'Walking together': How relationships shape physicians' clinical reasoning.

INTRODUCTION: The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning. METHODS: Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest. RESULTS: The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts. CONCLUSION: Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.

Having a Voice: Resident Perceptions of Supervision, Decision-Making and Patient Care Ownership.

OBJECTIVE: Heightened resident supervision due to patient safety concerns is increasingly common in pediatrics and may leave residents with fewer opportunities for independent decision-making, a diminished sense of autonomy, and decreased engagement. This may ultimately threaten their development into competent clinicians. Understanding how pediatric residents experience supervision's influence on their involvement in decision-making, engagement in patient care, and learning is crucial to safeguard their transition to independent practice. In relation to supervision, our research investigated: 1) how residents navigated their involvement with clinical decision-making and 2) how opportunities to make clinical decisions influenced their engagement in patient care and learning. METHODS: From 2019-2020, we recruited 38 pediatric residents from three different programs for a qualitative interview-based study. Through a constructivist stance, we explored clinical decision-making experiences and performed thematic analysis using an iterative and inductive process. RESULTS: We identified three themes: 1) Residents perceived having autonomy when they had space to make independent decisions, regardless of supervisor's presence; 2) Patient care ownership resulted from having a voice in a variety of contributions to patient care; and 3) Supervisors' behaviors modulated patient care ownership and thereby residents' sense of feeling heard, their engagement in patient care, and their learning. CONCLUSIONS: Our results suggest that focusing on patient care ownership may better fit with current learning environments than aiming for independence and autonomy. They provide insight on how, in the pediatric learning climate of enhanced supervision, supervisors can preserve resident engagement in patient care and learning by augmenting patient care ownership and ensuring residents have a voice.

What Residents Want: Perceptions of Learning During a Pediatrics Night Float Rotation.

OBJECTIVE: Most efforts to improve the educational value of night shifts focus on delivering content through structured sessions. Less is known about aligning curricular efforts with inherent nighttime learning. This study explored interns' nighttime experiences to better understand how learning works for the purpose of designing a curriculum to best support interns' learning at night. METHODS: The authors employed a constructivist grounded theory approach. They conducted semistructured interviews with 12 Family Medicine and Pediatric interns recruited during their first-night float rotation at a tertiary care children's hospital between February 2020 and August 2021. Interviews elicited stories about nighttime experiences on the basis of a modified critical incident technique. Four authors used an inductive approach to data analysis and codebook development, then all authors participated in a thematic review. RESULTS: The authors identified distinctions between interns' perceptions of teaching and learning, with participants reporting rich instances of experiential learning at night. The authors discovered that interns do not want a didactic teaching curriculum at night. Rather, they want support to optimize workplace learning: the opportunity to independently initiate patient assessments, informal teaching arising from patient care, reassurance that support from supervisors is readily available, orientation to resources, and feedback. CONCLUSIONS: Findings suggest informal workplace learning is already occurring at night and historical attempts to implement formal curricula may have a low return on investment. A curricular frameshift is recommended to support learning at night that emphasizes informal teaching responsive to learning needs that arise from patient care, integrating but not emphasizing formal didactics when necessary.

Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education.

This paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA's vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.

Interprofessional population health advocacy: Developing and implementing a panel management curriculum in five Veterans Administration primary care practices.

