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OBJECTIVE: The objective of the study was to explore the effectiveness of an immersive simulation experience using an aging simulation suit for fostering empathy towards geriatric patients with advanced mental illness. METHOD: Psychiatry residents were recruited during their clinical rotations at a Canadian mental health hospital. The participants took on the first-person perspective of a geriatric patient with mental illness initially through written reflection, and then physically inhabited this role by wearing an aging simulation suit to perform the task of meeting with a pharmacist to review current medications and prepare a dosette. Concurrently, an audio file was played through headphones to simulate auditory hallucinations. A pre- and post-Jefferson Scale of Empathy (JSE), reflective writing exercise, debrief transcription, and evaluation questionnaire were used to evaluate the intervention. Interviews conducted 3 month post-intervention explored its impact on their clinical practice. RESULTS: Fifteen psychiatry residents completed the study. There was a significant increase in JSE scores pre (M = 115.5, SD = 13.2) to post (M = 119.2, SD = 12.7) intervention, t(14) = 2.65, p = .02. The qualitative findings of the study demonstrated participants' improved understanding and awareness of the patient perspective and the ability to communicate this understanding and show intentions to help through practice change. CONCLUSION: An aging suit simulation with debriefing may be an effective educational intervention to incorporate into the medical curriculum to foster empathy for this stigmatized population.

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INTRODUCTION: Simulation has been identified as a key training modality to enhance interprofessional care for patients with co-occurring physical and mental illnesses. Fidelity is an important instructional design consideration for interprofessional simulation; however, research examining the contribution of physical, psychological, and sociological fidelity in achieving learning outcomes remains limited. This qualitative study explored the relationship between fidelity and learning from the perspective of interprofessional simulation course participants. METHODS: Semistructured interviews were conducted with participants from the Interprofessional Simulations of Patient Experiences Across the Care Continuum - Child and Youth course. Consistent with grounded theory, data collection and analysis proceeded in an iterative fashion and emergent themes were identified by the research team through a process of constant comparative analysis. RESULTS: Data saturation was reached after 10 interviews. High psychological fidelity allowed participants to engage in the simulation scenarios in ways that were congruent with their professional roles, which supported individual practice change. Tasks that were too closely aligned with their clinical experiences sometimes, however, limited new learning opportunities. Selective manipulations of sociological fidelity seemed to support learning outcomes related to understanding and appreciating the roles and responsibilities of other health professionals. Physical fidelity was less essential. CONCLUSIONS: Psychological and sociological fidelity were perceived by participants as being most critical to learning in interprofessional mental health simulation. Improving our understanding of how simulation works in this context is important to effectively direct the efforts of learners, instructors, and designers toward maximizing the benefit of simulation-based learning in a cost-efficient manner.

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OBJECTIVE: In response to the need for practitioners to improve their skills in integrating mental and physical healthcare, the Centre for Addiction and Mental Health (CAMH) (Canada) invited education specialists from Maudsley Simulation (UK) to pilot two of their existing interprofessional simulation courses on the mental-physical interface in Toronto. Participants' experiences as well as the courses' educational impact were evaluated. METHODS: Participants completed pre-and post-course questionnaires, a 2-week follow-up questionnaire, and individual interviews 6 months after course completion. RESULTS: Participants (n = 23) found the courses to be relevant and applicable to their practice. Over half of the participants interviewed (8/15) reported changing their practice as a result of the course. However, concerns regarding the sociological fidelity of these courses within the Canadian context were noted. CONCLUSION: The findings support the transferability of interprofessional simulation courses developed in other countries. It is important, however, to contextualize course material to fit local healthcare systems and to ensure sociological fidelity where professional roles may vary.

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INTRODUCTION: The ability to maintain good performance with low cognitive load is an important marker of expertise. Incorporating cognitive load measurements in the context of simulation training may help to inform judgements of competence. This exploratory study investigated relationships between demographic markers of expertise, cognitive load measures, and simulator performance in the context of point-of-care ultrasonography. METHODS: Twenty-nine medical trainees and clinicians at the University of Toronto with a range of clinical ultrasound experience were recruited. Participants answered a demographic questionnaire then used an ultrasound simulator to perform targeted scanning tasks based on clinical vignettes. Participants were scored on their ability to both acquire and interpret ultrasound images. Cognitive load measures included participant self-report, eye-based physiological indices, and behavioural measures. Data were analyzed using a multilevel linear modelling approach, wherein observations were clustered by participants. RESULTS: Experienced participants outperformed novice participants on ultrasound image acquisition. Ultrasound image interpretation was comparable between the two groups. Ultrasound image acquisition performance was predicted by level of training, prior ultrasound training, and cognitive load. There was significant convergence between cognitive load measurement techniques. A marginal model of ultrasound image acquisition performance including prior ultrasound training and cognitive load as fixed effects provided the best overall fit for the observed data. DISCUSSION: In this proof-of-principle study, the combination of demographic and cognitive load measures provided more sensitive metrics to predict ultrasound simulator performance. Performance assessments which include cognitive load can help differentiate between levels of expertise in simulation environments, and may serve as better predictors of skill transfer to clinical practice.

