Resilience status of dental students and derived training needs and interventions to promote resilience.

Background: The concept of resilience is defined differently in the literature, with the definition depending on the criteria under consideration. Currently, the most commonly used definition is: resilience as "psychological resistance to biological, psychological, and psychosocial developmental risks". In order to systematically enhance resilience, it is necessary to first determine specific training needs. This study examines the resilience status of dental students in Germany from different academic years and derives interventions for resilience enhancement, as the field of dentistry is considered one of the "most stressful professions". Methods: To determine the resilience status, a questionnaire was developed, consisting of the 10-Item Connor-Davidson Resilience Scale (10-Item CD-RISC), the Maslach Burnout Inventory Scale (MBI), the Negative Self-Image Scale (NSBS), and five self-formulated closed-ended questions. A total of 320 questionnaires were distributed, with 184 responses (43.7% female) received, including partially completed forms. Results: The resilience status shows an average moderate level of resilience (M=28.43; SD=5.57). The subcomponents of emotional exhaustion (M=23.66; SD=8.32) and reduced personal performance (M=33.69; SD=8.47) indicate an increased risk of burnout, but not depersonalization (M=5.04; SD=5.50). Overall, the participants have a positive self-image (M=1.72; SD=0.69). Conclusion: The study reveals that dental students have a moderate level of resilience. Dental students are not inherently prone to burnout, but they show reduced levels of emotional exhaustion and personal performance, suggesting a need for interventions in these areas. Possible interventions tailored to these training needs are discussed in the article. Further research is needed to determine the effectiveness of these interventions.

Development of individual competencies and team performance in interprofessional ward rounds: results of a study with multimodal observations at the Heidelberg Interprofessional Training Ward.

Introduction: Interprofessional training wards (IPTW) aim to improve undergraduates' interprofessional collaborative practice of care. Little is known about the effects of the different team tasks on IPTW as measured by external assessment. In Heidelberg, Germany, four nursing and four medical undergraduates (= one cohort) care for up to six patients undergoing general surgery during a four-week placement. They learn both professionally and interprofessionally, working largely on their own responsibility under the supervision of the medical and nursing learning facilitators. Interprofessional ward rounds are a central component of developing individual competencies and team performance. The aim of this study was to evaluate individual competencies and team performance shown in ward rounds. Methods: Observations took place in four cohorts of four nursing and four medical undergraduates each. Undergraduates in one cohort were divided into two teams, which rotated in morning and afternoon shifts. Team 1 was on morning shift during the first (t0) and third (t1) weeks of the IPTW placement, and Team 2 was on morning shift during the second (t0) and fourth (t1) weeks. Within each team, a tandem of one nursing and one medical undergraduate cared for a patient room with three patients. Ward round observations took place with each team and tandem at t0 and t1 using the IP-VITA instrument for individual competencies (16 items) and team performance (11 items). Four hypotheses were formulated for statistical testing with linear mixed models and correlations. Results: A total of 16 nursing and medical undergraduates each were included. There were significant changes in mean values between t0 and t1 in individual competencies (Hypothesis 1). They were statistically significant for all three sum scores: "Roles and Responsibilities", Patient-Centeredness", and "Leadership". In terms of team performance (Hypothesis 2), there was a statistically significant change in mean values in the sum score "Roles and Responsibilities" and positive trends in the sum scores "Patient-Centeredness" and "Decision-Making/Collaborative Clinical Reasoning". Analysis of differences in the development of individual competencies in the groups of nursing and medical undergraduates (Hypothesis 3) showed more significant differences in the mean values of the two groups in t0 than in t1. There were significant correlations between individual competencies and team performance at both t0 and t1 (Hypothesis 4). Discussion: The study has limitations due to the small sample and some sources of bias related to the external assessment by means of observation. Nevertheless, this study offers insights into interprofessional tasks on the IPTW from an external assessment. Results from quantitative and qualitative analysis of learners self-assessment are confirmed in terms of roles and responsibilities and patient-centeredness. It has been observed that medical undergraduates acquired and applied skills in collaborative clinic reasoning and decision-making, whereas nursing undergraduates acquired leadership skills. Within the study sample, only a small group of tandems remained constant over time. In team performance, the group of constant tandems tended to perform better than the group of random tandems. The aim of IPTW should be to prepare healthcare team members for the challenge of changing teams. Therefore, implications for IPTW implementation could be to develop learning support approaches that allow medical and nursing undergraduates to bring interprofessional competencies to team performance, independent of the tandem partner or team.