Health care systems expect primary care clinicians to manage panels of patients and improve population health, yet few have been trained to do so. An interprofessional panel management (PM) curriculum is one possible strategy to address this training gap and supply future primary care practices with clinicians and teams prepared to work together to improve the health of individual patients and populations. This paper describes a Veterans Administration (VA) sponsored multi-site interprofessional PM curriculum development effort. Five VA Centers of Excellence in Primary Care Education collaborated to identify a common set of interprofessionally relevant desired learning outcomes (DLOs) for the PM and to develop assessment instruments for monitoring trainees' PM learning. Authors cataloged teaching and learning activities across sites. Results from pilot testing were systematically discussed leading to iterative revisions of curricular elements. Authors completed a retrospective self-assessment of curriculum implementation for the academic year 2015-16 using a 5-point scale: contemplation (score = 0), pilot (1), action (2), maintenance (3), and embedded (4). Implementation scores were analyzed using descriptive statistics. DLOs were organized into five categories (individual patients, populations, guidelines/measures, teamwork, and improvement) along with a developmental continuum and mapped to program competencies. Instruction and implementation varied across sites based on resources and priorities. Between 2015 and 2016, 159 trainees (internal medicine residents, nurse practitioner students and residents, pharmacy residents, and psychology post-doctoral fellows) participated in the PM curriculum. Curriculum implementation scores for guidelines/measures and improvement DLOs were similar for all trainees; scores for individual patients, populations, and teamwork DLOs were more advanced for nurse practitioner and physician trainees. In conclusion, collaboratively identified DLOs for PM guided development of assessment instruments and instructional approaches for panel management activities in interprofessional teams. This PM curriculum and associated tools provide resources for educators in other settings.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice.

BACKGROUND: Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. RESEARCH QUESTION: How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? STUDY DESIGN AND METHODS: This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. RESULTS: We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. INTERPRETATION: Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Warning bells: How clinicians leverage their discomfort to manage moments of uncertainty.

OBJECTIVES: It remains unclear how medical educators can more effectively bridge the gap between trainees' intolerance of uncertainty and the tolerance that experienced physicians demonstrate in practice. Exploring how experienced clinicians experience, appraise and respond to discomfort arising from uncertainty could provide new insights regarding the kinds of behaviours we are trying to help trainees achieve. METHODS: We used a constructivist grounded theory approach to explore how emergency medicine faculty experienced, managed and responded to discomfort in settings of uncertainty. Using a critical incident technique, we asked participants to describe case-based experiences of uncertainty immediately following a clinical shift. We used probing questions to explore cognitive, emotional and somatic manifestations of discomfort, how participants had appraised and responded to these cues, and how they had used available resources to act in these moments of uncertainty. Two investigators coded the data line by line using constant comparative analysis and organised transcripts into focused codes. The entire research team discussed relationships between codes and categories, and developed a conceptual framework that reflected the possible relationships between themes. RESULTS: Participants identified varying levels of discomfort in their case descriptions. They described multiple cues alerting them to problems that were evolving in unexpected ways or problems with aspects of management that were beyond their abilities. Discomfort served as a trigger for participants to monitor a situation with greater attention and to proceed more intentionally. It also served as a prompt for participants to think deliberately about the types of human and material resources they might call upon strategically to manage these uncertain situations. CONCLUSIONS: Discomfort served as a dynamic means to manage and respond to uncertainty. To be 'tolerant' of uncertainty thus requires clinicians to embrace discomfort as a powerful tool with which to grapple with the complex problems pervasive in clinical practice.

"I Was Worried About the Patient, but I Wasn't Feeling Worried": How Physicians Judge Their Comfort in Settings of Uncertainty.

PURPOSE: Clinical educators often raise concerns that learners are not comfortable with uncertainty in clinical work, yet existing literature provides little insight into practicing clinicians' experiences of comfort when navigating the complex, ill-defined problems pervasive in practice. Exploring clinicians' comfort as they identify and manage uncertainty in practice could help us better support learners through their discomfort. METHOD: Between December 2018 and April 2019, the authors employed a constructivist grounded theory approach to explore experiences of uncertainty in emergency medicine faculty. The authors used a critical incident technique to elicit narratives about decision making immediately following participants' clinical shifts, exploring how they experienced uncertainty and made real-time judgments regarding their comfort to manage a given problem. Two investigators analyzed the transcripts, coding data line-by-line using constant comparative analysis to organize narratives into focused codes. These codes informed the development of conceptual categories that formed a framework for understanding comfort with uncertainty. RESULTS: Participants identified multiple forms of uncertainty, organized around their understanding of the problems they were facing and the potential actions they could take. When discussing their comfort in these situations, they described a fluid, actively negotiated state. This state was informed by their efforts to project forward and imagine how a problem might evolve, with boundary conditions signaling the borders of their expertise. It was also informed by ongoing monitoring activities pertaining to patients, their own metacognitions, and their environment. CONCLUSIONS: The authors' findings offer nuances to current notions of comfort with uncertainty. Uncertainty involved clinical, environmental, and social aspects, and comfort dynamically evolved through iterative cycles of forward planning and monitoring.

