classroom for preclinical medical students. Compared to students in the traditional classroom, students in the flipped classroom had significantly lower mean (SD) ratings of their learning experiences (3.48 (1.10) vs. 4.50 (0.72), p < 0.001, d = 1.10), but better performance on the hepatology content of the end-of-course examination (78.0% (11.7%) vs. 74.2 (15.1%), respectively, p < 0.01, d = 0.3). Based upon our qualitative data analyses, we propose that the flipped classroom induced a change in the learning process of students by requiring increased preparation for classroom learning and promoting greater learner autonomy, which resulted in better retention of learned material, but reduced enjoyment of the learning experience. This dissonance in outcomes is captured in the words of one flipped classroom student: “ . . . I hated it while I was learning it, but boy did I remember it . . . ". Based upon our dissonant outcomes and the inconsistent findings in the literature, we feel that there is still equipoise regarding the effectiveness of the flipped classroom, and further studies are needed to describe ways of making the flipped classroom a more effective (±more enjoyable) learning experience. [ABSTRACT FROM AUTHOR]

Despite the fact that the length of medical school training has remained stable for many years, the expectations of graduating medical students (and the schools that train them) continue to increase. In this Reflection, the authors discuss motives for educational inflation and suggest that these are likely innocent, well-intentioned, and subconscious-and include both a propensity to increase expectations of ourselves and others over time, and a reluctance to reduce training content and expectations. They then discuss potential risks of educational inflation, including reduced emphasis on core knowledge and clinical skills, and adverse effects on the emotional, psychological, and financial wellbeing of students. While acknowledging the need to change curricula to improve learning and clinical outcomes, the authors proffer that it is naïve to assume that we can inflate educational expectations at no additional cost. They suggest that before implementing and/or mandating change, we should consider of all the costs that medical schools and students might incur, including opportunity costs and the impact on the emotional and financial wellbeing of students. They propose a cost-effectiveness framework for medical education and advocate prioritization of interventions that improve learning outcomes with no additional costs or are cost-saving without adversely impacting learning outcomes. When there is an additional cost for improved learning outcomes or a decline in learning outcomes as a result of cost saving interventions, they suggest careful consideration and justification of this trade-off. And when there are neither improved learning outcomes nor cost savings they recommend resisting the urge to change. [ABSTRACT FROM AUTHOR]

Ultrasonography is increasingly used in medical education, but its impact on learning outcomes is unclear. Adding ultrasound may facilitate learning, but may also potentially overwhelm novice learners. Based upon the framework of cognitive load theory, this study seeks to evaluate the relationship between cognitive load associated with using ultrasound and learning outcomes. The use of ultrasound was hypothesized to facilitate learning in anatomy for 161 novice first-year medical students. Using linear regression analyses, the relationship between reported cognitive load on using ultrasound and learning outcomes as measured by anatomy laboratory examination scores four weeks after ultrasound-guided anatomy training was evaluated in consenting students. Second anatomy examination scores of students who were taught anatomy with ultrasound were compared with historical controls (those not taught with ultrasound). Ultrasound's perceived utility for learning was measured on a five-point scale. Cognitive load on using ultrasound was measured on a nine-point scale. Primary outcome was the laboratory examination score (60 questions). Learners found ultrasound useful for learning. Weighted factor score on 'image interpretation' was negatively, but insignificantly, associated with examination scores [ F (1,135) = 0.28, beta = −0.22; P = 0.61]. Weighted factor score on 'basic knobology' was positively and insignificantly associated with scores; [ F (1,138) = 0.27, beta = 0.42; P = 0.60]. Cohorts exposed to ultrasound had significantly higher scores than historical controls (82.4% ± SD 8.6% vs. 78.8% ± 8.5%, Cohen's d = 0.41, P < 0.001). Using ultrasound to teach anatomy does not negatively impact learning and may improve learning outcomes. Anat Sci Educ 10: 144-151. © 2016 American Association of Anatomists. [ABSTRACT FROM AUTHOR]