Dog assisted education in children with rheumatic diseases and adolescents with chronic pain in Germany.

Objectives: Animal assisted intervention is an increasingly accepted tool to improve human well-being. The present study was performed to assess whether dog assisted education has a positive effect on children suffering from rheumatic disorders with pain and adolescents with chronic pain syndrome. Design: Two groups of juvenile patients were recruited: 7-17-year-old children in children with rheumatic diseases and adolescents with chronic pain syndromes. Overall, n=26 participated in the intervention, and n=29 in the control group. Setting: The intervention group met once a month, 12 times overall, for working with man trailing dogs in various locations. Main outcome measures: The influence of dog assisted education on quality of life (PedsQLTM Scoring Algorithm), pain intensity, perception, coping (Paediatric Pain Coping Inventory-Revised), and state anxiety (State Trait Anxiety Inventory) was assessed. Results: The quality of life increased significantly in the investigated period, but for both, the intervention and the control group. The state anxiety of children was lower after the dog assisted education than before. After the dog training sessions, state anxiety was 18% to 30% lower than before the intervention. Some participants noted subjectively improved pain coping and changes in pain perception, which were not found in the data. Conclusion: Our results indicate that for children with rheumatic diseases and adolescents with chronic pain syndromes dog assisted education (1) might lead to an increase of the quality of life, (2) leads to decreased state anxiety from pre to post intervention and (3) does not influence pain perception, frequency and intensity.

[Measuring individual competencies and team performance in clinical learning settings of interprofessional collaborative practice: Empirical development of the Interprofessional Ward Round Individual and Team Assessment Tool (IP-VITA)]. / Individuelle Kompetenzen und Team-Performance in klinischen Lernsettings der interprofessionellen Zusammenarbeit erfassen: Die empirische Entwicklung des Interprofessionelle Visiten Individual und Team Assessment Tools (IP-VITA).

BACKGROUND: Interprofessional training wards (IPTW) can contribute to the development of interprofessional competencies. In order to evaluate the acquisition of competencies, instruments are needed that record both team performance and individual competencies in the clinical teaching setting in third-party assessment. This paper describes the Interprofessional Ward Round Individual and Team Assessment-Tool, IP-VITA ("Interprofessionelle Visiten Individual und Team Assessment Tool") and its development. METHOD: Based on the empirical exploration of the three observation instruments "Teamwork Assessment Scale" (TAS), "McMaster-Ottawa Scale" and "Individual Teamwork Observation and Feedback Tool" (iTOFT) in at least four rounds each at the HIPSTA (with n=8 students and trainees each), a preliminary version of the IP-VITA was created. This preliminary version was then refined in subsequent empirical steps: a consensual validation in the research team was followed by a "member check" with the clinical colleagues of the HIPSTA, the input from external experts and an empirical test in an alternative setting. RESULTS: The IP-VITA is an empirically developed multimodal instrument to assess the interprofessional competencies of trainees and students as well as their team performance in clinical settings with patient interaction. It comprises three parts. In part A, structural data, the persons involved and the essential patient characteristics are recorded. Part B consists of 12 items and a free-text field for recording behaviour at the individual level. Part C also consists of 12 items and evaluates behaviour at team level. DISCUSSION: The IP-VITA instrument was developed specifically for the context of evaluating interprofessional ward rounds in a clinical educational setting. The instrument takes into account the ambiguous position of the assessment of interprofessional collaboration between individual competence and team performance. Beyond the HIPSTA, it can be used as a formative assessment instrument, and it may also be useful for summative assessments.

Differences in clinical reasoning between female and male medical students.

