Medical students' responses to uncertainty: a cross-sectional study using a new self-efficacy questionnaire in Aotearoa New Zealand.

OBJECTIVES: Responding well to clinical uncertainty is a crucial skill for any doctor. To better understand how medical students develop this skill, Social Cognitive Theory can be used to explore students' perceived capability to respond to situations of uncertainty. This study aimed to construct a self-efficacy questionnaire and use it to measure medical students' responses to clinical uncertainty. DESIGN: A 29-item questionnaire was constructed. For each item, participants rated their confidence in responding to uncertain situations using a scale of 0-100. Data were analysed with descriptive and inferential statistics. SETTING: Aotearoa New Zealand. PARTICIPANTS: The questionnaire was distributed to 716 of 852 medical students in second, fourth and sixth year, at the three campuses of the Otago Medical School. RESULTS: The Self-Efficacy to Respond to Clinical Uncertainty (SERCU) questionnaire was completed by 495 participants (69% response rate) and found to be highly reliable (α=0.93). Exploratory factor analysis confirmed a unidimensional scale. A multiple linear regression model predicted self-efficacy scores from year of study, age, mode of entry, gender and ethnicity, F(11,470) = 4.252, p<0.001 adj. R²=0.069. Male students and those admitted to the programme 3 years postdegree or with significant allied health experience were predicted to have significantly higher self-efficacy scores. Year of study was not a significant predictor of average efficacy scores. CONCLUSIONS: Our research contributes a novel, highly reliable questionnaire that uses self-efficacy to measure medical student responses to uncertainty. The questionnaire revealed that students' confidence in responding to uncertainty may be more related to their background and life experience than to progression through the curriculum. Medical educators and researchers can use the SERCU questionnaire to obtain a new perspective on how their students respond to uncertainty, inform future research and tailor teaching about uncertainty.

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

Despite a variety of definitions of mindfulness, over the past 20 years there have been increasing claims that mindful practice is helpful in improving the accuracy of clinical diagnosis. We performed a systematic review and evidence synthesis in order to: determine the nature and definitions of mindful practice and associated terms; evaluate the quality of evidence for the benefits of mindful practice; and conclude whether mindful practice may reduce diagnostic error. We screened 14397 refereed reports from the five common literature databases, to include 33 reports related to the use of mindful practice in clinical diagnosis. Our evidence synthesis contained no randomised controlled trials (level I evidence) of mindful practice, the majority of supporting evidence (26 reports or 79%) comprised conceptual commentary or opinion (level IV evidence). However, 2 supporting reports constituted controlled studies without randomisation (level IIa), 1 report was quasi-experimental (level IIb), and 4 reports were comparative studies (level III). Thus, we may tentatively conclude that mindful practice appears promising as a method of improving diagnostic accuracy, but that further definitive studies of efficacy are required. We identified a taxonomy of 71 terms related to mindful practice, 7 of which were deemed core terms due to being each cited 5 times or more. The 7 core terms appear to be sufficient to describe the findings at higher levels of evidence in our evidence synthesis, suggesting that future definitive studies of mindful practice should focus on these common core terms in order to promote more generalisable findings.

Towards a new understanding of uncertainty in medical education.

RATIONALE, AIMS, AND OBJECTIVES: Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education. METHOD: A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty. RESULTS: Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education. CONCLUSION: The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.

Student experiences of learning clinical reasoning.

BACKGROUND: Students find learning clinical reasoning skills challenging. Viewing how students learn clinical reasoning skills from a sociocultural perspective, however, may allow helpful and unhelpful descriptions to be interpreted as experiences that promote or inhibit their participation in and opportunities to co-construct their clinical reasoning skills. METHODS: This interview study was conducted with 25 Year-6 undergraduate medical students. Interview data were first analysed thematically, and then the findings were analysed with the concepts of participation and co-construction. RESULTS: The themes identified were: (1) practising with undifferentiated patients; (2) teachers who were willing to make thinking explicit; (3) a lack of independence and involvement; (4) a lack of communication and feedback; and (5) confusion from different sources of information. When further analysed, the themes could be represented as points along a continuum of participating in, and co-constructing, clinical reasoning skills. DISCUSSION: Clinical educators will find the themes identified from students' experiences learning in a workplace environment helpful for understanding why some students may struggle to develop their clinical reasoning skills. An interpretation of findings from a sociocultural perspective offers a different approach for understanding students' difficulties when learning clinical reasoning: one where students are able to increase their participation in, and co-construction of, clinical reasoning in the context of working collaboratively to provide patient care. Students find learning clinical reasoning skills challenging.