Clinical decision making requires knowledge, experience and analytical/non-analytical types of decision processes. As clinicians progress from novice to expert, research indicates decision-making becomes less reliant on foundational biomedical knowledge and more on previous experience. In this study, we investigated how knowledge and experience were reflected in terms of differences in neural areas of activation. Novice and expert clinicians diagnosed simple or complex (easy, hard) cases while functional magnetic resonance imaging (fMRI) data were collected. Our results highlight key differences in the neural areas activated in novices and experts during the clinical decision-making process. fMRI data were collected from ten second year medical students (novices) and ten practicing gastroenterologists (experts) while they diagnosed sixteen (eight easy and eight hard) clinical cases via multiple-choice questions. Behavioral data were collected for diagnostic accuracy (correct/incorrect diagnosis) and time taken to assign a clinical diagnosis. Two analyses were performed with the fMRI data. First, data from easy and hard cases were compared within respective groups (easy > hard, hard > easy). Second, neural differences between novices and experts (novice > expert, expert > novice) were assessed. Experts correctly diagnosed more cases than novices and made their diagnoses faster than novices on both easy and hard cases (all p's < 0.05). Time taken to diagnose hard cases took significantly longer for both novices and experts. While similar neural areas were activated in both novices and experts during the decision making process, we identified significant hemispheric activation differences between novice and expert clinicians when diagnosing hard clinical cases. Specifically, novice clinicians had greater activations in the left anterior temporal cortex and left ventral lateral prefrontal cortex whereas expert clinicians had greater activations in the right dorsal lateral, right ventral lateral, and right parietal cortex. Hemispheric differences in activation were not observed between novices and experts while diagnosing easy clinical cases. While clinical decision-making engaged the prefrontal cortex (PFC) in both novices and experts, interestingly we observed expertise related differences in the regions and hemispheres of PFC activation between these groups for hard clinical cases. Specifically, in novices we observed activations in left hemisphere neural regions associated with factual rule-based knowledge, whereas in experts we observed right hemisphere activation in neural regions associated with experiential knowledge. Importantly, at the neural level, our data highlight differences in so called type 2 clinical decision-making processes related to prior knowledge and experience. [ABSTRACT FROM AUTHOR]

Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical reasoning and WM while participants read clinical cases with functional magnetic resonance imaging (fMRI). More specifically, we examined the impact of clinical case difficulty (easy, hard) and clinician level of expertise (2nd year medical students, senior gastroenterologists) on neural activity within regions of cortex associated with WM (i.e., the prefrontal cortex) during the reasoning process. fMRI was used to scan ten second-year medical students and ten practicing gastroenterologists while they reasoned through sixteen clinical cases [eight straight forward (easy) and eight complex (hard)] during a single 1-h scanning session. Within-group analyses contrasted the easy and hard cases which were then subsequently utilized for a between-group analysis to examine effects of expertise (novice > expert, expert > novice). Reading clinical cases evoked multiple neural activations in occipital, prefrontal, parietal, and temporal cortical regions in both groups. Importantly, increased activation in the prefrontal cortex in novices for both easy and hard clinical cases suggests novices utilize WM more so than experts during clinical reasoning. We found that clinician level of expertise elicited differential activation of regions of the human prefrontal cortex associated with WM during clinical reasoning. This suggests there is an important relationship between clinical reasoning and human WM. As such, we suggest future models of clinical reasoning take into account that the use of WM is not consistent throughout all clinical reasoning tasks, and that memory structure may be utilized differently based on level of expertise. [ABSTRACT FROM AUTHOR]