OBJECTIVES: In undergraduate medical education virtual patients (VPs) are a suitable method to teach clinical reasoning and support the visualization of this thinking process in a safe environment. The aim of our study was to investigate differences in the clinical reasoning process and diagnostic accuracy of female and male medical students. METHODS: During the summer term 2020, we provided access to 15 VPs for undergraduate students enrolled in a medical school in Bavaria, Germany. All interactions of the 179 learners within the VP system CASUS were recorded, exported, and analyzed. RESULTS: We found significant differences in the clinical reasoning of female and male learners. Female students documented more findings, differential diagnoses, tests, and treatment options and more often created a summary statement about the VP. Their overall performance was higher than those of their male peers, but we did not see any significant differences in diagnostic accuracy. CONCLUSIONS: The significant differences between male and female medical students should be considered when planning teaching and research activities. A future study should investigate whether these differences can also be found in physicians.

Implementing Remote Collaboration in a Virtual Patient Platform: Usability Study.

BACKGROUND: Learning with virtual patients is highly popular for fostering clinical reasoning in medical education. However, little learning with virtual patients is done collaboratively, despite the potential learning benefits of collaborative versus individual learning. OBJECTIVE: This paper describes the implementation of student collaboration in a virtual patient platform. Our aim was to allow pairs of students to communicate remotely with each other during virtual patient learning sessions. We hypothesized that we could provide a collaborative tool that did not impair the usability of the system compared to individual learning and that this would lead to better diagnostic accuracy for the pairs of students. METHODS: Implementing the collaboration tool had five steps: (1) searching for a suitable software library, (2) implementing the application programming interface, (3) performing technical adaptations to ensure high-quality connections for the users, (4) designing and developing the user interface, and (5) testing the usability of the tool in 270 virtual patient sessions. We compared dyad to individual diagnostic accuracy and usability with the 10-item System Usability Scale. RESULTS: We recruited 137 students who worked on 6 virtual patients. Out of 270 virtual patient sessions per group (45 dyads times 6 virtual patients, and 47 students working individually times 6 virtual patients minus 2 randomly selected deleted sessions) the students made successful diagnoses in 143/270 sessions (53%, SD 26%) when working alone and 192/270 sessions (71%, SD 20%) when collaborating (P=.04, η2=0.12). A usability questionnaire given to the students who used the collaboration tool showed a usability score of 82.16 (SD 1.31), representing a B+ grade. CONCLUSIONS: The collaboration tool provides a generic approach for collaboration that can be used with most virtual patient systems. The collaboration tool helped students diagnose virtual patients and had good overall usability. More broadly, the collaboration tool will provide an array of new possibilities for researchers and medical educators alike to design courses for collaborative learning with virtual patients.

[Impact of the experience of urological senior physicians in Germany on professional and personal aspects]. / Welchen Einfluss hat die Dauer der Oberarzttätigkeit auf die Berufsausübung und Zufriedenheit urologischer OberärztInnen in Deutschland?

BACKGROUND: Urological senior physicians in Germany are a heterogeneous group with various clinical priorities and career objectives. To date, there are no reliable data concerning the impact of the time span for which senior physicians have been holding their position on professional, personal and position-linked aspects. MATERIAL AND METHODS: The objective of this study was a comparative analysis of perspectives, private and professional settings, specific job-related activities and individual professional goals of urological senior physicians in Germany based on their experience in this position assessed as number of years (dichotomised at 8 years as senior physician). As part of a cross-sectional study, a 55-item web-based questionnaire was designed, which was sent via a link to members of a mailing list of the German Society of Urology. The survey was available for urological senior physicians between February and April 2019. Group differences were evaluated using multivariate regression models. RESULTS: 107 of 192 evaluable questionnaires were completed by senior physicians holding this position for less than 8 years (< 8y senior physicians), 85 were completed by senior physicians holding this position for at least 8 years (≥ 8y senior physicians). < 8y senior physicians worked significantly more often at university hospitals (42.1 % vs. 18.8 %, p = 0.002). Overall, 82.4 % of ≥ 8y senior physicians assessed themselves autonomously safe in performing open surgery, compared to 39.3 % among < 8y senior physicians (p < 0.001). No significant differences concerning the self-assessment were found for endourological procedures (94.1 % vs. 87.9 %) and for the overall lower-rated self-assessment concerning laparoscopy (29.4 % vs. 20.6 %) and robotic surgery (14.1 % vs. 10.3 %). Despite the high management responsibility associated with their position, only about one third of participants (34.8 %) had received specific postgraduate education preparing them for managing and executive tasks. CONCLUSION: This study shows significant differences among senior physicians regarding surgical skills depending on the time span they hold their position. Moreover, there is considerable dissatisfaction regarding the development of leadership skills and the preparation for managing tasks. In order to ensure availability of senior staff members for the field of urology in the future, it is important to consider their professional needs and to overcome existing shortcomings by education programs within well-orchestrated human resources development strategies.

