RESUMEN
BACKGROUND: Flaws in clinical reasoning are present in most diagnostic errors and occur even when physicians have enough knowledge to solve the problem. Deliberate reflection has been shown to improve diagnoses. The sources of faulty reasoning and how reflection counteracts them remain largely unknown. OBJECTIVE: To explore the causes of faulty reasoning and the mechanisms through which reflection neutralises them by investigating the influence of salient distracting clinical features on diagnostic decision-making. DESIGN AND SETTING: In a prior study, 34 internal medicine residents and 50 medical students of the Erasmus Medical Centre, Rotterdam, diagnosed four clinical cases by means of non-analytical reasoning and four by reflective reasoning. In the secondary analysis of the data presented here, five internists independently evaluated the diagnoses and examined the nature of the diagnostic errors in relation to case features that gave rise to these errors. MAIN OUTCOMES: Frequency of incorrect diagnoses caused by salient distracting features made through reflective and non-analytical reasoning. RESULTS: Among residents, reflective reasoning (Mean diagnostic accuracy score (M)=2.09, 95% CI 1.77 to 2.40) led to a significantly higher number of correct diagnoses than non-analytical reasoning (M=1.71, 95% CI 1.37 to 2.04; p=0.03). This higher diagnostic accuracy was associated with fewer incorrect diagnoses triggered by salient distracting clinical features (M=0.47, 95% CI 0.26 to 0.68) compared with non-analytical reasoning (M=0.85, 95% CI 0.59 to 1.11; p=0.02). Students did not benefit from reflection to improve diagnoses. CONCLUSION: Salient features in a case tend to attract physicians' attention and may misdirect diagnostic reasoning when they turn out to be unrelated to the problem, causing errors. Reflection helps by enabling physicians to overcome the influence of distracting features. The lack of effect for students suggests that this is only possible when there is enough knowledge to recognise which features discriminate between alternative diagnoses.
Asunto(s)
Competencia Clínica , Toma de Decisiones , Errores Diagnósticos , Humanos , Medicina Interna/educaciónRESUMEN
CONTEXT: Medical students often fail to finish medical school within the designated time. An academic dismissal (AD) policy aims to enforce satisfactory progress and to enable early identification and timely support or referral of struggling students. In this study, we assessed whether the implementation of an AD policy improved study progress in the first 2 years of medical school. Additionally, we analysed its effect on the help-seeking behaviour of struggling students. METHODS: We compared two AD cohorts (entering in 2005 and 2006, respectively) and two non-AD cohorts (entering in 2003 and 2004, respectively) on dropout rates, Year 1 curriculum completion rates and the percentage of students with an optimal study rate (i.e. all modules completed) at 1 and 2 years after enrolment. We also measured the effect on study progress of attending the support meetings offered. RESULTS: The AD (n = 809) and non-AD cohorts (n = 809) did not differ significantly in dropout rate at 5 months, in Year 1 completion rate at 2 years and in the percentage of optimally performing students at 1 year after enrolment. At 2 years after enrolment, more students from the AD cohorts had left and more non-AD students demonstrated optimal performance, but effect sizes (ESs) for these differences were small. Voluntary support at 4 months was attended by AD students more often than by non-AD students (68.9% versus 39.8%; χ(2) ((1)) = 43.95, p < 0.001, ES = 0.29). The AD students who attended the support meetings completed the Year 1 curriculum more often than those who did not (73.4% versus 52.5%; χ(2) ((1)) = 10.92, p < 0.001, ES = 0.20). Attending the obligatory support meeting at 7 months had a similar effect (70.5% versus 33.3%; χ(2) ((1)) = 13.60, p < 0.001, ES = 0.23). CONCLUSIONS: The presence of an AD policy did not lead to earlier dropout, higher completion rates or an improved study rate during the first 2 years at medical school. However, uptake of the support offered increased to almost 70%. Although support participants finished the Year 1 curriculum more often than non-participants, the current support system was not sufficient to improve overall study progress.