Exploring current physicians' failure to communicate clinical feedback back to transferring physicians after transitions of patient care responsibility: A mixed methods study.

INTRODUCTION: After patient care transitions occur, communication from the current physician back to the transferring physician may be an important source of clinical feedback for learning from outcomes of previous reasoning processes. Factors associated with this communication are not well understood. This study clarifies how often, and for what reasons, current physicians do or do not communicate back to transferring physicians about transitioned patients. METHODS: In 2018, 38 physicians at two academic teaching hospitals were interviewed about communication decisions regarding 618 transitioned patients. Researchers recorded quantitative and qualitative data in field notes, then coded communication rationales using directed content analysis. Descriptive statistics and mixed effects logistic regression analyses identified communication patterns and examined associations with communication for three conditions: When current physicians 1) changed transferring physicians' clinical decisions, 2) perceived transferring physicians' clinical uncertainty, and 3) perceived transferring physicians' request for communication. RESULTS: Communication occurred regarding 17% of transitioned patients. Transferring physicians initiated communication in 55% of these cases. Communication did not occur when current physicians 1) changed transferring physicians' clinical decisions (119 patients), 2) perceived transferring physicians' uncertainty (97 patients), and 3) perceived transferring physicians' request for communication (12 patients). Rationales for no communication included case contextual, structural, interpersonal, and cultural factors. Perceived uncertainty and request for communication were positively associated with communication (p < 0.001) while a changed clinical decision was not. DISCUSSION: Current physicians communicate infrequently with transferring physicians after assuming patient care responsibilities. Structural and interpersonal barriers to communication may be amenable to change. Clarity about transferring physicians' uncertainty and desire for communication back may improve clinical feedback communication.

A view from the sender side of feedback: anticipated receptivity to clinical feedback when changing prior physicians' clinical decisions-a mixed methods study.

When physicians transition patients, the physician taking over may change the diagnosis. Such a change could serve as an important source of clinical feedback to the prior physician. However, this feedback may not transpire if the current physician doubts the prior physician's receptivity to the information. This study explored facilitators of and barriers to feedback communication in the context of patient care transitions using an exploratory sequential, qualitative to quantitative, mixed methods design. Twenty-two internal medicine residents and hospitalist physicians from two teaching hospitals were interviewed and data were analyzed thematically. A prominent theme was participants' reluctance to communicate diagnostic changes. Participants perceived case complexity and physical proximity to facilitate, and hierarchy, unfamiliarity with the prior physician, and lack of relationship to inhibit communication. In the subsequent quantitative portion of the study, forty-one hospitalists completed surveys resulting in 923 total survey responses. Multivariable analyses and a mixed-effects model were applied to survey data with anticipated receptivity as the outcome variable. In the mixed-effects model, four factors had significant positive associations with receivers' perceived receptivity: (1) feedback senders' time spent on teaching services (ß = 0.52, p = 0.02), (2) receivers' trustworthiness and clinical credibility (ß = 0.49, p < 0.001), (3) preference of both for shared work rooms (ß = 0.15, p = 0.006), and (4) receivers being peers (ß = 0.24, p < 0.001) or junior colleagues (ß = 0.39, p < 0.001). This study suggests that anticipated receptivity to feedback about changed clinical decisions affects clinical communication loops. Without trusting relationships and opportunities for low risk, casual conversations, hospitalists may avoid such conversations.

Learning Challenges, Teaching Strategies, and Cognitive Load: Insights From the Experience of Seasoned Endoscopy Teachers.