Diagnostic Activities and Diagnostic Practices in Medical Education and Teacher Education: An Interdisciplinary Comparison.

In this article, we investigate diagnostic activities and diagnostic practices in medical education and teacher education. Previous studies have tended to focus on comparing knowledge between disciplines, but such an approach is complicated due to the content specificity of knowledge. We compared 142 learners from medical education and 122 learners from teacher education who were asked to (a) diagnose eight simulated cases from their respective discipline in a simulation-based learning environment and (b) write a justificatory report for each simulated case. We coded all justificatory reports regarding four diagnostic activities: generating hypotheses, generating evidence, evaluating evidence, and drawing conclusions. Moreover, using the method of Epistemic Network Analysis, we operationalized diagnostic practices as the relative frequencies of co-occurring diagnostic activities. We found significant differences between learners from medical education and teacher education with respect to both their diagnostic activities and diagnostic practices. Learners from medical education put relatively more emphasis on generating hypotheses and drawing conclusions, therefore applying a more hypothesis-driven approach. By contrast, learners in teacher education had a stronger focus on generating and evaluating evidence, indicating a more data-driven approach. The results may be explained by different epistemic ideals and standards taught in higher education. Further research on the issue of epistemic ideals and standards in diagnosing is needed. Moreover, we recommend that educators think beyond individuals' knowledge and implement measures to systematically teach and increase the awareness of disciplinary standards.

Learning clinical reasoning: how virtual patient case format and prior knowledge interact.

INTRODUCTION: Clinical reasoning has been fostered with varying case formats including the use of virtual patients. Existing literature points to different conclusions regarding which format is most beneficial for learners with diverse levels of prior knowledge. We designed our study to better understand which case format affects clinical reasoning outcomes and cognitive load, dependent on medical students' prior knowledge. METHODS: Overall, 142 medical students (3 rd to 6 th year) were randomly assigned to either a whole case or serial cue case format. Participants worked on eight virtual patients in their respective case format. Outcomes included diagnostic accuracy, knowledge, and cognitive load. RESULTS: We found no effect of case format on strategic knowledge scores pre- vs post-test (whole case learning gain = 3, 95% CI. -.01 to .01, serial cue learning gain = 3, 95% CI. -.06 to .00 p = .50). In both case formats, students with high baseline knowledge (determined by median split on the pre-test in conceptual knowledge) benefitted from learning with virtual patients (learning gain in strategic knowledge = 5, 95% CI .03 to .09, p = .01) while students with low prior knowledge did not (learning gain = 0, 95%CI -.02 to .02). We found no difference in diagnostic accuracy between experimental conditions (difference = .44, 95% CI -.96 to .08, p = .22), but diagnostic accuracy was higher for students with high prior knowledge compared to those with low prior knowledge (difference = .8, 95% CI 0.31 to 1.35, p < .01). Students with low prior knowledge experienced higher extraneous cognitive load than students with high prior knowledge (multiple measurements, p < .01). CONCLUSIONS: The whole case and serial cue case formats alone did not affect students' knowledge gain or diagnostic accuracy. Students with lower knowledge experienced increased cognitive load and appear to have learned less from their interaction with virtual patients. Cognitive load should be taken into account when attempting to help students learn clinical reasoning with virtual patients, especially for students with lower knowledge.

Guessing right - whether and how medical students give incorrect reasons for their correct diagnoses.