Most training programs use learners' subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study we found that preclinical medical students' ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. Here we explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. We asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher's clinical skills, physical attractiveness, and charisma. We used linear regression to study the association between these explanatory variables and teaching effectiveness ratings. We found no association between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95 % confidence interval] 0.73 [0.60, 0.85], p < 0.001 and 0.12 [0.01, 0.23], p = 0.03, respectively). The variables associated with effectiveness of classroom and clinical teachers differ, suggesting context specificity in teaching effectiveness ratings. Context specificity may be explained by differences in the exposure that learners have to teachers in the classroom versus clinical setting-so that raters in the clinical setting may base ratings upon observed behaviours rather than stereotype data. Alternatively, since subjective ratings of teaching effectiveness inevitably incorporate learners' context-specific needs, the attributes that make a teacher effective in one context may not meet the needs of learners in a different context. [ABSTRACT FROM AUTHOR]

There is an inherent conflict within clinician educators as we balance the roles of healthcare provider to patients in need of care with that of educator of learners in need of teaching. In this essay we use Beauchamp and Childress' principles of biomedical ethics as a framework to compare the relationship that clinician educators have with their patients and their learners, and suggest that while we typically apply ethical principles when addressing the needs of our patients, these principles are frequently lacking in our interactions with learners. This dichotomy reflects a person-by-situation interaction that may be partly explained by the expectations of the regulatory bodies that define how clinicians should interact with patients and how educators should interact with learners. The result is that we may fall short in applying respect for autonomy, beneficence/nonmaleficence, and justice when addressing the needs of our learners. Fortunately there are ways in which we can incorporate these ethical principles into our interactions with learners while still adhering to accreditation standards and institutional policy. These include flipped classrooms and simulated learning experiences, incorporating aspects of instructional design that have been shown to improve learning outcomes, providing additional resources to learners with greater needs, and organizing training curricula around entrustable professional activities. Although the consistent application of ethical principles with all learners during all learning experiences is likely unachievable, we can, and should, move towards more ethical treatment of our learners. [ABSTRACT FROM AUTHOR]

Context The incidence of medical error, adverse clinical events and poor quality health care is unacceptably high and there are data to suggest that poor coordination of care, or teamwork, contributes to adverse outcomes. So, can we assume that increased collaboration in multidisciplinary teams improves performance and health care outcomes for patients? Methods In this essay, the authors discuss some reasons why we should not presume that collective decision making leads to better decisions and collaborative care results in better health care outcomes. Results Despite an exponential increase in interventions designed to improve teamwork and interprofessional education ( IPE), we are still lacking good quality data on whether these interventions improve important outcomes. There are reasons why some of the components of 'effective teamwork', such as shared mental models, team orientation and mutual trust, could impair delivery of health care. For example, prior studies have found that brainstorming results in fewer ideas rather than more, and hinders rather than helps productivity. There are several possible explanations for this effect, including 'social loafing' and cognitive overload. Similarly, attributes that improve cohesion within groups, such as team orientation and mutual trust, may increase the risk of 'groupthink' and group conformity bias, which may lead to poorer decisions. Conclusions In reality, teamwork and IPE are not inherently good, bad or neutral; instead, as with any intervention, their effect is modified by the persons involved, the situation and the interaction between persons and situation. Thus, rather than assume better outcomes with teamwork and IPE interventions, as clinicians and educators we must demonstrate that our interventions improve the delivery of health care. [ABSTRACT FROM AUTHOR]

The article presents the authors' reflections regarding the role of mental information retrieval, memory, and testing on positive long-term learning and its particular implications on medical education. Topics addressed include the definition of learning as that which is apprehended in a long-term context, how testing retrieval is involved with the process and reinforces learning, and how evaluation of medical students' knowledge and abilities complicates this dynamic.

