Self-explanation, an instructional strategy to foster clinical reasoning in medical students

Clinical reasoning is a critical and complex skill that medical students have to develop in the course of their training. Although research on medical expertise has successfully examined the different components of that skill, designing educational interventions that support the development of clinical reasoning in students remains a challenge for medical educators. The theory of medical expertise describes how students' medical knowledge develops and is progressively restructured during their training and in particular through clinical exposure to patient problems. Instructional strategies to foster students' learning from practice with clinical cases are scarce. This article describes the use of self-explanation as such a strategy. Self-explanation is an active learning technique of proven effectiveness in other domains which consists of having students explaining to themselves information on tobe-learned materials. The mechanisms through which self-explanation fosters learning are described. Self-explanation promotes knowledge development and revision of mental representations through elaboration on new information, organisation and integration of new knowledge into existing cognitive structures and monitoring of the learning process. Subsequently, the article shows how self-explanation has recently been investigated in medicine as an instructional strategy to support students' clinical reasoning. Available studies have demonstrated that students' diagnostic performance improves when they use self-explanation while solving clinical problems of a less familiar clinical topic. Unfamiliarity seems to trigger more self-explanations and to stimulate students to reactivate relevant biomedical knowledge, which could lead to the development of more coherent representations of diseases. The benefit of students' self-explanation is increased when it is combined with listening to residents' self-explanation examples and with prompts. The positive effect of self-explanation gets stronger when students' diagnostic performance is tested on far-transfer clinical cases, suggesting that deeper understanding and meaningful learning do occur. Selfexplanation is a practical and inexpensive technique which could be incorporated into learning activities using clinical problems to promote diagnostic reasoning of medical students. Even though self-explanation is a promising learning technique, further studies are needed to explore other conditions that could maximise its benefit on learning clinical reasoning.</p

Ціна — запорука ефективності сільськогосподарського виробництва

Context: Structured reflection while practising the diagnosing of cases has been shown to improve medical students' learning of clinical diagnosis. The present study investigated whether additional instructional guidance increases the benefits of reflection by comparing the effects of free, cued and modelled reflection on learning. Methods: Fifty-eight Year 5 and 57 Year 6 medical students participated in a three-phase experiment. During the learning phase, participants diagnosed eight clinical cases under different experimental conditions: free reflection; cued reflection, and modelled reflection. In an immediate test and a delayed test administered 1 week later, they diagnosed new sets of eight different cases, four of which presented diseases they had studied during the learning phase. Learning was measured according to diagnostic accuracy on the cases that involved the four diseases that appeared in all phases. Results: Repeated-measures analysis of variance (anova) of mean scores for diagnostic accuracy (range: 0-1) showed a significant main effect of experimental condition (p < 0.001), year of training (p = 0.013), and performance moment (p = 0.003), without significant interaction effects. Overall, the modelled reflection group and the cued reflection group did not differ in performance (p = 1.00), but both outperformed the free reflection group (p < 0.001 for both comparisons). Overall performance increased in the delayed test relative to the immediate test (p = 0.004) and to the learning phase (p = 0.03), but did not differ in the latter two phases. Both Year 6 and Year 5 students rated studying examples of reflection as less effortful than either cued or free reflection in the learning phase (p < 0.001 for all comparisons). Conclusions: Students apparently learn more with less effort by studying correct structured reflection while practising the diagnosing of cases than by reflecting without any instructional guidance. Examples of reflection and cued reflection were more beneficial for learning than free reflection and may represent a useful instructional strategy for clinical teaching

Analytical solution of a plane strain pure bending problem in second gradient electroelasticity

Semi-inverse analytical solution of a pure bending problem for piezoelectric layer is developed in the framework of linear electroelasticity theory with strain gradient and electric field gradient effects. Two-dimensional solution is derived assuming plane strain state of a layer. It is shown that obtained solution can be used for the validation of size-dependent beam and plate models in second gradient electroelasticity theory

ANÁLISE DO ENSINO DA PRODUÇÃO ESCRITA DO ARTIGO DE OPINIÃO NO LIVRO DIDÁTICO DE LÍNGUA PORTUGUESA 9º ANO

Neste artigo apresentamos descrição e análise de uma proposta didática de produção de artigo deopinião em um livro didático de Língua Portuguesa (LP) destinado a alunos do 9º ano do Ensino Fundamental. Oobjetivo é expor e analisar essas atividades tendo como pressuposto a teoria dialógica de Bakhtin e o Círculo emconfronto com o guia do livro didático PNLD (2014). Primeiramente descrevemos a organização da unidade eem seguida procedemos à discussão de como é proposto o ensino da escrita do gênero para o aluno. A partir daanálise, verificamos algumas inadequações na proposição da atividade, pois os procedimentos de ensino dessegênero não levam o aluno a se colocar responsivamente. Os resultados indicam que o modelo de escrita indicadono livro didático (LD) analisado pressupõe uma perspectiva tradicional de escrita em que o aluno, a partir daoferta de um único exemplar do gênero a ser produzido, deverá seguir o modelo para que escreva o seu texto.Este trabalho possibilita traçar estratégias de análise do LD de LP para auxiliar no processo de ensino eaprendizagem do artigo de opinião