Background: Clinical reasoning is one of the central competencies in everyday clinical practice. Diagnostic competence is often measured based on diagnostic accuracy. It is implicitly assumed that a correct diagnosis is based on a proper diagnostic process, although this has never been empirically tested. The frequency and nature of errors in students' diagnostic processes in correctly solved cases was analyzed in this study. Method: 148 medical students processed 15 virtual patient cases in internal medicine. After each case, they were asked to state their final diagnosis and justify it. These explanations were qualitatively analyzed and assigned to one of the following three categories: correct explanation, incorrect explanation and diagnosis guessed right. Results: The correct diagnosis was made 1,135 times out of 2,080 diagnostic processes. The analysis of the associated diagnostic explanations showed that 92% (1,042) reasoning processes were correct, 7% (80) were incorrect, and 1% (13) of the diagnoses were guessed right. Causes of incorrect diagnostic processes were primarily a lack of pathophysiological knowledge (50%) and a lack of diagnostic skills (30%). Conclusion: Generally, if the diagnosis is correct, the diagnostic process is also correct. The rate of guessed diagnoses is quite low at 1%. Nevertheless, about every 14th correct diagnosis is based on a false diagnostic explanation and thus, a wrong diagnostic process. To assess the diagnostic competence, both the diagnosis result and the diagnostic process should be recorded.

Can clinical case discussions foster clinical reasoning skills in undergraduate medical education? A randomised controlled trial.

OBJECTIVE: Fostering clinical reasoning is a mainstay of medical education. Based on the clinicopathological conferences, we propose a case-based peer teaching approach called clinical case discussions (CCDs) to promote the respective skills in medical students. This study compares the effectiveness of different CCD formats with varying degrees of social interaction in fostering clinical reasoning. DESIGN, SETTING, PARTICIPANTS: A single-centre randomised controlled trial with a parallel design was conducted at a German university. Study participants (N=106) were stratified and tested regarding their clinical reasoning skills right after CCD participation and 2 weeks later. INTERVENTION: Participants worked within a live discussion group (Live-CCD), a group watching recordings of the live discussions (Video-CCD) or a group working with printed cases (Paper-Cases). The presentation of case information followed an admission-discussion-summary sequence. PRIMARY AND SECONDARY OUTCOME MEASURES: Clinical reasoning skills were measured with a knowledge application test addressing the students' conceptual, strategic and conditional knowledge. Additionally, subjective learning outcomes were assessed. RESULTS: With respect to learning outcomes, the Live-CCD group displayed the best results, followed by Video-CCD and Paper-Cases, F(2,87)=27.07, p<0.001, partial η2=0.384. No difference was found between Live-CCD and Video-CCD groups in the delayed post-test; however, both outperformed the Paper-Cases group, F(2,87)=30.91, p<0.001, partial η2=0.415. Regarding subjective learning outcomes, the Live-CCD received significantly better ratings than the other formats, F(2,85)=13.16, p<0.001, partial η2=0.236. CONCLUSIONS: This study demonstrates that the CCD approach is an effective and sustainable clinical reasoning teaching resource for medical students. Subjective learning outcomes underline the importance of learner (inter)activity in the acquisition of clinical reasoning skills in the context of case-based learning. Higher efficacy of more interactive formats can be attributed to positive effects of collaborative learning. Future research should investigate how the Live-CCD format can further be improved and how video-based CCDs can be enhanced through instructional support.

Crew resource management training in healthcare: a systematic review of intervention design, training conditions and evaluation.

OBJECTIVES: Crew resource management (CRM) training formats have become a popular method to increase patient safety by consideration of the role that human factors play in healthcare delivery. The purposes of this review were to identify what is subsumed under the label of CRM in a healthcare context and to determine how such training is delivered and evaluated. DESIGN: Systematic review of published literature. DATA SOURCES: PubMed, PsycINFO and ERIC were searched through 8 October 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Individually constructed interventions for healthcare staff that were labelled as CRM training, or described as based on CRM principles or on aviation-derived human factors training. Only studies reporting both an intervention and results were included. DATA EXTRACTION AND SYNTHESIS: The studies were examined and coded for relevant passages. Characteristics regarding intervention design, training conditions and evaluation methods were analysed and summarised both qualitatively and quantitatively. RESULTS: Sixty-one interventions were included. 48% did not explain any keyword of their CRM intervention to a reproducible detail. Operating room teams and surgery, emergency medicine, intensive care unit staff and anaesthesiology came in contact most with a majority of the CRM interventions delivered in a 1-day or half-day format. Trainer qualification is reported seldomly. Evaluation methods and levels display strong variation. CONCLUSIONS: Critical topics were identified for the CRM training community and include the following: the need to agree on common terms and definitions for CRM in healthcare, standards of good practice for reporting CRM interventions and their effects, as well as the need for more research to establish non-educational criteria for success in the implementation of CRM in healthcare organisations.