Although the clinical clerkship model is based upon sound pedagogy, including theories of social learning and situated learning, studies evaluating clinical performance of residents suggests that this model may not fully meet the learning needs of students. Here our objective was to design a curriculum to bridge the learning gaps of the existing clerkship model and then evaluate the impact of this on performance on clerkship summative evaluations. We followed Kern's framework to design our curriculum and then compared performance on the clerkship objective structured clinical examination (OSCE), all summative clerkship multiple choice question (MCQ) examinations, and the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 before and after the introduction of our curriculum. In the 2 years following the introduction of our clinical skills curriculum the mean score on the clerkship OSCE was significantly higher than in the 2 years prior to our curriculum [67.12 (5.3) vs. 62.44 (4.93), p < 0.001, d = 0.91]. With the exception of the surgical clerkship MCQ, performance on all clerkship summative MCQ examinations and MCCQE Part 1 was significantly higher following the introduction of our curriculum. In this study we found a significant improvement in the performance on clerks on summative evaluations of knowledge and clinical skills following the introduction of our clinical skills curriculum. Given the unpredictable nature of clinical rotations, the clerkship will always be a risk of failing to deliver the intended curriculum-so medical schools should continue to explore and evaluate ways of changing the delivery of clerkship training to improve learning outcomes. [ABSTRACT FROM AUTHOR]

Context Teaching effectiveness ratings ( TERs) are used to provide feedback to teachers on their performance and to guide decisions on academic promotion. However, exactly how raters make decisions on teaching effectiveness is unclear. Objectives The objectives of this study were to identify variables that medical students appraise when rating the effectiveness of a classroom teacher, and to explore whether the relationships among these variables and TERs are modified by the physical attractiveness of the teacher. Methods We asked 48 Year 1 medical students to listen to 2-minute audio clips of 10 teachers and to describe their impressions of these teachers and rate their teaching effectiveness. During each clip, we displayed either an attractive or an unattractive photograph of an unrelated third party. We used qualitative analysis followed by factor analysis to identify the principal components of teaching effectiveness, and multiple linear regression to study the associations among these components, type of photograph displayed, and TER. Results We identified two principal components of teaching effectiveness: charisma and intellect. There was no association between rating of intellect and TER. Rating of charisma and the display of an attractive photograph were both positively associated with TER and a significant interaction between these two variables was apparent (p < 0.001). The regression coefficient for the association between charisma and TER was 0.26 (95% confidence interval [ CI] 0.10-0.41) when an attractive picture was displayed and 0.83 (95% CI 0.66-1.00) when an unattractive picture was displayed (p < 0.001). Conclusions When medical students rate classroom teachers, they consider the degree to which the teacher is charismatic, although the relationship between this attribute and TER appears to be modified by the perceived physical attractiveness of the teacher. Further studies are needed to identify other variables that may influence subjective ratings of teaching effectiveness and to evaluate alternative strategies for rating teaching effectiveness. [ABSTRACT FROM AUTHOR]

Context: Learning skill of physical diagnosis is critical part of physiotherapy curriculum. Measuring skill acquisition objectively is the essential first step in improving clinical competence. Need for innovation: Acquisition of skills of performing physical examination by undergraduate students, which help in reaching correct diagnosis, is an important objective of curriculum designed for bachelor of physiotherapy course. Assessement of skill acquisition by students objectively, is an essential step in evaluation of improved clinical competence. Method: The ethical committee approval was obtained. Written consent obtained from students participated in the study. The Masters (observers) and bachelor students attended the OSCE training sessions and role play was enacted. There were 14 stations including 3 rest stations, 7 and 4 stations were observed and non-observed respectively. The performance of students is evaluated independently at each station, using checklist. Validated questionnaire feedback form was used for feedback both from students and observers. Lessons learnt: This programme has been a learning process for both master's students and bachelor students as they strive to achieve better outcomes in the provision of higher quality education to students, and enhanced skills required for differential diagnosis to understand pathology better. An OSCE can be used as effective learning tool besides being assessment tool. [ABSTRACT FROM AUTHOR]

