Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions.

Introduction: Self-regulated learning is a cyclical process of forethought, performance, and self-reflection that has been used as an assessment tool in medical education. No prior studies have evaluated SRL processes for answering multiple-choice questions (MCQs) and most evaluated one or two iterations of a non-MCQ task. SRL assessment during MCQs may elucidate reasons why learners are successful or not on these questions that are encountered repeatedly during medical education. Methods: Internal medicine clerkship students at three institutions participated in a SRL microanalytic protocol that targeted strategic planning, metacognitive monitoring, causal attributions, and adaptive inferences across seven MCQs. Responses were transcribed and coded according to previously published methods for microanalytic protocols. Results: Forty-four students participated. In the forethought phase, students commonly endorsed prioritizing relevant features as their diagnostic strategy (n = 20, 45%) but few mentioned higher-order diagnostic reasoning processes such as integrating clinical information (n = 5, 11%) or comparing/contrasting diagnoses (n = 0, 0%). However, in the performance phase, students' metacognitive processes included high frequencies of integration (n = 38, 86%) and comparing/contrasting (n = 24, 55%). In the self-reflection phase, 93% (n = 41) of students faulted their management reasoning and 84% (n = 37) made negative references to their abilities. Less than 10% (n = 4) of students indicated that they would adapt their diagnostic reasoning process for these questions. Discussion: This study describes in detail student self-regulatory processes during MCQs. We found that students engaged in higher-order diagnostic reasoning processes but were not explicit about it and seldom reflected critically on these processes after selecting an incorrect answer. Self-reflections focused almost exclusively on management reasoning and negative references to abilities which may decrease self-efficacy. Encouraging students to identify and evaluate diagnostic reasoning processes and make attributions to controllable factors may improve performance.

Effects of live and video simulation on clinical reasoning performance and reflection.

INTRODUCTION: In recent years, researchers have recognized the need to examine the relative effectiveness of different simulation approaches and the experiences of physicians operating within such environments. The current study experimentally examined the reflective judgments, cognitive processing, and clinical reasoning performance of physicians across live and video simulation environments. METHODS: Thirty-eight physicians were randomly assigned to a live scenario or video case condition. Both conditions encompassed two components: (a) patient encounter and (b) video reflection activity. Following the condition-specific patient encounter (i.e., live scenario or video), the participants completed a Post Encounter Form (PEF), microanalytic questions, and a mental effort question. Participants were then instructed to re-watch the video (i.e., video condition) or a video recording of their live patient encounter (i.e., live scenario) while thinking aloud about how they came to the diagnosis and management plan. RESULTS: Although significant differences did not emerge across all measures, physicians in the live scenario condition exhibited superior performance in clinical reasoning (i.e., PEF) and a distinct profile of reflective judgments and cognitive processing. Generally, the live condition participants focused more attention on aspects of the clinical reasoning process and demonstrated higher level cognitive processing than the video group. CONCLUSIONS: The current study sheds light on the differential effects of live scenario and video simulation approaches. Physicians who engaged in live scenario simulations outperformed and showed a distinct pattern of cognitive reactions and judgments compared to physicians who practiced their clinical reasoning via video simulation. Additionally, the current study points to the potential advantages of video self-reflection following live scenarios while also shedding some light on the debate regarding whether video-guided reflection, specifically, is advantageous. The utility of context-specific, micro-level assessments that incorporate multiple methods as physicians complete different parts of clinical tasks is also discussed.

First-year medical students' calibration bias and accuracy across clinical reasoning activities.

To be safe and effective practitioners and learners, medical professionals must be able to accurately assess their own performance to know when they need additional help. This study explored the metacognitive judgments of 157 first-year medical students; in particular, the study examined students' self-assessments or calibration as they engaged in a virtual-patient simulation targeting clinical reasoning practices. Examining two key subtasks of a patient encounter, history (Hx) and physical exam (PE), the authors assessed the level of variation in students' behavioral performance (i.e., effectiveness and efficiency) and judgments of performance (i.e., calibration bias and accuracy) across the two subtasks. Paired t tests revealed that the Hx subtask was deemed to be more challenging than the PE subtask when viewed in terms of both actual and perceived performance. In addition to students performing worse on the Hx subtask than PE, they also perceived that they performed less well for Hx. Interestingly, across both subtasks, the majority of participants overestimated their performance (98% of participants for Hx and 95% for PE). Correlation analyses revealed that the participants' overall level of accuracy in metacognitive judgments was moderately stable across the Hx and PE subtasks. Taken together, findings underscore the importance of assessing medical students' metacognitive judgments at different points during a clinical encounter.