Microlearning for patient safety: Crew resource management training in 15-minutes.

OBJECTIVES: We sought to establish the feasibility of chunking crew resource management (CRM) training into micro-size interventions and to compare different training approaches in the context of micro-learning. DESIGN: We evaluated whether participants in micro-learning CRM activities achieved learning objectives following training. In a between-subjects design, groups were observed for behaviour during a simulation that was part of a 15-minute modular intervention and tested for recollection afterwards. PARTICIPANTS: The 129 participants recruited for this study were medical students, who already had relevant experience treating patients. INTERVENTIONS: The experimental setting involved three 5-minute components: video, simulation, and debriefing. Different groups viewed videos involving different didactic concepts: one group observed a videotaped concrete example of a medical care team applying a CRM tool (example group), and one group observed a videotaped lecture on the same topic (lecture group). MAIN OUTCOME MEASURES: All simulations were videotaped and coded in detail for the occurrence of and time spent engaging in team behaviour and medical care. Questionnaires were administered before, immediately after, and two weeks after the intervention. We compared the groups' behaviour during the simulation (team cooperation and medical care), retention of knowledge from the training content, and results of the evaluation. RESULTS: Both groups exhibited most of the behaviours included in the content of the instructional videos during the simulations and recollected information 2 weeks later. The example group exhibited significantly more of the training content during the simulation and demonstrated better retention 2 weeks later. Although the example group spent more time on team coordination, there was no difference in the number of executed medical measures. CONCLUSION: Delivering CRM training in chunks of relatively short and highly standardised interventions appears feasible. In this study, the form of didactical presentation caused a difference in learning success between groups: a traditional lecture was outperformed by an instructional video demonstrating a practical example.

Scaffolding clinical reasoning of medical students with virtual patients: effects on diagnostic accuracy, efficiency, and errors.

Background Understanding clinical reasoning is a major challenge in medical education research. Little is known about the influence of scaffolding and feedback on the clinical reasoning of medical students. The aim of this study was to measure the effects of problem representation (cognitive representation of a clinical case) and structured scaffolding for reflection with or without feedback on the diagnostic efficiency and characterization of diagnostic errors of medical students. Methods One hundred and forty-eight advanced medical students were randomly assigned to one of five groups (2 × 2 design with a control group). They worked on 15 virtual clinical cases (five learning cases, five initial assessment cases, and five delayed assessment cases) in an electronic learning environment. After each case, they stated their presumed diagnosis and explained their diagnostic conclusion. Diagnostic accuracy, efficiency, and error distribution were analyzed. Results The diagnostic accuracy (number of correctly solved cases) and efficiency (solved cases/total time) did not differ significantly between any of the groups in the two different assessment phases [mean = 2.2-3.3 (standard deviation [SD] = 0.79-1.31), p = 0.08/0.27 and mean = 0.07-0.12 (SD = 0.04-0.08), p = 0.16/0.32, respectively]. The most important causes for diagnostic errors were a lack of diagnostic skills (20%), a lack of knowledge (18%), and premature closure (17%). Conclusions Neither structured reflections nor representation scaffolding improved diagnostic accuracy or efficiency of medical students compared to a control group when working with virtual patients.

Uncovering the relation between clinical reasoning and diagnostic accuracy - An analysis of learner's clinical reasoning processes in virtual patients.

