What and how advanced medical students learn from reasoning through multiple cases

The study reported in this article concerns the questions what and how fourth-year medical students can learn from a series of cases that have a similar underlying problem. This question is crucial in the theoretical sense as it looks at mechanisms of updating and improving knowledge structures, which are conjectured to consist of ‘illness scripts’, which integrate knowledge about enabling conditions for a disease, the underlying fault, and the consequences or signs and symptoms of the disease. It was found that much learning was implicit, whilst students explicitly paid attention to variations in enabling conditions and consequences, which led to improvement of these knowledge components. Integration of biomedical knowledge into the fault component was, however, hampered by lack of knowledge and by misconceptions that students were unable to debug in the absence of learning resources or detailed feedback. The practical importance of this study stems from its close parallels to the learning situation in clinical practice, where patients (or cases) are the most important learning resources, whilst feedback on results is often minimal. Implications and possible solutions for clinical teaching are discussed

The quest for self-regulation: A design-based approach with vocational teachers

Jossberger, H., Brand-Gruwel, S., Boshuizen, H. P. A., & Van de Wiel, M. (2010, August). The quest for self-regulation: A design-based approach with vocational teachers. Poster presentation at the EARLI Learning and Professional Development SIG Conference, Munich, Germany.In this design-based research study, we join in with vocational teachers and investigate how we can diminish obstacles and optimise students’ self-regulated learning and motivation in pre-vocational secondary education by better understanding the connection between teaching and learning in workplace simulations. The design of authentic and challenging learning tasks that provide students with a clear goal, visible assessment and performance criteria is suggested to be an important starting point. Moreover, direct feedback from the teacher on task level, process level, self-regulated learning level, and self level can reduce the discrepancy between current understanding and performance and promote self-regulated learning and motivation. Method triangulation is used for gathering data, including observations, logbooks of teachers, and questionnaires for students. This research is still in progress, but the set up promises a practice oriented approach, in which teachers are actively involved.NWO project number 411-05-20

Monitoring: A Strategy to Detect Imminent Mistakes

Jossberger, H., Brand-Gruwel, S., Boshuizen, H. P. A., & Van de Wiel, M. (2010, August). Monitoring: A strategy to detect imminent mistakes. In D. Sembill (Chair), Human Fallibility: The Ambiguity of Errors for Work and Learning. Symposium conducted at the EARLI Learning and Professional Development SIG Conference, Munich, Germany.The aim of this empirical study was to unravel generic self-regulated learning behaviours and to seek to investigate micro processes of planning, monitoring, and evaluating in workplace simulations. Eighteen students from upper secondary vocational education participated. Students were observed during a practical lesson and interviewed afterward to gain detailed insights into their behaviours, thoughts, and (inter)actions. Information was collected on the way they executed a task, how they dealt with problems and mistakes and why they interacted with peers or the teacher. Students self-regulated during task execution. Monitoring appeared to be an activity that was regularly executed by keeping a close eye on the product students were working on. Teachers were consulted when students had doubts and needed confirmation or when they wanted more information. They consulted their peers when they wanted to get a faster answer and thought that this peer had enough knowledge to help them out.NWO project number 411-05-20

Knowledge development and restructuring in the domain of medicine; the role of theory and practice

How does the knowledge of the medical student, clerk, intern, and registrar develop and how do formal and informal, classroom and experiential learning contribute to this process? These questions were investigated in two experiments, focusing on knowledge restructuring rather than knowledge acquisition. The experiments showed that practical experience plays an important role in knowledge restructuring. The process was, however, not as continuous as was expected. Notably, advanced students appeared to have considerable knowledge about conditions in patients and their environments that can predispose to disease. However, they rarely applied it in clinical reasoning. Contrary to what was found in expert physicians, advanced students' knowledge about enabling conditions seems not yet to be integrated into their other knowledge about diseases

Assessing Knowledge Structures in a Constructive Statistical Learning Environment

In this report, the method of free recall is put forward as a tool to evaluate a prototypical statistical learning environment. A number of students from the faculty of Health Sciences, Maastricht University, the Netherlands, were required to write down whatever they could remember of a statistics course in which they had participated. By means of examining the free recall protocols of the participants, insight can be obtained into the mental representations they had formed with respect to three statistical concepts. Quantitative as well as qualitative analyses of the free recall protocols showed that the effect of the constructive learning environment was not in line with the expectations. Despite small-group discussions on the statistical concepts, students appeared to have disappointingly low levels of conceptual understanding

Samen in Zee met Zelfregulatie: Een Design-Based Aanpak met Vmbo Leraren

Jossberger, H., Brand-Gruwel, S., Boshuizen, H. P. A., & Van der Wiel, M. (2010, June). Samen in Zee met Zelfregulatie: Een Design-Based Aanpak met Vmbo Leraren. Poster presented at the 37th Onderwijs Research Dagen (ORD), Enschede, Nederland.In dit onderzoek gaan we met een ontwerpgerichte aanpak samen in zee met docenten om vanuit de theorie te kijken hoe zelfregulatie bij leerlingen in het vmbo geoptimaliseerd kan worden door onderwijzen en leren beter op elkaar af te stemmen. Daarbij speelt de docent een belangrijke rol.NWO project 411-05-20

Exploring deliberate practice in medicine: how do physicians learn in the workplace?