Multidimensional assessment of self-regulated learning with middle school math students.

This study examined the convergent and predictive validity of self-regulated learning (SRL) measures situated in mathematics. The sample included 100 eighth graders from a diverse, urban school district. Four measurement formats were examined including, 2 broad-based (i.e., self-report questionnaire and teacher ratings) and 2 task-specific measures (i.e., SRL microanalysis and behavioral traces). Convergent validity was examined across task-difficulty, and the predictive validity was examined across 3 mathematics outcomes: 2 measures of mathematical problem solving skill (i.e., practice session math problems, posttest math problems) and a global measure of mathematical skill (i.e., standardized math test). Correlation analyses were used to examine convergent validity and revealed medium correlations between measures within the same category (i.e., broad-based or task-specific). Relations between measurement classes were not statistically significant. Separate regressions examined the predictive validity of the SRL measures. While controlling all other predictors, a SRL microanalysis metacognitive-monitoring measure emerged as a significant predictor of all 3 outcomes and teacher ratings accounted for unique variance on 2 of the outcomes (i.e., posttest math problems and standardized math test). Results suggest that a multidimensional assessment approach should be considered by school psychologists interested in measuring SRL. (PsycINFO Database Record

Effects of the Self-Regulation Empowerment Program (SREP) on middle school students' strategic skills, self-efficacy, and mathematics achievement.

The current study examined the effectiveness of an applied self-regulated learning intervention (Self-Regulation Empowerment Program (SREP)) relative to an existing, school-based remedial mathematics intervention for improving the motivation, strategic skills, and mathematics achievement of academically at-risk middle school students. Although significant group differences in student self-regulated learning (SRL) were not observed when using self-report questionnaires, medium to large and statistically significant group differences were observed across several contextualized, situation-specific measures of strategic and regulatory thinking. The SREP group also exhibited a statistically significant and more positive trend in achievement scores over two years in middle school relative to the comparison condition. Finally, SREP students and coaches reported SREP to be a socially-valid intervention, in terms of acceptability and importance. The importance of this study and critical areas for future research are highlighted and discussed.

Microanalytic Assessment of Self-Regulated Learning During Clinical Reasoning Tasks: Recent Developments and Next Steps.

Helping medical educators obtain and use assessment data to assist medical students, residents, and physicians in reducing diagnostic errors and other forms of ineffective clinical practice is of critical importance. Self-Regulated Learning-Microanalytic Assessment and Training is an assessment-to-intervention framework designed to address this need by generating data about trainees' strategic processes (e.g., focusing on clinical task procedures), regulatory processes (e.g., planning how to do a task), and motivational processes (e.g., increasing confidence for performing a task) as they perform clinical activities. In this article, the authors review several studies that have used an innovative assessment approach, called self-regulated learning (SRL) microanalysis, to generate data about how trainees regulate their thinking and actions during clinical reasoning tasks. Across the studies, initial findings revealed that medical students often do not exhibit strategic thinking and action during clinical reasoning practice tasks even though some regulatory processes (e.g., planning) are predictive of important medical education outcomes. Further, trainees' motivation beliefs, strategic thinking, and self-evaluative judgments tend to shift rapidly during clinical skills practice and may also vary across different parts of a patient encounter. Collectively, these findings underscore the value of dynamically assessing trainees' SRL as they complete clinical tasks. The findings also set the stage for exploring how medical educators can best use SRL microanalytic assessment data to guide remedial practices and the provision of feedback to trainees. Implications and future research directions for connecting assessments to intervention in medical education are discussed.

Examining shifts in medical students' microanalytic motivation beliefs and regulatory processes during a diagnostic reasoning task.

This study examined within-group shifts in the motivation beliefs and regulatory processes of second-year medical students as they engaged in a diagnostic reasoning activity. Using a contextualized assessment methodology called self-regulated learning microanalysis, the authors found that the 71 medical student participants showed statistically significant and relatively robust declines in their self-efficacy beliefs and strategic regulatory processes following negative feedback about their performance on the diagnostic reasoning task. Descriptive statistics revealed that changes in strategic thinking following negative corrective feedback were most characterized by shifts away from task-specific processes (e.g., integration, differentiating diagnoses) to non-task related factors. Implications and areas for future research are presented and discussed.

Examining parents' ratings of middle-school students' academic self-regulation using principal axis factoring analysis.

