Self-monitoring accuracy does not increase throughout undergraduate medical education

Context: Accurate self-assessment of one's performace on a moment-by-moment basis (ie, accurate self-monitoring) is vital for the self-regulation of practising physicians and indeed for the effective regulation of self-directed learning during medical education. However, little is currently known about the functioning of self-monitoring and its co-development with medical knowledge across medical education. This study is the first to simultaneously investigate a number of relevant aspects and measures that have so far been studied separately: different measures of self-monitoring for a broad area of medical knowledge across 10 different performance levels. Methods: This study assessed the self-monitoring accuracy of medical students (n = 3145) across 10 semesters. Data collected during the administration of the formative Berlin Progress Test Medicine (PTM) were analysed. The PTM comprises 200 multiple-choice questions covering all major medical disciplines and organ systems. A self-report indicator (ie, confidence) and two behavioural indicators of self-monitoring accuracy (ie, response time and the likelihood of changing an initial answer to a correct rather than an incorrect item) were examined for their development over semesters. Results: Analyses of more than 390 000 observations (of approximately 250 students per semester) showed that confidence was higher for correctly than for incorrectly answered items and that 86% of items answered with high confidence were indeed correct. Response time and the likelihood of the initial answer being changed were higher when the initial answer was incorrect than when it was correct. Contrary to expectations, no differences in self-monitoring accuracy were observed across semesters. Conclusions: Convergent evidence from different measures of self-monitoring suggests that medical students self-monitor their knowledge on a question-by-question basis well, although not perfectly, and to the same degree as has been found in studies outside medicine. Despite large differences in performance, no variations in self-monitoring across semesters (with the exception of the first semester) were observed

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context

Differential diagnosis checklists reduce diagnostic error differentially: a randomized experiment

Introduction Wrong and missed diagnoses contribute substantially to medical error. Can a prompt to generate alternative diagnoses (prompt) or a differential diagnosis checklist (DDXC) increase diagnostic accuracy? How do these interventions affect the diagnostic process and self-monitoring? Methods Advanced medical students (N = 90) were randomly assigned to one of four conditions to complete six computer-based patient cases: group 1 (prompt) was instructed to write down all diagnoses they considered while acquiring diagnostic test results and to finally rank them. Groups 2 and 3 received the same instruction plus a list of 17 differential diagnoses for the chief complaint of the patient. For half of the cases, the DDXC contained the correct diagnosis (DDXC+), and for the other half, it did not (DDXC−; counterbalanced). Group 4 (control) was only instructed to indicate their final diagnosis. Mixed-effects models were used to analyse results. Results Students using a DDXC that contained the correct diagnosis had better diagnostic accuracy, mean (standard deviation), 0.75 (0.44), compared to controls without a checklist, 0.49 (0.50), P < 0.001, but those using a DDXC that did not contain the correct diagnosis did slightly worse, 0.43 (0.50), P = 0.602. The number and relevance of diagnostic tests acquired were not affected by condition, nor was self-monitoring. However, participants spent more time on a case in the DDXC−, 4:20 min (2:36), P ≤ 0.001, and DDXC+ condition, 3:52 min (2:09), than in the control condition, 2:59 min (1:44), P ≤ 0.001. Discussion Being provided a list of possible diagnoses improves diagnostic accuracy compared with a prompt to create a differential diagnosis list, if the provided list contains the correct diagnosis. However, being provided a diagnosis list without the correct diagnosis did not improve and might have slightly reduced diagnostic accuracy. Interventions neither affected information gathering nor self-monitoring

Development and usability testing of a fully immersive VR simulation for REBOA training.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training. METHODS Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed. RESULTS REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3-85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8-5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8-50.2) and user satisfaction high (USEQ median 26, IQR 23-29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001). CONCLUSIONS Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning

The effect of social media communication on consumer perceptions of brands

Researchers and brand managers have limited understanding of the effects social media communication has on how consumers perceive brands. We investigated 504 Facebook users in order to observe the impact of firm-created and user-generated social media communication on brand equity, brand attitude and purchase intention by using a standardized online survey throughout Poland. To test the conceptual model, we analyzed 60 brands across three different industries: non-alcoholic beverages, clothing and mobile network operators. When analyzing the data, we applied the structural equation modeling technique to both investigate the interplay of firm-created and user-generated social media communication and examine industry-specific differences. The results of the empirical studies showed that user-generated social media communication had a positive influence on both brand equity and brand attitude, whereas firm-created social media communication affected only brand attitude. Both brand equity and brand attitude were shown to have a positive influence on purchase intention. In addition, we assessed measurement invariance using a multi-group structural modeling equation. The findings revealed that the proposed measurement model was invariant across the researched industries. However, structural path differences were detected across the models

Insights from computational modeling in inflammation and acute rejection in limb transplantation

Acute skin rejection in vascularized composite allotransplantation (VCA) is the major obstacle for wider adoption in clinical practice. This study utilized computational modeling to identify biomarkers for diagnosis and targets for treatment of skin rejection. Protein levels of 14 inflammatory mediators in skin and muscle biopsies from syngeneic grafts [n = 10], allogeneic transplants without immunosuppression [n = 10] and allografts treated with tacrolimus [n = 10] were assessed by multiplexed analysis technology. Hierarchical Clustering Analysis, Principal Component Analysis, Random Forest Classification and Multinomial Logistic Regression models were used to segregate experimental groups. Based on Random Forest Classification, Multinomial Logistic Regression and Hierarchical Clustering Analysis models, IL-4, TNF-α and IL-12p70 were the best predictors of skin rejection and identified rejection well in advance of histopathological alterations. TNF-α and IL-12p70 were the best predictors of muscle rejection and also preceded histopathological alterations. Principal Component Analysis identified IL-1α, IL-18, IL-1β, and IL-4 as principal drivers of transplant rejection. Thus, inflammatory patterns associated with rejection are specific for the individual tissue and may be superior for early detection and targeted treatment of rejection. © 2014 Wolfram et al

Urbane Resilienz gegenüber extremen Wetterereignissen: Gemeinsamer Verbundabschlussbericht des Forschungsprojektes ExTrass

Das Projekt ExTrass hatte zwei Ziele: Das erste Ziel war es, Klimaresilienz in den drei Fallstudienstädten Potsdam, Remscheid und Würzburg messbar zu stärken. Das zweite Ziel war es, Transferpotenziale zwischen Groß- und Mittelstädten in Deutschland zu identifizieren und besser nutzbar zu machen, sodass die Wirkung von Pilotvorhaben über die direkt involvierten Städte hinausgehen kann. Dies sollte in enger Zusammenarbeit mit den Stadtverwaltungen sowie zivilgesellschaftlichen Akteur:innen des Katastrophenschutzes erfolgen. Dabei standen folgende Leitfragen im Fokus: • Wie verbreitet sind Klimaanpassungsaktivitäten in Großstädten und größeren kreisfreien Mittelstädten in Deutschland? • Welche hemmenden und begünstigenden Faktoren beeinflussen die Klimaanpassung? • Welche Maßnahmen der Klimaanpassung werden tatsächlich umgesetzt, und wie kann die Umsetzung verbessert werden? Was behindert? • Inwiefern lassen sich Beispiele guter Praxis auf andere Städte übertragen, adaptieren oder weiterentwickeln