Pupillometry as a tool to study expertise in medicine

Background Pupillometry has been studied as a physiological marker for quantifying cognitive load since the early 1960s. It has been established that small changes in pupillary size can provide an index of the cognitive load of a participant as he/she performs a mental task. The utility of pupillometry as a measure of expertise is less well established, although recent research in the fields of education, medicine and psychology indicates that differences in pupillary size during domain-specific tasks allows differentiation between experts and novices in appropriately designed experiments.Purpose The goal of this review is to explore the existing body of evidence for the use of pupillometry as a measure of expertise and to identify its strengths and constraints within the context of expertise research in the medical sciences.Results Pupillometry is a robust metric that allows researchers to better understand cognitive load in medical practitioners with varying levels of expertise. In medical expertise research, it has been used to study surgeons, anesthetists and emergency physicians. Its strengths include its ability to provide quantitative and objective outputs, to be measured unobtrusively with new technology and to be precisely computed as cognitive load changes over the course of completion of a task. Constraints associated with this methodology include its potential inaccuracy with changes in ambient light and pupillary accommodation as well as the need for relatively expensive equipment. Conclusion With recent technological advances, pupillometry has become a simple and robust method for quantifying physiological changes attributable to cognitive load and is increasingly being utilized in medical education. It can be used as a reliable marker of mental effort and has been shown to differentiate levels of expertise in medical practitioners

Rétroaction multisources à la suite d’une simulation en réanimation : une étude qualitative

Background: The direct observation and assessment of learners’ resuscitation skills by an attending physician is challenging due to the unpredictable and time-sensitive nature of these events. Multisource feedback (MSF) may address this challenge and improve the quality of assessments provided to learners. We aimed to describe the similarities and differences in the assessment rationale of attending physicians, registered nurses, and resident peers in the context of a simulation-based resuscitation curriculum. Methods: We conducted a qualitative content analysis of narrative MSF of medical residents in their first postgraduate year of training who were participating in a simulation-based resuscitation course at two Canadian institutions. Assessments included an entrustment score and narrative comments from attending physicians, registered nurses, and resident peers in addition to self-assessment. Narrative comments were transcribed and analyzed thematically using a constant comparative method. Results: All 87 residents (100%) participating in the 2017-2018 course provided consent. A total of 223 assessments were included in our analysis. Four themes emerged from the narrative data: 1) Communication, 2) Leadership, 3) Demeanor, and 4) Medical Expert. Relative to other assessor groups, feedback from nurses focused on patient-centred care and communication while attending physicians focused on the medical expert theme. Peer feedback was the most positive. Self-assessments included comments within each of the four themes. Conclusions: In the context of a simulation-based resuscitation curriculum, MSF provided learners with different perspectives in their narrative assessment rationale and may offer a more holistic assessment of resuscitation skills within a competency-based medical education (CBME) program of assessment.Contexte : Le contexte imprévisible et contraignant au niveau du temps lors de l’observation directe et de la rétroaction associée sur les compétences en réanimation des apprenants constituent un défi pour un médecin superviseur. La rétroaction multisources (RMS) peut être un moyen de relever ce défi et d'améliorer la qualité des rétroactions fournies aux apprenants. Nous visons à décrire les similitudes et les différences quant à la démarche évaluative auprès de médecins traitants, d’infirmières cliniciennes et de pairs résidents dans le cadre d'un cours de réanimation offert par simulation. Méthodes : Nous avons réalisé une analyse de contenu à partir des rétroactions narratives offertes aux résidents en première année de formation postdoctorale dans deux universités canadiennes dans le cadre d’un cours de réanimation offert par simulation. En plus de l’auto-évaluation, la rétroaction comportait un score de confiance et des commentaires narratifs de la part de médecins superviseurs, d’infirmières cliniciennes et des pairs. Les commentaires ont été transcrits et analysés par thèmes en appliquant la méthode générale de comparaison constante. Résultats : Un consentement pour participer à l’étude a été obtenu auprès des 87 résidents (100 %) qui ont suivi le cours en 2017-2018. Nous avons analysé un total de 223 rétroactions. Quatre thèmes ont émergé à partir des données narratives soit : 1) la communication, 2) le leadership, 3) le comportement, et 4) l’expertise médicale. Alors que les infirmières ont ciblé leurs commentaires sur les soins centrés sur le patient et la communication, les médecins superviseurs ont les ont ciblés sur l’expertise médicale. Les commentaires des pairs étaient les plus positifs. Les auto-évaluations comportaient des commentaires sur chacun des quatre thèmes. Conclusions : Dans le contexte d’un cours de réanimation offert par simulation, la RMS a permis aux apprenants d’obtenir des évaluations narratives selon différentes perspectives. Permettant ainsi une approche plus holistique de rétroaction sur les habiletés en réanimation dans le cadre d’un programme d’évaluation axé sur les compétences