Medical Education 2010: 44: 864–873 Objectives Ethical reasoning in medicine is not well understood and medical educators often find it difficult to justify what and how they teach and assess in medical ethics. To facilitate the development of moral values and professional conduct, a model of ethical reasoning was created. The purposes of this paper are to describe the ethical reasoning model and to indicate how it can be used to foster moral and ethical behaviours. Methods The ethical reasoning model was created from information derived from two sources: (i) an examination of different ethical models described in the literature, and (ii) think-aloud interviews with ethical experts in Taiwan and Canada. All the components and cognitive steps used by experts in ethical decision making were extracted and categorised. Interview subjects consisted of 16 voluntary ethics experts. The ethical reasoning models reported in the literature were divided into two groups according to whether they were justification-based or task-based models. Neither of the two types represented the ‘whole picture’ of ethical reasoning in medicine. This analysis enabled us to identify five universal cognitive steps and the gaps between ‘logical decision’ and ‘action’. Results The think-aloud interviews verified the multi-dimensional components or steps used by experts when resolving ethical problems. The resulting model, designated the Medical Ethical Reasoning (MER) Model, reflects interactions within three domains: medical and ethical knowledge; cognitive reasoning processes, and attitude. Conclusions The MER Model accurately reflects how doctors resolve ethical dilemmas and is seen to be helpful in identifying what and how educators should teach and assess in ethical reasoning. The model can also serve as a communication framework for curricular design. A ‘humane’ doctor is competent in providing quality, ethical patient care. Making an appropriate ethical decision is the foundation for subsequent ethical behaviours. By contrast with the abundant evidence cited in previous research describing how doctors solve medical problems, there is little empirical evidence indicating how doctors make appropriate ethical decisions. Thus, the cognition of ethical reasoning in medicine is not well understood. This paper represents a step towards overcoming this problem. [ABSTRACT FROM AUTHOR]

Background: A primary goal of education is to promote long-term knowledge storage and retrieval. Objective: A prospective interventional study design was used to investigate our research question: Does a dispersed curriculum promote better short- and long-term retention over a massed course? Methods: Participants included 20 gastroenterology residents from the University of Calgary ( N = 10) and University of Toronto ( N = 10). Participants completed a baseline test of nutrition knowledge. The nutrition course was imparted to University of Calgary residents for 4 h occurring 1 h weekly over 4 consecutive weeks: dispersed delivery (DD). At the University of Toronto the course was taught in one 4h academic half-day: massed delivery (MD). Post-curriculum tests were administered at 1 week and 3 months to assess knowledge retention. Results: The baseline scores were 46.39 ± 6.14% and 53.75 ± 10.69% in the DD and MD groups, respectively. The 1 week post-test scores for the DD and MD groups were 81.67 ± 8.57%, p < 0.001 and 78.75 ± 4.43, p < 0.001 which was significantly higher than baseline. The 3-month score was significantly higher in the DD group, but not in the MD group (65.28 ± 9.88%, p = 0.02 vs. 58.93 ± 12.06%, p = 0.18). The absolute pre-test to 1-week post-test difference was significantly higher at 35.28 ± 7.65% among participants in the DD group compared to 25.0 ± 11.80% in the MD group, p = 0.048. Similarly, the absolute pre-test to 3-month post-test difference was significantly higher at 18.9 ± 6.7% among the participants in the DD group, compared to 6.8 ± 11.8% in the MD group, p = 0.021. Conclusions: Long-term nutrition knowledge is improved with DD compared with MD. [ABSTRACT FROM AUTHOR]