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Consejo/métodos , Educación de Pregrado en Medicina/métodos , Evaluación Educacional/métodos , Abandono Escolar/psicología , Estudiantes de Medicina/psicología , Estudios de Cohortes , Consejo/normas , Educación de Pregrado en Medicina/normas , Femenino , Humanos , Masculino , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
OBJECTIVES: A recent controlled study by our group showed that the dropout rate in the first 2 years of study of medical students selected for entry by the assessment of a combination of non-cognitive and cognitive abilities was 2.6 times lower than that of a control group of students admitted by lottery. The aim of the present study was to compare the performance of these two groups in the clinical phase. METHODS: A prospective cohort study was performed to compare the performance of 389 medical students admitted by selection with that of 938 students admitted by weighted lottery between 2001 and 2004. Follow-up of these cohorts lasted 5.5-8.5 years. The main outcome measures were the mean grade obtained on the first five discipline-specific clerkships by all cohorts and the mean grade achieved on all 10 clerkships by the cohorts of 2001 and 2002. RESULTS: Selected students obtained a significantly higher mean grade during their first five clerkships than lottery-admitted students (mean ± standard error [SE] 7.95 ± 0.03, 95% confidence interval [CI] 7.90-8.00 versus mean ± SE 7.84 ± 0.02, 95% CI 7.81-7.87; p < 0.001). This difference reflected the fact that selected students achieved a grade of ≥ 8.0 1.5 times more often than lottery-admitted students. An analysis of all mean grades awarded on 10 clerkships revealed the same results. Moreover, the longer follow-up period over the clerkships showed that the relative risk for dropout was twice as low in the selected student group as in the lottery-admitted student group. CONCLUSIONS: The selected group received significantly higher mean grades on their first five clerkships, which could not be attributed to factors other than the selection procedure. Although the risk for dropout before the clinical phase increased somewhat in both groups, the actual dropout rate proved to be twice as low in the selected group.
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Prácticas Clínicas/normas , Educación Médica/normas , Evaluación Educacional/normas , Internado y Residencia/normas , Criterios de Admisión Escolar/estadística & datos numéricos , Estudiantes de Medicina/psicología , Logro , Estudios de Casos y Controles , Estudios de Cohortes , Prueba de Admisión Académica , Educación Médica/métodos , Educación Médica/estadística & datos numéricos , Evaluación Educacional/estadística & datos numéricos , Femenino , Humanos , Internado y Residencia/estadística & datos numéricos , Masculino , Países Bajos , Estudios Prospectivos , Adulto JovenRESUMEN
Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices' decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases.
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Atención , Estado de Conciencia , Competencia Profesional , Pensamiento , Errores Diagnósticos , HumanosRESUMEN
AIM: A need was felt to improve the quality of admission and licensing procedures for international medical graduates in The Netherlands. METHOD: A clinical skills assessment was designed as part of a new procedure to realize a high-stakes, fair, transparent, and a time-limited path of admission for international medical graduates to the Dutch health care system. Additionally, it should provide a well-founded advice about length and content of additional medical training, should this be indicated by the outcome of the assessment. RESULTS: The clinical skills assessment procedure was developed as a Dutch variant of the "Step 2 Clinical Skills examination" of the Educational Commission for Foreign Medical Graduates (ECFMG) in collaboration with the United States National Board of Medical Examiners, which has a well-documented validity and reliability. The experience with the new procedure is yet limited, but enough to warrant a report. DISCUSSION: Worldwide, a number of countries have developed such high-stake assessment procedures, but they show little uniformity and transparency. By describing the design and development of our procedure, we do not pretend to set a standard, but we hope to contribute to more fair, accurate and uniform approaches for doctors moving from one country to another.
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Competencia Clínica/normas , Evaluación Educacional/métodos , Médicos Graduados Extranjeros , Humanos , Países Bajos , Criterios de Admisión EscolarRESUMEN
OBJECTIVES: We aimed to discover, through a controlled experiment, whether cognitive and non-cognitive assessment would select higher-achieving applicants to medical school than selection by lottery. METHODS: We carried out a prospective cohort study to compare 389 medical students who had been admitted by selection and 938 students who had been admitted by weighted lottery, between 2001 and 2004. Main outcome measures were dropout rates, study rate (credits per year) and mean grade per first examination attempt per year. Study rates in the 4 pre-clinical years of medical school were used to categorise students' performance as average or optimal. RESULTS: Pre-admission variables did not differ between the two groups. The main outcome of the selection experiment was that relative risk for dropping out of medical school was 2.6 times lower for selected students than for lottery-admitted controls (95% confidence interval 1.59-4.17). Significant differences between the groups in the percentage of optimally performing students and grade point average for first examination attempts were found only in the 2001 cohort, when results favoured the selected group. The results of the selection process took into account both the assessment procedure involved and the number of students who withdrew voluntarily. CONCLUSIONS: This is the first controlled study to show that assessing applicants' non-cognitive and cognitive abilities makes it possible to select students whose dropout rate will be lower than that of students admitted by lottery. The dropout rate in our overall cohort was 2.6 times lower in the selected group.