Specific Disease Knowledge as Predictor of Susceptibility to Availability Bias in Diagnostic Reasoning:a Randomized Controlled Experiment

BACKGROUND: Bias in reasoning rather than knowledge gaps has been identified as the origin of most diagnostic errors. However, the role of knowledge in counteracting bias is unclear. OBJECTIVE: To examine whether knowledge of discriminating features (findings that discriminate between look-alike diseases) predicts susceptibility to bias. DESIGN: Three-phase randomized experiment. Phase 1 (bias-inducing): Participants were exposed to a set of clinical cases (either hepatitis-IBD or AMI-encephalopathy). Phase 2 (diagnosis): All participants diagnosed the same cases; 4 resembled hepatitis-IBD, 4 AMI-encephalopathy (but all with different diagnoses). Availability bias was expected in the 4 cases similar to those encountered in phase 1. Phase 3 (knowledge evaluation): For each disease, participants decided (max. 2 s) which of 24 findings was associated with the disease. Accuracy of decisions on discriminating features, taken as a measure of knowledge, was expected to predict susceptibility to bias. PARTICIPANTS: Internal medicine residents at Erasmus MC, Netherlands. MAIN MEASURES: The frequency with which higher-knowledge and lower-knowledge physicians gave biased diagnoses based on phase 1 exposure (range 0-4). Time to diagnose was also measured. KEY RESULTS: Sixty-two physicians participated. Higher-knowledge physicians yielded to availability bias less often than lower-knowledge physicians (0.35 vs 0.97; p = 0.001; difference, 0.62 [95% CI, 0.28-0.95]). Whereas lower-knowledge physicians tended to make more of these errors on subjected-to-bias than on not-subjected-to-bias cases (p = 0.06; difference, 0.35 [CI, - 0.02-0.73]), higher-knowledge physicians resisted the bias (p = 0.28). Both groups spent more time to diagnose subjected-to-bias than not-subjected-to-bias cases (p = 0.04), without differences between groups. CONCLUSIONS: Knowledge of features that discriminate between look-alike diseases reduced susceptibility to bias in a simulated setting. Reflecting further may be required to overcome bias, but succeeding depends on having the appropriate knowledge. Future research should examine whether the findings apply to real practice and to more experienced physicians

Can We Teach Reflective Reasoning in General-Practice Training Through Example-Based Learning and Learning by Doing?

Purpose: Flaws in physicians’ reasoning frequently result in diagnostic errors. The method of deliberate reflection was developed to stimulate physicians to deliberately reflect upon cases, which has shown to improve diagnostic performance in complex cases. In the current randomised controlled trial, we investigated whether deliberate reflection can be taught to general-practice residents. Additionally, we investigated whether engaging in deliberate reflection or studying deliberate-reflection models would be more effective. Methods: The study consisted of one learning session and two test sessions. Forty-four general-practice residents were randomly assigned to one of three study conditions in the learning session: (1) control without reflecting (n = 14); (2) engaging in deliberate reflection (n = 11); or (3) studying deliberate-reflection models (n = 19). To assess learning, they diagnosed new cases in both a same-day test and a delayed test one week later. In the delayed test, participants were additionally asked to elaborate on their decisions. We analysed diagnostic accuracy and whether their reasoning contained key elements of deliberate reflection. Results: We found no significant differences between the study conditions in diagnostic accuracy on the same-day test, p = .649, or on diagnostic accuracy, p = .747, and reflective reasoning, p = .647, on the delayed test. Discussion: Against expectations, deliberate reflection did not increase future reflective reasoning. Future studies are needed to investigate whether residents either did not sufficiently learn the procedure, did not adopt it when diagnosing cases without instructions to reflect, or whether the reflective-reasoning process as itself cannot be taught

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices’ decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases

To observe or not to observe peers when learning physical examination skills; That is the question