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Students cannot learn from feedback unless they pay attention to it. This study investigated relationships between the personal factors of achievement goal orientations, achievement emotions, and attention to feedback in BioWorld, a computer environment for learning clinical reasoning. Novice medical students (N = 28) completed questionnaires to measure their achievement goal orientations and then thought aloud while solving three endocrinology patient cases and reviewing corresponding expert solutions. Questionnaires administered after each case measured participants' experiences of five feedback emotions: pride, relief, joy, shame, and anger. Attention to individual text segments of the expert solutions was modelled using logistic regression and the method of generalized estimating equations. Participants did not attend to all of the feedback that was available to them. Performance-avoidance goals and shame positively predicted attention to feedback, and performance-approach goals and relief negatively predicted attention to feedback. Aspects of how the feedback was displayed also influenced participants' attention. Findings are discussed in terms of their implications for educational theory as well as the design and use of computer learning environments in medical education.

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Background. Identifying which patients are most likely to be at risk of chronic pain and other postconcussion symptoms following mild traumatic brain injury (MTBI) is a difficult clinical challenge. Objectives. To examine the relationship between pain catastrophizing, defined as the exaggerated negative appraisal of a pain experience, and early MTBI outcome. Methods. This cross-sectional design included 58 patients diagnosed with a MTBI. In addition to medical chart review, postconcussion symptoms were assessed by self-report at 1 month (Time 1) and 8 weeks (Time 2) after MTBI. Pain severity, psychological distress, level of functionality, and pain catastrophizing were measured by self-report at Time 2. Results. The pain catastrophizing subscales of rumination, magnification, and helplessness were significantly correlated with pain severity (r = .31 to .44), number of postconcussion symptoms reported (r = .35 to .45), psychological distress (r = .57 to .67), and level of functionality (r = -.43 to -.29). Pain catastrophizing scores were significantly higher for patients deemed to be at high risk of postconcussion syndrome (6 or more symptoms reported at both Time 1 and Time 2). Conclusions. Higher levels of pain catastrophizing were related to adverse early MTBI outcomes. The early detection of pain catastrophizing may facilitate goal-oriented interventions to prevent or minimize the development of chronic pain and other postconcussion symptoms.

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BACKGROUND: This review, which focused on faculty development initiatives designed to improve teaching effectiveness, synthesized findings related to intervention types, study characteristics, individual and organizational outcomes, key features, and community building. METHODS: This review included 111 studies (between 2002 and 2012) that met the review criteria. FINDINGS: Overall satisfaction with faculty development programs was high. Participants reported increased confidence, enthusiasm, and awareness of effective educational practices. Gains in knowledge and skills, and self-reported changes in teaching behaviors, were frequently noted. Observed behavior changes included enhanced teaching practices, new educational initiatives, new leadership positions, and increased academic output. Organizational changes were infrequently explored. Key features included evidence-informed educational design, relevant content, experiential learning, feedback and reflection, educational projects, intentional community building, longitudinal program design, and institutional support. CONCLUSION: This review holds implications for practice and research. Moving forward, we should build on current success, broaden the focus beyond individual teaching effectiveness, develop programs that extend over time, promote workplace learning, foster community development, and secure institutional support. We should also embed studies in a theoretical framework, conduct more qualitative and mixed methods studies, assess behavioral and organizational change, evaluate transfer to practice, analyse key features, and explore the role of faculty development within the larger organizational context.