PURPOSE: Learners of medical procedures must develop, refine, and apply schemas for both cognitive and psychomotor constructs, which may strain working memory capacity. Procedures with limitations in visual and tactile information may add risk of cognitive overload. The authors sought to elucidate how experienced procedural teachers perceived learners' challenges and their own teaching strategies in the exemplar setting of gastrointestinal endoscopy. METHOD: The authors interviewed 22 experienced endoscopy teachers in the United States, Canada, and the Netherlands between May 2016 and March 2019 and performed thematic analysis using template analysis method. Interviews addressed learner challenges and teaching strategies from the teacher participants' perspectives. Cognitive load theory informed data interpretation and analysis. RESULTS: Participants described taking steps to "diagnose" trainee ability and identify struggling trainees. They described learning challenges related to trainees (performance over mastery goal orientation, low self-efficacy, lack of awareness), tasks (psychomotor challenges, mental model development, tactile understanding), teachers (teacher-trainee relationship, inadequate teaching, teaching variability), and settings (internal/external distractions, systems issues). Participants described employing strategies that could match intrinsic load to learners' levels (teaching along developmental continuum, motor instruction, technical assistance/takeover), minimize extraneous load (optimize environment, systems solutions, emotional support, define expectations), and optimize germane load (promote mastery, teach schemas, stop and focus). CONCLUSIONS: Participants provided insight into possible challenges while learning complex medical procedures with limitations in sensory channels, as well as teaching strategies that may address these challenges at individual and systems levels. Using cognitive load theory, the authors provide recommendations for procedural teachers.

Reflections From the Rearview Mirror: Internal Medicine Physicians' Reactions to Clinical Feedback After Transitions of Responsibility.

PURPOSE: Learning from practice is important for continuous improvement of practice. Yet little is known about how physicians assimilate clinical feedback and use it to refine their diagnostic approaches. This study described physicians' reactions to learning that their provisional diagnosis was either consistent or inconsistent with the subsequent diagnosis, identified emotional responses to those findings, and explored potential consequences for future practices. METHOD: In 2016-2017, 22 internal medicine hospitalist and resident physicians at Oregon Health & Science University completed semistructured interviews. Critical incident prompts elicited cases of patient care transitions before the diagnosis was known. Interview questions explored participants' subsequent follow-up. Matrix analysis of case elements, emotional reactions, and perceived practice changes was used to compare patterns of responses between cases of confirming versus disconfirming clinical feedback. RESULTS: Participants described 51 cases. When clinical feedback confirmed provisional diagnoses (17 cases), participants recalled positive emotions, judged their performance as sufficient, and generally reinforced current approaches. When clinical feedback was disconfirming (34 cases), participants' emotional reactions were mostly negative, frequently tempered with rationalizations, and often associated with perceptions of having made a mistake. Perceived changes in practice mostly involved nonspecific strategies such as "trusting my intuition" and "broadening the differential," although some described case-specific strategies that could be applied in similar contexts in the future. CONCLUSIONS: Internists' experiences with posttransition clinical feedback are emotionally charged. Internists' reflections on clinical feedback experiences suggest they are primed to adapt practices for the future, although the usefulness of those adaptations for improving practice is less clear.

Nurse Practitioner residents' perceptions of competency development during a year-long immersion in Veterans Affairs primary care.

BACKGROUND: Nurse Practitioner (NP) Postgraduate Residency programs are rapidly expanding. Currently, little is known about trainees' self-perceptions during these experiences. PURPOSE: Describe NP residents' perceptions of their strengths, areas for improvement, and goals while participating in the Veterans Affairs Centers of Excellence in Primary Care Education NP Residency program. METHODS: NP residents responded to open-ended questions at three time points across their training year. Responses were analyzed using inductive and deductive approaches. FINDINGS: NP residents self-reported strengths in patient-centered care and interprofessional teamwork. They identified clinical skill acquisition as the major area for improvement. Their short- and long-term goals focused on personal and professional growth. DISCUSSION: These results suggest NPs prioritize clinical skill acquisition during a primary care residency. In contrast, leadership and performance improvement skills did not capture their attention. When aggregated at the programmatic level, assessments identified opportunities to improve the NP Residency program curriculum.

