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

Thresholds for dis/trust:Exploring the impact of standards-based reforms on the process of being and becoming a VET teacher in England and Austria

The paper seeks to illustrate how interventionist education reforms shape trust-building processes, and its impact upon teacher professionalism in vocational education and training (VET) across national contexts. Through an analysis of VET teacher narratives in England and Austria, the paper draws attention to the ways in which policy instrumentalism has created a culture of distrust in VET. Drawing upon foundational work on system trust developed by Niklas Luhmann, we illustrate how conditions for trust sit at symbolic thresholds, which set the conditions for professional recognition within VET. Our analysis revealed that attempts to standardise VET strategy is fuelled by the need for existential security and predictability, leading to tensions in the cultivation of system trust. Conditions for professional recognition were based on practices of documentation and subordination, narrowly constituting legitimate self-expression in organisations. This constitutes a crisis of trust in VET teacher professionalism which undermines pedagogical autonomy and integrity. We seek to highlight the impact that reduced trust in the governance of VET can contribute to issues associated with teacher motivation, wellbeing and retention. The consideration of trust is therefore essential both for policy design and implementation in VET organisations

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

Telemedicine and Online Platforms as an Opportunity to Optimise Qualitative Data Collection, Explore and Understand Disease Pathways in a Novel Pandemic Like COVID-19

This article explores digital technology used in the health sector today. There are several ways digital technology is being used for quantitative study aims during the current COVID-19 Pandemic e.g. online symptom checkers. The knowledge gap in COVID-19 as in all novel conditions, consist of both quantitative and qualitative attributes. Digital tool use is prevalent during the COVID-19 Pandemic but most of the data being collected is quantitative in nature. We therefore recommend taking advantage of this telemedicine era and explore optimisation of qualitative data collection, for the purpose of gaining a better understanding of the phenomenon

The role of vocational education and training in the integration of refugees in Austria, Denmark and Germany

Context: Vocational education and training (VET) plays a crucial role in the social inclusion of refugees. The aim of this paper is to examine how the VET systems of Austria, Denmark and Germany responded to the arrival of young refugees since 2015. VET in these countries are all categorised as systems of collective skill formation, which offer apprenticeships in addition to school-based training. The article examines and juxtaposes the legal rights, the actual opportunities and the barriers to refugees’ participation in and completion of VET at upper secondary level in the three selected countries. Methods: The study is based on reviews of literature and an analysis of refugee policies in the three countries. The literature search used a snowballing strategy and included policy documents, research publications and grey literature from organisations of civil society. The literature review employed a narrative, issue-focused approach to explore and compare key categories relating to the research question. To elaborate, refine and structure the categories for each of the three countries we used an input-process-output model (Adams, 1993) and a combination of deductive and inductive analysis procedure. Findings: The findings of the study are divided into six categories that structure the analysis: admission requirements, validation of prior learning, vocational guidance, language training, social support measures and access to apprenticeships. The analysis finds that both asylum seekers and recognised refugees have more opportunities in Germany than in the other two countries regarding the key categories. The findings show no major differences in the position of the social partners in the three countries in relation to refugees’ participation in VET, however the national governments reacted differently to the influx of refugees. In Austria and Denmark, new governments with strong anti-immigration agendas took office and reduced the access to and participation in VET for asylum seekers and refugees. At the same time, the German government introduced various integration measures for refugees in cooperation with employers with the aim of making VET more accessible to refugees. Conclusion: To access and complete VET, refugees depend on supporting measures to overcome a variety of barriers, e.g. regarding language training and access to apprenticeships. Overall, reforms in Germany demonstrate promising initiatives to overcome the barriers to the integration of refugees in VET, while reforms in Austria and Denmark have limited refugees’ opportunities to access and complete VET. (DIPF/Orig.

Optical Coherence Tomography and Optical Coherence Tomography Angiography in Monitoring Coats’ Disease

Purpose. The aim of this study was to evaluate the usefulness of optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) in monitoring pediatric patients with Coats’ disease. Material and Methods. This retrospective study included 9 Caucasian patients receiving treatment for Coats’ disease at the Children’s Memorial Health Institute Ophthalmology Department between December 2014 and May 2016. The course of the disease was monitored with OCTA in combination with OCT and fluorescein angiography (FA). Results. OCT B-scans obtained in all patients correlated with FA findings. Reliable OCTA images were obtained in 8 patients. In one patient, numerous artifacts due to poor visual acuity and retinal detachment confounded the interpretation of findings. Conclusions. OCTA and OCT, in combination with FA, are useful in Coats’ disease diagnostics and treatment monitoring. As noninvasive methods, OCT and OCTA may be performed more often than FA, which enable precise monitoring of the disease and making decisions as to its further treatment

Is language an issue? Accuracy of the German computerized diagnostic decision support system ISABEL and cross-validation with the English counterpart.

OBJECTIVES Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients (Isabel Symptom Checker) from ISABEL Healthcare have not been validated yet. METHODS We entered clinical features of 50 patient vignettes taken from an emergency medical text book and 50 real cases with a confirmed diagnosis derived from the electronic health record (EHR) of a large academic Swiss emergency room into the German versions of Isabel Pro and Isabel Symptom Checker. We analysed the proportion of DDx lists that included the correct diagnosis. RESULTS Isabel Pro and Symptom Checker provided the correct diagnosis in 82 and 71 % of the cases, respectively. Overall, the correct diagnosis was ranked in 71 , 61 and 37 % of the cases within the top 20, 10 and 3 of the provided DDx when using Isabel Pro. In general, accuracy was higher with vignettes than ED cases, i.e. listed the correct diagnosis more often (non-significant) and ranked the diagnosis significantly more often within the top 20, 10 and 3. On average, 38 ± 4.5 DDx were provided by Isabel Pro and Symptom Checker. CONCLUSIONS The German versions of Isabel achieved a somewhat lower accuracy compared to previous studies of the English version. The accuracy decreases substantially when the position in the suggested DDx list is taken into account. Whether Isabel Pro is accurate enough to improve diagnostic quality in clinical ED routine needs further investigation

Measuring consumers' engagement with brand-related social-media content: development and validation of a scale that identifies levels of social-media engagement with brands

The main purpose of this study is to develop a scale to measure consumer's engagement with social media brand-related content. The reported scale (CESBC) comprises three dimensions: consumption, contribution, and creation. Qualitative techniques were used to generate an initial pool of items that capture different levels of consumer engagement with social media brand-related content. Quantitative data from a consumer survey (=2252) was then collected in two phases to calibrate and validate the ensuing scale. Results confirmed the structure and psychometric properties of the CESBC. As expected, each subscale is significantly correlated with nomological network constructs, i.e., brand equity and brand attitudes

Was British business destined to leave the EU?

Was British business destined to leave the EU? While corporate UK was strongly opposed to Brexit, their strategies tell a slightly different story, write Michael Mayer, Julia Hautz, Christian Stadler and Richard Whittington. Always good to start with a confession: we are what Brexiteers call Remoaners. As Michael Bloomberg says, "it is really hard to understand why a country that was doing ..