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BACKGROUND: Cognitive load theory (CLT) provides a rich framework to inform instructional design. Despite the applicability of CLT to simulation-based medical training, findings from multimedia learning have not been consistently replicated in this context. This lack of transferability may be related to issues in measuring cognitive load (CL) during simulation. The authors conducted a review of CLT studies across simulation training contexts to assess the validity evidence for different CL measures. METHOD: PRISMA standards were followed. For 48 studies selected from a search of MEDLINE, EMBASE, PsycInfo, CINAHL, and ERIC databases, information was extracted about study aims, methods, validity evidence of measures, and findings. Studies were categorized on the basis of findings and prevalence of validity evidence collected, and statistical comparisons between measurement types and research domains were pursued. RESULTS: CL during simulation training has been measured in diverse populations including medical trainees, pilots, and university students. Most studies (71%; 34) used self-report measures; others included secondary task performance, physiological indices, and observer ratings. Correlations between CL and learning varied from positive to negative. Overall validity evidence for CL measures was low (mean score 1.55/5). Studies reporting greater validity evidence were more likely to report that high CL impaired learning. CONCLUSIONS: The authors found evidence that inconsistent correlations between CL and learning may be related to issues of validity in CL measures. Further research would benefit from rigorous documentation of validity and from triangulating measures of CL. This can better inform CLT instructional design for simulation-based medical training.

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Theory-based instructional design is a top priority in medical education. The goal of this Show and Tell article is to present our theory-driven approach to the design of instruction for clinical educators. We adopted cognitive load theory as a framework to design and evaluate a series of professional development workshops that were delivered at local, national and international academic conferences in 2014. We used two rating scales to measure participants' cognitive load. Participants also provided narrative comments as to how the workshops could be improved. Cognitive load ratings from 59 participants suggested that the workshop design optimized learning by managing complexity for different levels of learners (intrinsic load), stimulating cognitive processing for long-term memory storage (germane load), and minimizing irrelevant distracters (extraneous load). Narrative comments could also be classified as representing intrinsic, extraneous, or germane load, which provided specific directions for ongoing quality improvement. These results demonstrate that a cognitive load theory approach to workshop design and evaluation is feasible and useful in the context of medical education.

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CONTEXT: The effective implementation of cognitive load theory (CLT) to optimise the instructional design of simulation-based training requires sensitive and reliable measures of cognitive load. This mixed-methods study assessed relationships between commonly used measures of total cognitive load and the extent to which these measures reflected participants' experiences of cognitive load in simulation-based procedural skills training. METHODS: Two groups of medical residents (n = 38) completed three questionnaires after participating in simulation-based procedural skills training sessions: the Paas Cognitive Load Scale; the NASA Task Load Index (TLX), and a cognitive load component (CLC) questionnaire we developed to assess total cognitive load as the sum of intrinsic load (how complex the task is), extraneous load (how the task is presented) and germane load (how the learner processes the task for learning). We calculated Pearson's correlation coefficients to assess agreement among these instruments. Group interviews explored residents' perceptions about how the simulation sessions contributed to their total cognitive load. Interviews were audio-recorded, transcribed and subjected to qualitative content analysis. RESULTS: Total cognitive load scores differed significantly according to the instrument used to assess them. In particular, there was poor agreement between the Paas Scale and the TLX. Quantitative and qualitative findings supported intrinsic cognitive load as synonymous with mental effort (Paas Scale), mental demand (TLX) and task difficulty and complexity (CLC questionnaire). Additional qualitative themes relating to extraneous and germane cognitive loads were not reflected in any of the questionnaires. CONCLUSIONS: The Paas Scale, TLX and CLC questionnaire appear to be interchangeable as measures of intrinsic cognitive load, but not of total cognitive load. A more complete understanding of the sources of extraneous and germane cognitive loads in simulation-based training contexts is necessary to determine how best to measure and assess their effects on learning and performance outcomes.