This study examined the reliability and validity of a parent rating scale, the Self-Regulation Strategy Inventory: Parent Rating Scale (SRSI-PRS), using a sample of 451 parents of sixth- and seventh-grade middle-school students. Principal axis factoring (PAF) analysis revealed a 3-factor structure for the 23-item SRSI-PRS: (a) Managing Behavior and Learning (α = .92), (b) Maladaptive Regulatory Behaviors (α = .76), and (c) Managing Environment (α = .84). The majority of the observed relations between these 3 subscales, and the SRSI-SR, student motivation beliefs, and student mathematics grades were statistically significant and in the small to medium range. After controlling for various student variables and motivation indices of parental involvement, 2 SRSI-PRS factors (Managing Behavior and Learning, Maladaptive Regulatory Behaviors) reliably predicted students' achievement in their mathematics course. This study provides initial support for the validity and reliability of the SRSI-PRS and underscores the advantages of obtaining parental ratings of students' SRL behaviors.

Exploring clinical reasoning in novices: a self-regulated learning microanalytic assessment approach.

OBJECTIVES: The primary objectives of this study were to examine the regulatory processes of medical students as they completed a diagnostic reasoning task and to examine whether the strategic quality of these regulatory processes were related to short-term and longer-term medical education outcomes. METHODS: A self-regulated learning (SRL) microanalytic assessment was administered to 71 second-year medical students while they read a clinical case and worked to formulate the most probable diagnosis. Verbal responses to open-ended questions targeting forethought and performance phase processes of a cyclical model of SRL were recorded verbatim and subsequently coded using a framework from prior research. Descriptive statistics and hierarchical linear regression models were used to examine the relationships between the SRL processes and several outcomes. RESULTS: Most participants (90%) reported focusing on specific diagnostic reasoning strategies during the task (metacognitive monitoring), but only about one-third of students referenced these strategies (e.g. identifying symptoms, integration) in relation to their task goals and plans for completing the task. After accounting for prior undergraduate achievement and verbal reasoning ability, strategic planning explained significant additional variance in course grade (ΔR(2 ) = 0.15, p < 0.01), second-year grade point average (ΔR(2) = 0.14, p < 0.01), United States Medical Licensing Examination Step 1 score (ΔR(2) = 0.08, p < 0.05) and National Board of Medical Examiner subject examination score in internal medicine (ΔR(2) = 0.10, p < 0.05). CONCLUSIONS: These findings suggest that most students in the formative stages of learning diagnostic reasoning skills are aware of and think about at least one key diagnostic reasoning process or strategy while solving a clinical case, but a substantially smaller percentage set goals or develop plans that incorporate such strategies. Given that students who developed more strategic plans achieved better outcomes, the potential importance of forethought regulatory processes is underscored.

Self-regulation theory: applications to medical education: AMEE Guide No. 58.

Self-regulation theory, as applied to medical education, describes the cyclical control of academic and clinical performance through several key processes that include goal-directed behaviour, use of specific strategies to attain goals, and the adaptation and modification to behaviours or strategies to optimise learning and performance. Extensive research across a variety of non-medical disciplines has highlighted differences in key self-regulation processes between high- and low-achieving learners and performers. Structured identification of key self-regulation processes can be used to develop specific remediation approaches that can improve performance in academic and complex psycho-motor skills. General teaching approaches that are guided by a self-regulation perspective can also enhance academic performance. Self-regulation theory offers an exciting potential for improving academic and clinical performance in medical education.

Assessing self-regulatory processes during clinical skill performance: a pilot study.

BACKGROUND: Self-regulated learning (SRL) is a cyclical process involving the proactive use of strategies and feedback to optimise performance. Previous research has used SRL microanalysis to assess and inform the training of athletic skills but there has been no previous research in clinical contexts. AIMS: The aim of this pilot study was to evaluate the use SRL microanalysis to assess the regulatory profiles of students who were successful and unsuccessful in a venipuncture task. METHOD: A SRL microanalysis protocol was administered to seven 3rd-year undergraduate medical students whilst they performed a venipuncture on a simulation mannequin arm. RESULTS: The use of SRL microanalytic questions had good inter-rater reliability. Students who were successful in venipuncture had high levels of strategic thinking before, during and after the clinical task, whereas the students who struggled on this task tended to focus on outcomes. CONCLUSIONS: The results shown in this study mirror the findings from previous research using SRL microanalysis. SRL microanalysis has strong potential as a structured assessment technique targeting the self-regulatory processes underlying clinical skill performance. Further research is recommended, especially on how the assessment of self-regulatory skills can be used to guide training for struggling students.