Déstabilisés et agités : état émotionnel, charge cognitive et performance des résidents juniors lors d’une réanimation simulée

Background: Patient resuscitation can be overwhelming for junior postgraduate medical residents due to its inherent complexity and high-stakes environment. Emotional states of unpleasant hyperarousal burden cognitive resources, contributing to cognitive overload and performance decline. Our objective is to characterize the associations between pre-scenario emotional state and junior residents’ cognitive load and performance in a simulated-resuscitation, to provide evidence for informed curricular development. Methods: PGY-1 residents self-rated their emotional state before four simulated-resuscitation scenarios, and their cognitive load after. Faculty assessed performance with entrustment scores. Factor analysis identified the principal components of emotional state data. Linear regression models examined the relationship between pre-scenario emotional components, cognitive load, and performance scores.  Results: 47/47 medical and surgical residents (100%) participated and completed Emotional State (99.5%) and Cognitive Load (98.9%) surveys. Positive invigoration and negative tranquility were the principal components. Pre-scenario tranquility was negatively associated with cognitive load (b= -0.23, p < 0.0001), and cognitive load was negatively associated with performance scores (b= -0.27, p < 0.0001). Pre-scenario invigoration was negatively associated with cognitive load (b=-0.18,p = 0.0001), and positively associated with performance scores (b= 0.08, p = 0.0193).  Conclusion: Amongst junior residents participating in simulated resuscitation scenarios, pre-scenario agitation (negative tranquility) is associated with increased cognitive load, which itself is associated with lower performance scores. These findings suggest residency programs should consider developing curriculum aimed at modulating residents’ emotional agitation and reducing residents’ cognitive burden to improve resuscitation performance.Contexte : La réanimation de patients peut être éprouvante pour les stagiaires postdoctoraux juniors en raison de la complexité qui y est inhérente et de la gravité de l’enjeu. Les états émotionnels désagréables d’hyperexcitation épuisent les ressources cognitives, contribuant ainsi à la surcharge cognitive et à la baisse de la performance. Notre objectif était de mettre en évidence le rapport entre l’état émotionnel des résidents juniors avant une simulation de réanimation d’un côté et leur charge cognitive et leur performance lors de celle-ci de l’autre, pour produire des données probantes pouvant servir à la conception éclairée de programmes d’enseignement. Méthodes : Des résidents de première année ont autoévalué leur état émotionnel avant chacun des quatre scénarios de réanimation simulée, ainsi que leur charge cognitive après les simulations. Des membres du corps professoral ont évalué leur performance par l’attribution de scores de confiance. Les principales composantes des données sur l’état émotionnel ont été déterminées par le biais d’une analyse factorielle. On s’est servi de modèles de régression linéaire pour établir la relation entre les composantes émotionnelles avant la simulation, la charge cognitive et les scores de performance. Résultats : Les 47 résidents en médecine et en chirurgie qui ont participé à l’étude (100 %) ont rempli les questionnaires sur l’état émotionnel (99,5 %) et la charge cognitive (98,9 %). La stimulation positive et la tranquillité négative sont les principales composantes dégagées. La tranquillité avant la simulation était négativement corrélée avec la charge cognitive (b= -0,23, p<0,0001), et la charge cognitive était négativement liée aux scores de performance (b= -0,27, p<0,0001). La stimulation avant la simulation était négativement corrélée avec la charge cognitive (b=-0.18, p=0.0001), et positivement corrélée avec les scores de performance (b= 0.08, p=0.0193). Conclusion : Chez les résidents juniors qui ont participé à des scénarios de réanimation simulée, l’agitation précédant cette dernière (tranquillité négative) était liée à une charge cognitive accrue, qui elle-même a donné lieu à des scores de performance plus faibles. Ces résultats montrent la pertinence de concevoir des programmes qui visent à réduire l’agitation émotionnelle et la charge cognitive des résidents afin d’améliorer leurs performances en réanimation