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BACKGROUND: Due to the increasing complexity of medical education and practice, the preparation of healthcare professionals for leadership roles and responsibilities has become increasingly important. To date, the literature on faculty development designed to promote leadership in medical education has not been reviewed in a systematic fashion. AIM: The objective of this review is to synthesize the existing evidence that addresses the following question: 'What are the effects of faculty development interventions designed to improve leadership abilities on the knowledge, attitudes, and skills of faculty members in medicine and on the institutions in which they work?' SEARCH STRATEGY: The search, which covered the period 1980-2009, included six databases (Medline, EMBASE, CINAHL, Web of Science, ERIC, and ABI/Inform) and used the following keywords: faculty development; in-service training; doctor; medic; physician; faculty; leadership; management; administration; executive; and change agent. Hand searches were also conducted, and expert recommendations were solicited. INCLUSION AND EXCLUSION CRITERIA: Articles with a focus on faculty development to improve leadership, targeting basic science and clinical faculty members, were reviewed. All study designs that included outcome data beyond participant satisfaction were examined. From an initial 687 unique records, 48 articles met the review criteria in three broad categories: (1) reports in which leadership was the primary focus of the intervention; (2) reports in which leadership was a component of a broader focus on educational development; and (3) reports in which leadership was a component of a broader focus on academic career development. DATA EXTRACTION: Data were extracted by three coders using the standardized Best Evidence Medical Education coding sheet adapted for our use. One reviewer coded all of the articles, and two reviewers each coded half of the dataset. Coding differences were resolved through discussion. DATA SYNTHESIS: Data were synthesized using Kirkpatrick's four levels of educational outcomes. Findings were grouped by intervention type and level of outcome. RESULTS: Forty-eight articles described 41 studies of 35 different interventions. The majority of the interventions targeted clinical faculty members and included workshops, short courses, fellowships, and other longitudinal programs. The majority of studies were quantitative in nature, though five studies used a qualitative design, and 12 studies used mixed methods. All quantitative studies were quasi-experimental and most employed a single group design; only two studies had a comparison group. Qualitative study designs were typically not specified. The majority of evaluation data, primarily collected post-intervention, consisted of participants' responses to questionnaires and interviews. KEY POINTS AND SUMMARY OF OUTCOMES: Despite methodological limitations, the faculty development literature tends to support the following outcomes: ▪ High satisfaction with faculty development programs. Participants consistently found programs to be useful and of both personal and professional benefit. They also valued the practical relevance and applicability of the instructional methods used. ▪ A change in attitudes toward organizational contexts and leadership roles. Participants reported positive changes in attitudes toward their own organizations as well as their leadership capabilities. Some reported an increased awareness of--and commitment to--their institution's vision and challenges, whereas others reported greater self-awareness of personal strengths and limitations, increased motivation, and confidence in their leadership roles. A greater sense of community and appreciation of the benefits of networking were also identified. ▪ Gains in knowledge and skills. Participants reported increased knowledge of leadership concepts, principles, and strategies (e.g., leadership styles and strategic planning), gains in specific leadership skills (e.g., personal effectiveness and conflict resolution), and increased awareness of leadership roles in academic settings. ▪ Changes in leadership behavior. Self-perceived changes in leadership behavior were consistently reported and included a change in leadership styles, the application of new skills to the workplace (e.g., departmental reorganization and team building), the adoption of new leadership roles and responsibilities, and the creation of new collaborations and networks. Observed changes primarily suggested new leadership positions. ▪ Limited changes in organizational practice. Although not frequently examined, changes in organizational practice included the implementation of specific educational innovations, an increased emphasis on educational scholarship, and the establishment of collegial networks. ▪ Key features of faculty development. Features contributing to positive outcomes included the use of: multiple instructional methods within single interventions; experiential learning and reflective practice; individual and group projects; peer support and the development of communities of practice; mentorship; and institutional support. ▪ Avenues for future development: Moving forward, faculty development programs should: ground their work in a theoretical framework; articulate their definition of leadership; consider the role of context; explore the value of extended programs and follow-up sessions; and promote the use of alternative practices including narrative approaches, peer coaching, and team development. METHODOLOGICAL ISSUES: More rigorous and diverse research designs are needed to capture the complexity of interventions in this area. Varied methods of assessment, utilizing multiple data sources to tap changes at the interpersonal and organizational level should be explored, as should the maintenance of change over time. Process-oriented studies, comparing different faculty development strategies and clarifying the process of change through faculty development, should also become a priority. CONCLUSION: Participants value leadership development activities and report changes in attitudes, knowledge, skills and behavior. Moreover, despite methodological limitations, certain program characteristics seem to be associated with positive outcomes. Further research is required to explore these associations and document changes at both the individual and organizational level.

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Systems biology presents a new paradigm for elucidating the processes required to organize and sustain life. We now have access to whole genome sequences, gene expression data for multiple cell types, and databases for regulatory elements governing these genes. These resources make it feasible to identify conserved genomic sequences across multiple species, transcription factors regulating the expression of genes with similar expression patterns within a given cell type and to compare expression levels of specific genes between normal and diseased cellular states. In order to utilize this wealth of information, new computational tools that integrate these datasets in a genome-wide context are required. Using the protamine cluster as an example, we present a series of in-house applications that we have developed to integrate, contextualize and visualize datasets across multiple hierarchies.

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