Humans and machines: Moving towards a more symbiotic approach to learning clinical reasoning.

Artificial intelligence is a growing phenomenon that is driving major changes to how we deliver healthcare. One of its most significant and challenging contributions is likely to be in diagnosis. Artificial intelligence is challenging the physician's exclusive role in diagnosis and in some areas, its diagnostic accuracy exceeds that of humans. We argue that we urgently need to consider how we will incorporate AI into our teaching of clinical reasoning in the undergraduate curriculum; students need to successfully navigate the benefits and potential issues of new and developing approaches to AI in clinical diagnosis. We offer a pedagogical framework for this challenging change to our curriculum.

Clinical reasoning as a threshold skill.

Background: Threshold skills are defined as new ways of thinking about and performing in a discipline. They represent transformed ways of thinking and doing that are pivotal to learners' progress. Our aim was to establish whether clinical reasoning exhibited features of a threshold skill. Methods: Twenty-five final-year medical students were interviewed with a five-question protocol about how they were learning clinical reasoning. Students' responses were analyzed using a deductive method to identify features of threshold skills. Results: Students' descriptions of learning clinical reasoning exhibited five features: transformation, troublesomeness, integration, association with practice, and issues with transferability. Conclusions: Viewing clinical reasoning as a threshold skill is a novel interpretation of its nature and has implications for learning, teaching, and research. Students can be reassured that, although initially troublesome, with practice, they will not only learn the skill but also how to use it more effectively. Teachers can help students to understand that clinical reasoning is difficult to learn and will require time and repeated practice under supervision to develop.

Identifying developmental features in students' clinical reasoning to inform teaching.

BACKGROUND: There is increasing evidence that students at different levels of training may benefit from different methods of learning clinical reasoning. Two of the common methods of teaching are the "whole - case" format and the "serial cue" approach. There is little empirical evidence to guide teachers as to which method to use and when to introduce them. METHODS: We observed 23 students from different stages of training to examine how they were taking a history and how they were thinking whilst doing this. Each student interviewed a simulated patient who presented with a straightforward and a complex presentation. We inferred how students were reasoning from how they took a history and how they described their thinking while doing this. RESULTS: Early in their training students can only take a generic history. Only later in training are they able to take a focused history, remember the information they have gathered, use it to seek further specific information, compare and contrast possibilities and analyze their data as they are collecting it. CONCLUSIONS: Early in their training students are unable to analyze data during history taking. When they have started developing illness scripts, they are able to benefit from the "serial cue" approach of teaching clinical reasoning.

Self-Reflected Well-Being via a Smartphone App in Clinical Medical Students: Feasibility Study.

BACKGROUND: Well-being in medical students has become an area of concern, with a number of studies reporting high rates of clinical depression, anxiety, burnout, and suicidal ideation in this population. OBJECTIVE: The aim of this study was to increase awareness of well-being in medical students by using a smartphone app. The primary objective of this study was to determine the validity and feasibility of the Particip8 app for student self-reflected well-being data collection. METHODS: Undergraduate medical students of the Dunedin School of Medicine were recruited into the study. They were asked to self-reflect daily on their well-being and to note what experiences they had encountered during that day. Qualitative data were also collected both before and after the study in the form of focus groups and "free-text" email surveys. All participants consented for the data collected to be anonymously reported to the medical faculty. RESULTS: A total of 29 participants (69%, 20/29 female; 31%, 9/29 male; aged 21-30 years) were enrolled, with overall median compliance of 71% at the study day level. The self-reflected well-being scores were associated with both positive and negative experiences described by the participants, with most negative experiences associated with around 20% lower well-being scores for that day; the largest effect being "receiving feedback that was not constructive or helpful," and the most positive experiences associated with around 20% higher scores for that day. CONCLUSIONS: The study of daily data collection via the Particip8 app was found to be feasible, and the self-reflected well-being scores showed validity against participant's reflections of experiences during that day.