A manually annotated Actinidia chinensis var. chinensis (kiwifruit) genome highlights the challenges associated with draft genomes and gene prediction in plants.

BACKGROUND: Most published genome sequences are drafts, and most are dominated by computational gene prediction. Draft genomes typically incorporate considerable sequence data that are not assigned to chromosomes, and predicted genes without quality confidence measures. The current Actinidia chinensis (kiwifruit) 'Hongyang' draft genome has 164 Mb of sequences unassigned to pseudo-chromosomes, and omissions have been identified in the gene models. RESULTS: A second genome of an A. chinensis (genotype Red5) was fully sequenced. This new sequence resulted in a 554.0 Mb assembly with all but 6 Mb assigned to pseudo-chromosomes. Pseudo-chromosomal comparisons showed a considerable number of translocation events have occurred following a whole genome duplication (WGD) event some consistent with centromeric Robertsonian-like translocations. RNA sequencing data from 12 tissues and ab initio analysis informed a genome-wide manual annotation, using the WebApollo tool. In total, 33,044 gene loci represented by 33,123 isoforms were identified, named and tagged for quality of evidential support. Of these 3114 (9.4%) were identical to a protein within 'Hongyang' The Kiwifruit Information Resource (KIR v2). Some proportion of the differences will be varietal polymorphisms. However, as most computationally predicted Red5 models required manual re-annotation this proportion is expected to be small. The quality of the new gene models was tested by fully sequencing 550 cloned 'Hort16A' cDNAs and comparing with the predicted protein models for Red5 and both the original 'Hongyang' assembly and the revised annotation from KIR v2. Only 48.9% and 63.5% of the cDNAs had a match with 90% identity or better to the original and revised 'Hongyang' annotation, respectively, compared with 90.9% to the Red5 models. CONCLUSIONS: Our study highlights the need to take a cautious approach to draft genomes and computationally predicted genes. Our use of the manual annotation tool WebApollo facilitated manual checking and correction of gene models enabling improvement of computational prediction. This utility was especially relevant for certain types of gene families such as the EXPANSIN like genes. Finally, this high quality gene set will supply the kiwifruit and general plant community with a new tool for genomics and other comparative analysis.

Chart stalking, list making, and physicians' efforts to track patients' outcomes after transitioning responsibility.

CONTEXT: Transitions of patient care responsibility occur frequently between physicians. Resultant discontinuities make it difficult for physicians to observe clinical outcomes. Little is known about what physicians do to overcome the practical challenges to learning these discontinuities create. This study explored physicians' activities in practice as they sought follow-up information about patients. METHODS: Using a constructivist grounded theory approach, semi-structured interviews with 18 internal medicine hospitalist and resident physicians at a single tertiary care academic medical center explored participants' strategies when deliberately conducting follow-up after they transitioned responsibility for patients to other physicians. Following open coding, the authors used activity theory (AT) to explore interactions among the social, cultural and material influences related to follow-up. RESULTS: The authors identified three themes related to follow-up: (i) keeping lists to track patients, (ii) learning to create tracking systems and (iii) conducting follow-up. Analysis of participants' follow-up processes as an activity system highlighted key tensions in the system and participants' work adaptations. Tension within functionality of electronic health records for keeping lists (tools) to find information about patients' outcomes (object) resulted in using paper lists as workarounds. Tension between paper lists (tools) and protecting patients' health information (rules) led to rule-breaking or abandoning activities of locating information. Finding time to conduct desired follow-up produced tension between this and other activity systems. CONCLUSION: In clinical environments characterised by discontinuity, lists of patients served as tools for guiding patient care follow-up. The authors offer four recommendations to address the tensions identified through AT: (i) optimise electronic health record tracking systems to eliminate the need for paper lists; (ii) support physicians' skill development in developing and maintaining tracking systems for follow-up; (iii) dedicate time in physicians' work schedules for conducting follow-up; and (iv) engage physicians and patients in determining guidelines for longitudinal tracking that optimise physicians' learning and respect patients' privacy.