Medical professionals need to keep on learning as part of their everyday work to deliver high-quality health care. Although the importance of physicians’ learning is widely recognized, few studies have investigated how they learn in the workplace. Based on insights from deliberate practice research, this study examined the activities physicians engage in during their work that might further their professional development. As deliberate practice requires a focused effort to improve performance, the study also examined the goals underlying this behaviour. Semi-structured interviews were conducted with 50 internal medicine physicians: 19 residents, 18 internists working at a university hospital, and 13 working at a non-university hospital. The results showed that learning in medical practice was very much embedded in clinical work. Most relevant learning activities were directly related to patient care rather than motivated by competence improvement goals. Advice and feedback were sought when necessary to provide this care. Performance standards were tied to patients’ conditions. The patients encountered and the discussions with colleagues about patients were valued most for professional development, while teaching and updating activities were also valued in this respect. In conclusion, physicians’ learning is largely guided by practical experience rather than deliberately sought. When professionals interact in diagnosing and treating patients to achieve high-quality care, their experiences contribute to expertise development. However, much could be gained from managing learning opportunities more explicitly. We offer suggestions for increasing the focus on learning in medical practice and further research

The diagnostic role of gut feelings in general practice A focus group study of the concept and its determinants

Contains fulltext : 81297.pdf (publisher's version ) (Open Access)BACKGROUND: General practitioners sometimes base clinical decisions on gut feelings alone, even though there is little evidence of their diagnostic and prognostic value in daily practice. Research into these aspects and the use of the concept in medical education require a practical and valid description of gut feelings. The goal of our study was therefore to describe the concept of gut feelings in general practice and to identify their main determinants METHODS: Qualitative research including 4 focus group discussions. A heterogeneous sample of 28 GPs. Text analysis of the focus group discussions, using a grounded theory approach. RESULTS: Gut feelings are familiar to most GPs in the Netherlands and play a substantial role in their everyday routine. The participants distinguished two types of gut feelings, a sense of reassurance and a sense of alarm. In the former case, a GP is sure about prognosis and therapy, although they may not always have a clear diagnosis in mind. A sense of alarm means that a GP has the feeling that something is wrong even though objective arguments are lacking. GPs in the focus groups experienced gut feelings as a compass in situations of uncertainty and the majority of GPs trusted this guide. We identified the main determinants of gut feelings: fitting, alerting and interfering factors, sensation, contextual knowledge, medical education, experience and personality. CONCLUSION: The role of gut feelings in general practice has become much clearer, but we need more research into the contributions of individual determinants and into the test properties of gut feelings to make the concept suitable for medical education

Gut Feelings as a Third Track in General Practitioners’ Diagnostic Reasoning

BACKGROUND: General practitioners (GPs) are often faced with complicated, vague problems in situations of uncertainty that they have to solve at short notice. In such situations, gut feelings seem to play a substantial role in their diagnostic process. Qualitative research distinguished a sense of alarm and a sense of reassurance. However, not every GP trusted their gut feelings, since a scientific explanation is lacking. OBJECTIVE: This paper explains how gut feelings arise and function in GPs' diagnostic reasoning. APPROACH: The paper reviews literature from medical, psychological and neuroscientific perspectives. CONCLUSIONS: Gut feelings in general practice are based on the interaction between patient information and a GP's knowledge and experience. This is visualized in a knowledge-based model of GPs' diagnostic reasoning emphasizing that this complex task combines analytical and non-analytical cognitive processes. The model integrates the two well-known diagnostic reasoning tracks of medical decision-making and medical problem-solving, and adds gut feelings as a third track. Analytical and non-analytical diagnostic reasoning interacts continuously, and GPs use elements of all three tracks, depending on the task and the situation. In this dual process theory, gut feelings emerge as a consequence of non-analytical processing of the available information and knowledge, either reassuring GPs or alerting them that something is wrong and action is required. The role of affect as a heuristic within the physician's knowledge network explains how gut feelings may help GPs to navigate in a mostly efficient way in the often complex and uncertain diagnostic situations of general practice. Emotion research and neuroscientific data support the unmistakable role of affect in the process of making decisions and explain the bodily sensation of gut feelings.The implications for health care practice and medical education are discussed

Diagnostisch denken over alledaagse ziekten

Stolper cf, van de wiel mwj, van royen p. Diagnostic thinking about everyday ailments. Huisarts wet 2016;59(11):478-81. Everyday, or minor, ailments are those that are not chronic, acute, or potentially life-threatening. Because general practitioners can think in terms of prognosis, they are able to distinguish between minor ailments and less common, serious diseases that almost always require intervention. General practice medicine is characterized by a certain degree of diagnostic uncertainty. This article approaches the diagnostic process from three perspectives: psychological, decision-making, and a combination of the two. Skilled intuition and contextual knowledge are powerful tools that allow gps to make diagnostic or prognostic decisions with a certain degree of certainty. Mistakes can be made, and this article shows where they might occur and how they can be avoided. Diagnostic uncertainty can have a positive role, in that explicit feedback about diagnostic decisions and disease management fosters the development of expertise