Perspective: viewing "strugglers" through a different lens: how a self-regulated learning perspective can help medical educators with assessment and remediation.

Medical educators are responsible for training current and future generations of physicians; this includes the early and accurate identification of "struggling" medical trainees, which has implications for future training, practice, and success.The authors propose a theory-based framework, Self-Regulated Learning-Microanalytic Assessment and Training (SRL-MAT), that is specifically designed to foster individual medical trainee self-regulatory beliefs and behaviors, and thus provide a distinct method to assist medical trainees who struggle. The SRL-MAT is grounded in social-cognitive theory and research and makes a variety of important assumptions about learning and the essential techniques needed to evaluate trainee functioning. Two critical assumptions are that (1) self-efficacy beliefs are a key personal process affecting trainee behavior, and (2) trainee beliefs and behaviors are dynamic and fluid in nature and thus will often vary across educational contexts, as well as for specific tasks within those contexts. To address these assumptions, the SRL-MAT uses an emergent assessment approach called self-regulated learning microanalysis, a procedure that involves asking a series of temporally sequenced questions about specific regulatory processes as trainees engage in an authentic task or activity. The framework, which is grounded in a foundation of established educational research, is adaptable to practically any task that has a clear beginning and end. The authors believe this framework could make important contributions to traditional medical training assessment frameworks that have been used to identify and remediate strugglers.

Self-regulation, motivation, and math achievement in middle school: variations across grade level and math context.

The current study examined grade level, achievement group, and math-course-type differences in student self-regulation and motivation in a sample of 880 suburban middle-school students. Analysis of variance was utilized to assess group differences in student self-regulation and motivation, and linear regression analysis was used to identify variables that best predicted students' use of regulatory strategies. A key finding was that although seventh graders exhibited a more maladaptive self-regulation and motivation profile than sixth graders, achievement groups in seventh grade (high, moderate, low) were more clearly differentiated across both self-regulation and motivation than achievement groups in sixth grade. The pattern of achievement group differences also varied across math course type, as self-regulation and motivation processes more consistently differentiated achievement groups in advanced classes than regular math courses. Finally, task interest was shown to be the primary motivational predictor of students' use of regulatory strategies during math learning. The study highlights the importance of identifying shifting student motivation and self-regulation during the early middle school years and the potential role that context may have on these processes.

Detection of group B streptococci in Lim broth by use of group B streptococcus peptide nucleic acid fluorescent in situ hybridization and selective and nonselective agars.

The sensitivity, specificity, and positive and negative predictive values for the detection of group B streptococci from Lim enrichment broth with sheep blood agar (SBA), with selective Streptococcus agar (SSA), and by a peptide nucleic acid fluorescent in situ hybridization (PNA FISH) assay were as follows: for culture on SBA, 68.4%, 100%, 100%, and 87.9%, respectively; for culture on SSA, 85.5%, 100%, 100%, and 94.1%, respectively; and for the PNA FISH assay, 97.4%, 98.3%, 96.1%, and 98.9%, respectively.

Training physical education students to self-regulate during basketball free throw practice.

The additive effects of self-regulation training in forethought, performance, and self-reflection phase processes on acquiring a novel motoric skill (i.e., basketball free throws) and self-reflective beliefs were studied with 50 college students. The results showed a positive linear trend between the number of self-regulatory phases, in which the participants were trained, and their free throw shooting performance and shooting adaptation. The two- and three-phase training groups displayed significantly more accurate free throws and were able to self-correct their shooting form more frequently following missed shots than all other groups. Participants who received three-phase training displayed the most adaptive motivational profile, characterized by making strategic attributions and adaptive inferences and by using self/process criteria during self-evaluations.

Rapid and specific detection of Mycobacterium tuberculosis by using the Smart Cycler instrument and a specific fluorogenic probe.

A procedure using the Smart Cycler instrument and a fluorescence quencher (FQ) probe for the specific identification of Mycobacterium tuberculosis complex (MTB) was used to detect organisms in 366 acid-fast bacillus smear-positive respiratory specimens. It was compared to culture and the AMPLICOR M. tuberculosis PCR test. MTB was isolated from 198 of these samples. The FQ PCR assay was sensitive (197 of 198, 99.5%) and specific (165 of 168, 98.2%); no significant difference was observed between the two PCR protocols. After DNA extraction, a final result was available within 1.5 h with the real-time PCR protocol.