BACKGROUND: Clinical reasoning is an important topic in healthcare training, assessment, and research. Virtual patients (VPs) are a safe environment to teach, assess and perform research on clinical reasoning and diagnostic accuracy. Our aim was to explore the details of the clinical reasoning process and diagnostic accuracy of undergraduate medical students when working with VPs using a concept mapping tool. METHODS: Over seven months we provided access to 67 German and 30 English VPs combined with a concept mapping tool to visualize and measure the clinical reasoning process of identifying problems, differential diagnoses, recommended tests and treatment options, and composing a summary statement about a VP. A final diagnosis had to be submitted by the learners in order to conclude the VP scenario. Learners were allowed multiple attempts or could request the correct diagnosis from the system. RESULTS: We analyzed 1,393 completed concept maps from 317 learners. We found significant differences between maps with a correct final diagnosis on one or multiple attempts and maps in which learners gave up and requested the solution from the system. These maps had lower scores, fewer summary statements, and fewer problems, differential diagnoses, tests, and treatments. CONCLUSIONS: The different use patterns and scores between learners who had the correct final diagnosis on one or multiple attempts and those who gave up, indicate that diagnostic accuracy in the form of a correct final diagnosis on the first attempt has to be reconsidered as a sole indicator for clinical reasoning competency. For the training, assessment, and research of clinical reasoning we suggest focusing more on the details of the process to reach a correct diagnosis, rather than whether it was made in the first attempt.

How case representations of medical students change during case processing - Results of a qualitative study.

Objective: Representations are mental summaries of a clinical case and help in understanding a clinical problem. However, it is still largely unknown which clinical information medical students include in their case representations. In this study, therefore, the structure and quality of students' case representations were examined to better understand the diagnostic process and its relationship to diagnostic accuracy. What information do medical students include in their representations and is there an association between this information and the diagnostic accuracy? Method: 43 medical students in the fourth and fifth clinical year worked on four clinical cases. During the diagnostic process, they were asked three times per case to write a case representation. 516 representations were qualitatively evaluated using a content-based coding scheme. An analysis was made of the nature and composition of the clinical information. In addition, the association between the general representation structure and the correct case solution was examined. Results: At the beginning, students include most of the clinical information in their representation (66%), but as the case progresses, they begin to select the information offered (2nd representation 42%, 3rd representation 38%). The length of the representation (number of words) does not correlate with the correct case solution (r=-0.08-0.31). The representations do not depend on the case difficulty but have a significant individual component: the representations written by a student are formally very similar in all four cases (r=0.60-0.86). Conclusion: Medical students can select the relevant clinical information and include it in their case representations. Lack of representation does not seem to be a reason for misdiagnosis; Students' deficits in diagnosis are more likely due to knowledge gaps.

Undergraduate medical students' behavioural intentions towards medical errors and how to handle them: a qualitative vignette study.

OBJECTIVES: In undergraduate medical education, the topics of errors in medicine and patient safety are under-represented. The aim of this study was to explore undergraduate medical students' behavioural intentions when confronted with an error. DESIGN: A qualitative case vignette survey was conducted including one of six randomly distributed case scenarios in which a hypothetical but realistic medical error occurred. The six scenarios differed regarding (1) who caused the error, (2) the presence of witnesses and (3) the consequences of the error for the patient. Participants were asked: 'What would you do?". Answers were collected as written free texts and analysed according to qualitative content analysis. SETTING: Students from German medical schools participated anonymously through an online questionnaire tool. PARTICIPANTS: Altogether, n=159 students answered a case scenario. Participants were on average 24.6 years old (SD=7.9) and 69% were female. They were undergraduate medical students in their first or second year (n=27), third, fourth or fifth year (n=107) or final year (n=21). RESULTS: During the inductive coding process, 19 categories emerged from the original data and were clustered into four themes: (1) considering communication; (2) considering reporting; (3) considering consequences; and (4) emotional responsiveness. When the student him/herself caused the error in the scenario, participants did mention communication with colleagues and taking preventive action less frequently than if someone else had caused the error. When a witness was present, participants more frequently mentioned disclosure of the error and taking actions than in the absence of a witness. When the outcome was significant to the patient, participants more often showed an emotional response than if there were no consequences. CONCLUSIONS: The study highlights the importance of coping strategies for healthcare professionals to adequately deal with errors. Educators need to introduce knowledge and skills on how to deal with errors and emotional preparedness for errors into undergraduate medical education.