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Cognición , Criterios de Admisión Escolar , Facultades de Medicina , Estudiantes de Medicina/psicología , Evaluación Educacional , Humanos , Países Bajos , Determinación de la Personalidad , Estudios Prospectivos , Abandono EscolarRESUMEN
Clinical rotations play an important role in the medical curriculum and are considered crucial for student learning. However, competencies that should be learned can differ from those that are assessed. In order to explore which competencies are considered important for daily performance of student on the wards and to what extent clinical teachers consider the same competencies important for clerkship grading, a survey that consisted of 21 different student characteristics was administered to clinical teachers. Two independent factor analyses using structural equation modeling were conducted to abstract underlying latent relationships among the different student characteristics and to define a clinical competence profile for daily performance of students on the wards and clerkship grading. Differences between the degree of importance for student daily ward performance and clerkship grading are considered and discussed. The results of the survey indicate that the degree of importance of competencies are rated different for daily performance of students on the wards and clerkship grades. Competencies related to the diagnostic process are more important for clerkship grading, whereas interpersonal skills, professional qualities, and motivation are more important for daily ward performance. It is concluded that the components of clinical competence considered important for adequate performance are not necessarily in alignment with what is required for grading. Future research should focus on an explanation why clinical educators think differently about the importance of competencies for student examination in contrast to what is required for adequate daily performance on the wards.
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Prácticas Clínicas/normas , Competencia Clínica/normas , Evaluación Educacional/normas , Estudiantes de Medicina , Actitud del Personal de Salud , Prácticas Clínicas/organización & administración , Evaluación Educacional/métodos , Análisis Factorial , Docentes Médicos , Humanos , Modelos EducacionalesRESUMEN
BACKGROUND: Induction chemotherapy before surgical resection increases survival compared with surgical resection alone in patients with stage IIIA-N2 non-small-cell lung cancer (NSCLC). We hypothesized that, following a response to induction chemotherapy, surgical resection would be superior to thoracic radiotherapy as locoregional therapy. METHODS: Selected patients with histologic or cytologic proven stage IIIA-N2 NSCLC were given three cycles of platinum-based induction chemotherapy. Responding patients were subsequently randomly assigned to surgical resection or radiotherapy. Survival curves were estimated using Kaplan-Meier analyses from time of randomization. RESULTS: Induction chemotherapy resulted in a response rate of 61% (95% confidence interval [CI] = 57% to 65%) among the 579 eligible patients. A total of 167 patients were allocated to resection and 165 to radiotherapy. Of the 154 (92%) patients who underwent surgery, 14% had an exploratory thoracotomy, 50% a radical resection, 42% a pathologic downstaging, and 5% a pathologic complete response; 4% died after surgery. Postoperative radiotherapy was administered to 62 (40%) of patients in the surgery arm. Among the 154 (93%) irradiated patients, overall compliance to the radiotherapy prescription was 55%, and grade 3/4 acute and late esophageal and pulmonary toxic effects occurred in 4% and 7%; one patient died of radiation pneumonitis. Median and 5-year overall survival for patients randomly assigned to resection versus radiotherapy were 16.4 versus 17.5 months and 15.7% versus 14%, respectively (hazard ratio = 1.06, 95% CI = 0.84 to 1.35). Rates of progression-free survival were also similar in both groups. CONCLUSION: In selected patients with pathologically proven stage IIIA-N2 NSCLC and a response to induction chemotherapy, surgical resection did not improve overall or progression-free survival compared with radiotherapy. In view of its low morbidity and mortality, radiotherapy should be considered the preferred locoregional treatment for these patients.