Context The assessment of ethical problem solving in medicine has been controversial and challenging. The purposes of this study were: (i) to create a new instrument to measure doctors’ decisions on and reasoning approach towards resolving ethical problems; (ii) to evaluate the scores generated by the new instrument for their reliability and validity, and (iii) to compare doctors’ ethical reasoning abilities between countries and among medical students, residents and experts. Methods This study used 15 clinical vignettes and the think-aloud method to identify the processes and components involved in ethical problem solving. Subjects included volunteer ethics experts, postgraduate Year 2 residents and pre-clerkship medical students. The interview data were coded using the instruments of the decision score and Ethical Reasoning Inventory (ERI). The ERI assessed the quality of ethical reasoning for a particular case (Part I) and for an individual globally across all the vignettes (Part II). Results There were 17 Canadian and 32 Taiwanese subjects. Based on the Canadian standard, the decision scores between Taiwanese and Canadian subjects differed significantly, but made no discrimination among the three levels of expertise. Scores on the ERI Parts I and II, which reflect doctors’ reasoning quality, differed between countries and among different levels of expertise in Taiwan, providing evidence of construct validity. In addition, experts had a greater organised knowledge structure and considered more relevant variables in the process of arriving at ethical decisions than did residents or students. The reliability of ERI scores was 0.70–0.99 on Part I and 0.75–0.80 on Part II. Conclusions Expertise in solving ethical problems could not be differentiated by the decisions made, but could be differentiated according to the reasoning used to make those decisions. The difference between Taiwanese and Canadian experts suggests that cultural considerations come into play in the decisions that are made in the course of providing humane care to patients. [ABSTRACT FROM AUTHOR]

Diagnosing is a knowledge-based skill: to diagnose one must retrieve knowledge from long-term memory and then apply this to a new clinical problem. Prior research on expertise found differences in knowledge structure between experts and novices, and it is assumed that the superior diagnostic performance of experts is somehow related to their superior knowledge structure. Here our objective was to study knowledge structure in final year medical students and to examine the association between knowledge structure and diagnostic performance. Ninety-one students participated. We used concept sorting to assess knowledge structures for four clinical problems. We performed qualitative analysis of knowledge structures, categorizing these as either problem-specific, where knowledge was predominantly structured around concepts specific to that clinical problem, or generic, where knowledge was structured around general concepts that could apply to all clinical problems. We evaluated diagnostic performance using problem-solving questions. Knowledge structure varied between different problems, but for each problem most students had problem-specific knowledge structure. These students had better diagnostic performance than those with generic structure (68.5 vs. 55.3%, d = 0.45, P = 0.004). This difference persisted after adjusting for overall medical knowledge (performance on the Medical Council of Canada Part 1 examination) and clinical problem. We found that most students organize their knowledge around problem-specific concepts, and that this type of knowledge was associated with better diagnostic performance. This may be due to easier knowledge retrieval if there is congruence between how knowledge is stored and how it is applied when diagnosing. [ABSTRACT FROM AUTHOR]

Context Despite the impartiality implied in its title, the objective structured clinical examination (OSCE) is vulnerable to systematic biases, particularly those affecting raters’ performance. In this study our aim was to examine OSCE ratings for evidence of differential rater function over time (DRIFT), and to explore potential causes of DRIFT. Methods We studied ratings for 14 internal medicine resident doctors over the course of a single formative OSCE, comprising 10 12-minute stations, each with a single rater. We evaluated the association between time-slot and rating for a station. We also explored a possible interaction between time-slot and station difficulty, which would support the hypothesis that rater fatigue causes DRIFT, and considered ‘warm-up’ as an alternative explanation for DRIFT by repeating our analysis after excluding the first two OSCE stations. Results Time-slot was positively associated with rating on a station (regression coefficient 0.88, 95% confidence interval [CI] 0.38–1.38; P = 0.001). There was an interaction between time-slot and station difficulty: for the more difficult stations the regression coefficient for time-slot was 1.24 (95% CI 0.55–1.93; P = 0.001) compared with 0.52 (95% CI − 0.08 to 1.13; P = 0.09) for the less difficult stations. Removing the first two stations from our analyses did not correct DRIFT. Conclusions Systematic biases, such as DRIFT, may compromise internal validity in an OSCE. Further work is needed to confirm this finding and to explore whether DRIFT also affects ratings on summative OSCEs. If confirmed, the factors contributing to DRIFT, and ways to reduce these, should then be explored. [ABSTRACT FROM AUTHOR]