Getting Inside the Expert's Head:An Analysis of Physician Cognitive Processes During Trauma Resuscitations

Study objective: Crisis resource management skills are integral to leading the resuscitation of a critically ill patient. Despite their importance, crisis resource management skills (and their associated cognitive processes) have traditionally been difficult to study in the real world. The objective of this study was to derive key cognitive processes underpinning expert performance in resuscitation medicine, using a new eye-tracking-based video capture method during clinical cases. Methods: During an 18-month period, a sample of 10 trauma resuscitations led by 4 expert trauma team leaders was analyzed. The physician team leaders were outfitted with mobile eye-tracking glasses for each case. After each resuscitation, participants were debriefed with a modified cognitive task analysis, based on a cued-recall protocol, augmented by viewing their own first-person perspective eye-tracking video from the clinical encounter. Results: Eye-tracking technology was successfully applied as a tool to aid in the qualitative analysis of expert performance in a clinical setting. All participants stated that using these methods helped uncover previously unconscious aspects of their cognition. Overall, 5 major themes were derived from the interviews: logistic awareness, managing uncertainty, visual fixation behaviors, selective attendance to information, and anticipatory behaviors. Conclusion: The novel approach of cognitive task analysis augmented by eye tracking allowed the derivation of 5 unique cognitive processes underpinning expert performance in leading a resuscitation. An understanding of these cognitive processes has the potential to enhance educational methods and to create new assessment modalities of these previously tacit aspects of expertise in this field

Adam Szulewski - PhD project data for study 1

Study 1: The use of task-evoked pupillary response as an objective measure of cognitive load in novices and trained physicians: a new tool for the assessment of expertise. In 2013, 20 emergency medicine trainees were recruited and divided into novice (n = 10) and trained physician (n = 10) groups. The authors used mobile eyetracking glasses to assess changes in pupil diameter as participants answered arithmetic questions, general knowledge questions, and clinical emergency medicine questions in a controlled setting. Questions were categorized by difficulty a priori

Adam Szulewski - PhD project data for study 5

Study 5: Starting to think like an expert: an analysis of resident cognitive processes during simulation-based resuscitation examinations. Simulation is commonly used to teach crisis resource management skills and assess them in emergency medicine residents. However, our understanding of the cognitive processes underlying crisis resource management skills is limited because these processes are difficult to assess and describe. The objective of this study is to uncover and characterize the cognitive processes underlying crisis resource management skills and to describe how these processes vary between residents according to performance in a simulation-based examination. Twenty-two of 24 eligible emergency medicine trainees from 1 tertiary academic center completed 1 or 2 resuscitation- based examinations in the simulation laboratory. Resident performance was assessed by a blinded expert using an entrustment- based scoring tool. Participants wore eye-tracking glasses that generated first-person video that was used to augment subsequent interviews led by an emergency medicine faculty member