Corrigendum: Phytohormone and Putative Defense Gene Expression Differentiates the Response of 'Hayward' Kiwifruit to Psa and Pfm Infections.

[This corrects the article on p. 1366 in vol. 8, PMID: 28824694.].

"You Have to Know the End of the Story": Motivations to Follow Up After Transitions of Clinical Responsibility.

PURPOSE: Physicians routinely transition responsibility for patient care to other physicians. When transitions of responsibility occur before the clinical outcome is known, physicians may lose opportunities to learn from the consequences of their decision making. Sometimes curiosity about patients does not end with the transition and physicians continue to follow them. This study explores physicians' motivations to follow up after transitioning responsibilities. METHOD: Using a constructivist grounded theory approach, the authors conducted 18 semistructured interviews in 2016 with internal medicine hospitalist and resident physicians at a single tertiary care academic medical center. Constant comparative methods guided the qualitative analysis, using motivation theories as sensitizing constructs. RESULTS: The authors identified themes that characterized participants' motivations to follow up. Curiosity about patients' outcomes determined whether or not follow-up occurred. Insufficient curiosity about predictable clinical problems resulted in the choice to forgo follow-up. Sufficient curiosity due to clinical uncertainty, personal attachment to patients, and/or concern for patient vulnerability motivated follow-up to fulfill goals of knowledge building and professionalism. The authors interpret these findings through the lenses of expectancy-value (EVT) and self-determination (SDT) theories of motivation. CONCLUSIONS: Participants' curiosity about what happened to their patients motivated them to follow up. EVT may explain how participants made choices in time-pressured work settings. SDT may help interpret how follow-up fulfills needs of relatedness. These findings add to a growing body of literature endorsing learning environments that consider task-value trade-offs and support basic psychological needs of autonomy, competency, and relatedness to motivate learning.

Phytohormone and Putative Defense Gene Expression Differentiates the Response of 'Hayward' Kiwifruit to Psa and Pfm Infections.

Pseudomonas syringae pv. actinidiae (Psa) and Pseudomonas syringae pv. actinidifoliorum (Pfm) are closely related pathovars infecting kiwifruit, but Psa is considered one of the most important global pathogens, whereas Pfm is not. In this study of Actinidia deliciosa 'Hayward' responses to the two pathovars, the objective was to test whether differences in plant defense responses mounted against the two pathovars correlated with the contrasting severity of the symptoms caused by them. Results showed that Psa infections were always more severe than Pfm infections, and were associated with highly localized, differential expression of phytohormones and putative defense gene transcripts in stem tissue closest to the inoculation site. Phytohormone concentrations of jasmonic acid (JA), jasmonate isoleucine (JA-Ile), salicylic acid (SA) and abscisic acid were always greater in stem tissue than in leaves, and leaf phytohormones were not affected by pathogen inoculation. Pfm inoculation induced a threefold increase in SA in stems relative to Psa inoculation, and a smaller 1.6-fold induction of JA. Transcript expression showed no effect of inoculation in leaves, but Pfm inoculation resulted in the greatest elevation of the SA marker genes, PR1 and glucan endo-1,3-beta-glucosidase (ß-1,3-glucosidase) (32- and 25-fold increases, respectively) in stem tissue surrounding the inoculation site. Pfm inoculation also produced a stronger response than Psa inoculation in localized stem tissue for the SA marker gene PR6, jasmonoyl-isoleucine-12-hydrolase (JIH1), which acts as a negative marker of the JA pathway, and APETALA2/Ethylene response factor 2 transcription factor (AP2 ERF2), which is involved in JA/SA crosstalk. WRKY40 transcription factor (a SA marker) was induced equally in stems by wounding (mock inoculation) and pathovar inoculation. Taken together, these results suggest that the host appears to mount a stronger, localized, SA-based defense response to Pfm than Psa.