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/radioterapia , Neoplasias Pulmonares/cirugía , Neumonectomía , Adulto , Anciano , Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico , Carcinoma de Pulmón de Células no Pequeñas/patología , Quimioterapia Adyuvante , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Pulmonares/tratamiento farmacológico , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Compuestos Organoplatinos/administración & dosificación , Estudios Prospectivos , Radioterapia Adyuvante , Inducción de Remisión/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Before the 1970s, research into the development of clinical competence was mainly focused on general problem-solving abilities. The scope of research changed when Elstein and colleagues discovered that individual ability to solve clinical problems varies considerably across cases. It was concluded that problem solving abilities are highly dependent on domain-specific knowledge rather than on general problem solving skills. Elstein called this phenomenon "case specificity." PURPOSE: The finding of content specificity will be contrasted with the existence of a general clinical problem solving ability, and the relationship between preclinical knowledge and a problem solving ability will be investigated. METHODS: A correlation matrix was calculated with clerkship final scores from 10 disciplines to examine the magnitude of the interrelations. A confirmatory factor analysis was applied to the corresponding covariances using structural equation modeling to investigate whether scores on finals shared any common variance across clerkships. Finally, two additional models were tested to examine the nature of the relationship between preclinical knowledge and problem solving. RESULTS: Low to moderate correlations across clerkship disciplines were found, supporting the original findings of content specificity. Further investigation showed that in addition to specific knowledge, a general, content-independent ability is needed to perform on these examinations. CONCLUSIONS: Clinical competence, as measured in this study, is based on a combination of specific preclinical knowledge and a problem-solving ability. Case specificity fits perfectly well in this interactional perspective on clinical problem solving but does not explain it. The phenomenon "case specificity" is therefore not solely a result of content knowledge, but of level of experience and level of case difficulty.
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Prácticas Clínicas/normas , Competencia Clínica/normas , Solución de Problemas , Aprendizaje Basado en Problemas , Prácticas Clínicas/organización & administración , Evaluación Educacional/métodos , Humanos , Medicina , Modelos Educacionales , Países Bajos , Psicología Educacional , Especialización , Estudiantes de Medicina/psicologíaRESUMEN
PURPOSE: It remains unclear if inflammation itself may induce cancer, if inflammation is a result of tumor growth, or a combination of both exists. The aim of this study was to examine whether C-reactive protein (CRP) levels and CRP gene variations were associated with an altered risk of colorectal, lung, breast, or prostate cancer. PATIENTS AND METHODS: A total of 7,017 participants age > or = 55 years from the Rotterdam Study were eligible for analyses. Mean follow-up time was 10.2 years. High-sensitivity CRP measurements were performed to identify additional values of 0.2 to 1.0 mg/L compared with standard procedures. Genotypes of the CRP gene were determined with an allelic discrimination assay. RESULTS: High levels (> 3 mg/L) of CRP were associated with an increased risk of incident cancer (hazard ratio, 1.4; 95% CI, 1.1 to 1.7) compared with persons with low levels (< 1 mg/L), even after a potential latent period of 5 years was introduced. Although CRP seems to affect several cancer sites, the association was strongest for lung cancer (hazard ratio, 2.8; 95% CI, 1.6 to 4.9). A CRP single nucleotide polymorphism associated with decreased CRP levels was associated with an increased lung cancer risk of 2.6 (95% CI, 1.6 to 4.4) in homozygous carriers. CONCLUSION: Baseline CRP levels seem to be a biomarker of chronic inflammation preceding lung cancer, even after subtracting a 5-year latent period. Furthermore, CRP gene variation associated with low CRP blood levels was relatively common in patients with lung cancer. Both chronic inflammation and impaired defense mechanisms resulting in chronic inflammation might explain these results.
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Biomarcadores de Tumor/genética , Biomarcadores de Tumor/metabolismo , Proteína C-Reactiva/genética , Proteína C-Reactiva/metabolismo , Neoplasias/epidemiología , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/epidemiología , Enfermedad Crónica , Neoplasias Colorrectales/epidemiología , Femenino , Frecuencia de los Genes , Variación Genética , Haplotipos , Humanos , Inflamación/sangre , Neoplasias Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Neoplasias/sangre , Neoplasias/genética , Países Bajos/epidemiología , Oportunidad Relativa , Polimorfismo de Nucleótido Simple , Estudios Prospectivos , Neoplasias de la Próstata/epidemiología , Proyectos de Investigación , Medición de Riesgo , Factores de RiesgoRESUMEN
BACKGROUND: Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear. OBJECTIVES: This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence. METHODS: Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software. RESULTS: Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters. CONCLUSION: Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.