Background: Learning physical examination skills is an essential element of medical education. Teaching strategies include practicing the skills either alone or in-group. It is unclear whether students benefit more from training these skills individually or in a group, as the latter allows them to observing their peers. The present study, conducted in a naturalistic setting, investigated the effects of peer observation on mastering psychomotor skills necessary for physical examination. Methods. The study included 185 2§ssup§nd§esup§-year medical students, participating in a regular head-to-toe physical examination learning activity. Students were assigned either to a single-student condition (n = 65), in which participants practiced alone with a patient instructor, or to a multiple-student condition (n = 120), in which participants practiced in triads under patient instructor supervision. The students subsequently carried out a complete examination that was videotaped and subsequently evaluated. Student's performance was used as a measure of learning. Results: Students in the multiple-student condition learned more than those who practiced alone (8

Palliative patients in the portuguese public hospitals

Introdução: A identificação e referenciação precoce dos doentes com necessidades paliativas é fundamental para que em tempo útil possam usufruir da efetividade da intervenção precoce de cuidados paliativos. Referenciar para cuidados Paliativos é um importante, crescente e complexo desafio e processo para a prática dos profissionais de saúde, nomeadamente para os médicos. A falta de informação e formação podem impedir a proatividade no processo de referenciação precoce. Atualmente, existem já alguns instrumentos multidimensionais que ajudam a identificar a população com necessidades paliativas. A pergunta surpresa, validada para Portugal, “Ficaria surpreendido se este doente morresse durante o próximo ano?” é uma ferramenta importante, útil e fiável para esta identificação. Objetivo: determinar a prevalência de doentes adultos com necessidades paliativas internados em hospitais públicos. Como objetivos secundários, determinar o número de doentes referenciados para cuidados paliativos e identificar os motivos de não referenciação destes doentes. Materiais e Métodos: Estudo analítico, observacional e transversal, realizado no primeiro trimestre de 2015 em 11 hospitais do SNS. O instrumento de colheita de dados consistiu num questionário com caracterização demográfica e clinica, a pergunta surpresa relativa a 1 ano, 6 e 1 mês e, 15 dias, e 19 possíveis motivos para não referenciação dos doentes. Os dados recolhidos forma analisados com recurso à estatística descritiva e analítica, considerando-se significância estatística se p<0.05. Resultados: De um total de 1273 doentes, 51.4% eram doentes com necessidades paliativas, a maioria proveniente dos serviços de oncologia (79.3%) e medicina (62.3%), e maioritariamente com doença oncológica (67.2%). Apenas estavam referenciados 6.8 a 9.9% dos doentes, maioritariamente oncológicos (15.1%) ou com 15 ou menos dias de vida (9.8%). Os cinco principais motivos para não referenciação foram: ainda estar a fazer tratamento ativo (61.5%), “ainda se poder fazer alguma coisa do ponto de vista curativo” (40.9%), o doente estar controlado a nível sintomático (33.2%), ainda não estar a morrer (27.6%) e os cuidados paliativos não serem uma mais-valia para o doente (15.4%). Conclusão: Elevada prevalência de doentes e baixa taxa de referenciação. É necessária e imperiosa a formação e capacitação dos profissionais de saúde para uma adequada identificação e referenciação e tempo útil dos doentes com necessidades paliativas.Early identification and referral of patients with palliative needs is essential so they can benefit from the effectiveness of early intervention of palliative care. Referral for palliative care is an important, growing and complex challenge and process for the practice of health professionals, particularly for physicians. Lack of information and training may prevent proactivity in the process of early refer Currently, some multidimensional instruments help to identify the population with palliative needs. The surprise question, validated for Portugal, “Would you be surprised if this patient died during the next year?” is an important, useful and reliable tool for this identification.Aim: to determine the prevalence of adult patients with palliative needs hospitalized in public hospitals; to determine who were referenced for palliative care and to identify the reasons for non-referral of these patients.Material and Methods: an analytical, observational and cross-sectional study was performed in the first quarter of 2015 in 11 hospitals of the Portuguese Health System. The data collection instrument consisted of a questionnaire with demographic and clinical characterization, the surprise question regarding 1 year, 6 and 1 month and, 15 days, and 19 possible reasons for non-referral of patients. The collected data were analyzed using descriptive and analytical statistics, considering statistical significance if p <0.05.Results: From a total of 1273 patients, 51.4% were patients with palliative needs, the majority coming from the oncology (79.3%) and medicine services (62.3%), and mainly with oncological disease (67.2%). Only 6.8 to 9.9% of the patients were referred, mainly oncological (15.1%) or with 15 days or less of life (9.8%). The five main reasons for non-referral were: still being under active treatment (61.5%), “still able to do something from a curative point of view” (40.9%), the patient being symptomatically controlled (33.2%), not considered to be actively dying (27.6%) and not being an added value to the patient (15.4%).Conclusions: High prevalence of patients with palliative care need, low referral rate. The training and qualification of health professionals is necessary and imperative for an adequate identification and referral in a useful time of patients with palliative needs