Using theory to interpret how senior clinicians define, learn, and teach clinical reasoning.

This article was migrated. The article was marked as recommended. Introduction: Dual process theory and script theory have been used to understand and explain how students learn clinical reasoning. This study used these tools to interpret how experienced teachers described their definitions of clinical reasoning, their own history learning about clinical reasoning, and their methods of teaching clinical reasoning. Methods: Interview data from 14 senior clinicians were investigated thematically using a general inductive approach then interpreted using principles and concepts associated with dual process theory and script theory, including the concept of deliberate practice and script consciousness. Results and Discussion: Senior clinicians' definitions of clinical reasoning were consistent with the literature. Few of them recalled being explicitly taught clinical reasoning. They identified teaching as a way to further develop their own clinical reasoning. They taught it opportunistically using an apprenticeship and role-modelling approach in clinical contexts. Their teaching techniques included supervised practice, reflection, think aloud, focused data collection guided by the clinical presentation, and iterative reasoning. Conclusion: Dual process theory, script theory, and the concepts of mindful practice and deliberate practice were found to be useful tools to understand how senior clinicians taught and learned clinical reasoning. These findings are guiding our clinical reasoning curriculum and faculty development programme.

Learning clinical reasoning.

Errors in clinical reasoning continue to account for significant morbidity and mortality, despite evidence-based guidelines and improved technology. Experts in clinical reasoning often use unconscious cognitive processes that they are not aware of unless they explain how they are thinking. Understanding the intuitive and analytical thinking processes provides a guide for instruction. How knowledge is stored is critical to expertise in clinical reasoning. Curricula should be designed so that trainees store knowledge in a way that is clinically relevant. Competence in clinical reasoning is acquired by supervised practice with effective feedback. Clinicians must recognise the common errors in clinical reasoning and how to avoid them. Trainees can learn clinical reasoning effectively in everyday practice if teachers provide guidance on the cognitive processes involved in making diagnostic decisions.

Medical students' and clinical teachers' perceptions of Maori health teaching.

AIMS: To investigate the views of medical students early in their clinical training and their clinical teachers with respect to Maori health teaching and learning. METHOD: A survey approach was used to appraise responses from 276 students early in their clinical training and 135 clinical teachers. All participants were asked to respond to a set of questions about the teaching and assessment of Hauora Maori (Maori health). These responses were analysed using descriptive statistics and inspection of the distribution of responses (skewness and kurtosis). A further open ended question was asked about suggested changes to the medical school and the responses relating to Hauora Maori were analysed using a summative content analysis system. RESULTS: The distribution of the data revealed strongly skewed responses in the direction of disagreement in relation to four of the six student questionnaire items indicating that most students question the quality of Hauora Maori teaching and assessment. Also, two of the five items from the clinical teacher questionnaire were strongly skewed to the disagreement option suggesting that many clinical teachers felt underprepared to teach this aspect of the curriculum. The content analysis identified a range of views, often polarised, with responses at the negative end of the spectrum revealing a degree of resistance to Maori health teaching and learning. CONCLUSIONS: The findings of this study raise concerns about the extent to which medical students are supported to achieve Hauora Maori learning outcomes. The consistency between medical student and clinical teacher findings points to systemic issues, and the solutions are likely to be multi-layered. At the institutional level, Maori health needs to be consistently presented as a legitimate and critical area of medical education. At the educational level, it is important that all teachers are supported to provide high quality teaching, learning and assessment of Hauora Maori across the curriculum.

Comparison of wavelet transform and time-domain analysis of second trimester uterine artery Doppler waveforms in screening for pre-eclampsia.

The aim of this study was to compare time-domain waveform analysis of second-trimester uterine artery Doppler using the resistance index (RI) with waveform analysis using a mathematical tool known as wavelet transform for the prediction of pre-eclampsia (PE). This was a retrospective, nested case-cohort study of 336 women, 37 of whom subsequently developed PE. Uterine artery Doppler waveforms were analysed using both RI and waveform analysis. The utility of these indices in screening for PE was then evaluated using receiver operating characteristic curves. There were significant differences in uterine artery RI between the PE women and those with normal pregnancy outcome. After wavelet analysis, significant difference in the mean amplitude in wavelet frequency band 4 was noted between the 2 groups. The sensitivity for both Doppler RI and frequency band 4 for the detection of PE at a 10% false-positive rate was 45%. This small study demonstrates the application of wavelet transform analysis of uterine artery Doppler waveforms in screening for PE. Further prospective studies are needed in order to clearly define if this analytical approach to waveform analysis may have the potential to improve the detection of PE by uterine artery Doppler screening.

Paediatric trainee supervision: management changes and perceived education value.

AIM: Supervision in postgraduate training is an under-researched area. We measured the amount, type and effect of supervision on patient care and perceived education value in a general paediatric service. METHOD: We designed a structured observation form and questionnaire to document the type, duration and effect of supervision on patient management and perceived education value. RESULTS: Most supervision occurred without the paediatrician confirming the trainee's findings. Direct observation of the trainee was rare. Management was changed in 30% of patients seen on the inpatient ward round and in 42% of the patients discussed during the chart reviews but not seen by the paediatrician. Management was changed in 48% of the cases when the paediatrician saw the patient with the trainee in outpatients but in only 21% of patients when the patient was but not seen. Changes made to patient management, understanding and perceived education value, differed between inpatient and out patient settings. There was more impact when the paediatrician saw the patient with the trainee in outpatients; while for inpatients, the opposite was true. Trainees rated the value of the supervision more highly than their supervisors did. Trainees' comments on what they learnt from their supervisor related almost exclusively to clinical knowledge rather than professional behaviours. CONCLUSIONS: We observed little evidence of supervisors directly observing trainees and trainees learning professional behaviours. A review of supervisory practices to promote more effective learning is needed. Communicating to paediatricians the value their trainees place on their input could have a positive effect on their engagement in supervision.

evPaeds: undergraduate clinical reasoning.

BACKGROUND: Clinical reasoning is one of the most important skills that medical students need to develop. Our medical students learn clinical reasoning in small group discussion sessions and during their clinical attachments. We wanted to provide additional opportunities for them to develop these important skills. CONTEXT: Our undergraduate paediatric curriculum is based on 25 clinical presentations, and is delivered on the website myPaediatrics. We used simple show-and-hide case examples in each presentation to illustrate to students how to use the knowledge and skills they acquire to solve the clinical presentations. These are popular with students but provide little opportunity for interaction. INNOVATION: Based on two commonly available formats for the virtual patient, neither of which had fully met the specific needs of our undergraduate students, we developed hybrid software: evPaeds. Close collaboration with students and teachers ensured that evPaeds met the unique learning needs of undergraduate students. evPaeds incorporates the Paediatric Decision Tree, which encourages students to make decisions on investigations and management, with immediate feedback. Explicitly referring to the basic sciences in our virtual patients resulted in them being valuable to students in both the pre-clinical and clinical years. IMPLICATIONS: evPaeds has proven popular with students to practise and develop clinical reasoning, individually or in small group sessions.

Clinical teachers working in primary care: what would they like changed in the medical school?

INTRODUCTION: General practitioners (GPs) working as clinical teachers are likely to influence medical students' level of community-based learning. This paper aimed to ascertain clinical teachers' views in relation to The University of Auckland about their clinical learning environment. METHOD: A total of 34 clinical teachers working in primary care contributed to this study. To gauge their level of involvement in teaching and learning, the clinical teachers were asked about issues such as their confidence, available time, sufficient clinical learning opportunities, clear learning objectives to teach students and what they would like changed. FINDINGS: The GPs appeared confident, felt there were sufficient learning opportunities for students and that their students were part of the team. Less experienced teachers expressed less confidence than more experienced peers. There was some hesitancy in terms of coping with time and feedback. Some clinical teachers were unclear about the learning objectives presented to students. CONCLUSION: Several issues that emerged--including available time and financial rewards--are difficult to resolve. Curriculum and selection are evolving issues requiring constant monitoring and alignment with increasing numbers of students studying medicine, increased ethical awareness, more diverse teaching systems and more advanced technologies. Non-faculty clinicians need adequate representation on curriculum committees and involvement in clinical education initiatives. Issues of cultural competency and professional development were raised, suggesting the need for more established links between university and GPs.