Sherbino, Jonathan

Substantial research has illuminated the clinical reasoning processes involved in diagnosis (diagnostic reasoning). Far less is known about the processes entailed in patient management (management reasoning), including decisions about treatment, further testing, follow-up visits, and allocation of limited resources. The authors’ purpose is to articulate key differences between diagnostic and management reasoning, implications for health professions education, and areas of needed research. Diagnostic reasoning focuses primarily on classification (i.e., assigning meaningful labels to a pattern of symptoms, signs, and test results). Management reasoning involves negotiation of a plan and ongoing monitoring/adjustment of that plan. A diagnosis can usually be established as correct or incorrect, whereas there are typically multiple reasonable management approaches. Patient preferences, clinician attitudes, clinical contexts, and logistical constraints should not influence diagnosis, whereas management nearly always involves prioritization among such factors. Diagnostic classifications do not necessarily require direct patient interaction, whereas management prioritizations require communication and negotiation. Diagnoses can be defined at a single time point (given enough information), whereas management decisions are expected to evolve over time. Finally, management is typically more complex than diagnosis. Management reasoning may require educational approaches distinct from those used for diagnostic reasoning, including teaching distinct skills (e.g., negotiating with patients, tolerating uncertainty, and monitoring treatment) and developing assessments that account for underlying reasoning processes and multiple acceptable solutions. Areas of needed research include if and how cognitive processes differ for management and diagnostic reasoning, how and when management reasoning abilities develop, and how to support management reasoning in clinical practice.

ABSTRACT Background Physician well-being is garnering increasing attention. In 2016, the Journal of Graduate Medical Education (JGME) published a review by Kristin Raj, MD, entitled “Well-Being in Residency: A Systematic Review.” There is benefit in contextualizing the literature on resident well-being through an academic journal club. Objective We summarized an asynchronous, online journal club discussion about this systematic review and highlighted themes that were identified in the review. Methods In January 2017, JGME and the Academic Life in Emergency Medicine (ALiEM) blog facilitated an open-access, online, weeklong journal club on the featured JGME article. Online discussions and interactions were facilitated via blog posts and comments, a video discussion on Google Hangouts on Air, and Twitter. We performed a thematic analysis of the discussion and captured web analytics. Results Over the first 14 days, the blog post was viewed 1070 unique times across 52 different countries. A total of 130 unique participants on Twitter posted 480 tweets using the hashtag #JGMEscholar. Thematic analysis revealed 5 major domains: the multidimensional nature of well-being, measurement of well-being, description of wellness programs and interventions, creation of a culture of wellness, and critique of the methodology of the review. Conclusions Our online journal club highlighted several gaps in the current understanding of resident well-being, including the need for consensus on the operational definition, the need for effective instruments to evaluate wellness programs and identify residents in distress, and a national research collaboration to assess wellness programs and their impact on resident well-being.

Objectives Debriefing is a common feature of technology‐enhanced simulation ( TES ) education. However, evidence for its effectiveness remains unclear. We sought to characterise how debriefing is reported in the TES literature, identify debriefing features that are associated with improved outcomes, and evaluate the effectiveness of debriefing when combined with TES . Methods We systematically searched databases, including MEDLINE , EMBASE and Scopus, and reviewed previous bibliographies for original comparative studies investigating the use of TES with debriefing in training health care providers. Reviewers, in duplicate, evaluated study quality and abstracted information on instructional design, debriefing and outcomes. Effect sizes ( ES ) were pooled using random‐effects meta‐analysis. Results From 10 903 potentially eligible studies, we identified 177 studies (11 511 learners) that employed debriefing as part of TES . Key characteristics of debriefing (e.g. duration, educator presence and characteristics, content, structure/method, timing, use of video) were usually incompletely reported. A meta‐analysis of four studies demonstrated that video‐assisted debriefing has negligible and non‐significant effects for time skills ( ES = 0.10) compared with non‐video‐assisted debriefing. Meta‐analysis demonstrated non‐significant effects in favour of expert modelling with short debriefing in comparison with long debriefing (ES range = 0.21–0.74). Among studies comparing terminal with concurrent debriefing, results were variable depending on outcome measures and the context of training (e.g. medical resuscitation versus technical skills). Eight additional studies revealed insight into the roles of other debriefing‐related factors (e.g. multimedia debriefing, learner‐led debriefing, debriefing duration, content of debriefing). Among studies that compared simulation plus debriefing with no intervention, pooled ES s were favourable for all outcomes (ES range = 0.28–2.16). Conclusions Limited evidence suggests that video‐assisted debriefing yields outcomes similar to those of non‐video‐assisted debriefing. Other debriefing design features show mixed or non‐significant results. As debriefing characteristics are usually incompletely reported, future debriefing research should describe all the key debriefing characteristics along with their associated descriptors.

Abstract Objectives Technology‐enhanced simulation is used frequently in emergency medicine ( EM ) training programs. Evidence for its effectiveness, however, remains unclear. The objective of this study was to evaluate the effectiveness of technology‐enhanced simulation for training in EM and identify instructional design features associated with improved outcomes by conducting a systematic review. Methods The authors systematically searched MEDLINE , EMBASE , CINAHL , ERIC , Psych INFO , Scopus, key journals, and previous review bibliographies through May 2011. Original research articles in any language were selected if they compared simulation to no intervention or another educational activity for the purposes of training EM health professionals (including student and practicing physicians, midlevel providers, nurses, and prehospital providers). Reviewers evaluated study quality and abstracted information on learners, instructional design (curricular integration, feedback, repetitive practice, mastery learning), and outcomes. Results From a collection of 10,903 articles, 85 eligible studies enrolling 6,099 EM learners were identified. Of these, 56 studies compared simulation to no intervention, 12 compared simulation with another form of instruction, and 19 compared two forms of simulation. Effect sizes were pooled using a random‐effects model. Heterogeneity among these studies was large (I 2 ≥ 50%). Among studies comparing simulation to no intervention, pooled effect sizes were large (range = 1.13 to 1.48) for knowledge, time, and skills and small to moderate for behaviors with patients (0.62) and patient effects (0.43; all p < 0.02 except patient effects p = 0.12). Among comparisons between simulation and other forms of instruction, the pooled effect sizes were small (≤0.33) for knowledge, time, and process skills (all p > 0.1). Qualitative comparisons of different simulation curricula are limited, although feedback, mastery learning, and higher fidelity were associated with improved learning outcomes. Conclusions Technology‐enhanced simulation for EM learners is associated with moderate or large favorable effects in comparison with no intervention and generally small and nonsignificant benefits in comparison with other instruction. Future research should investigate the features that lead to effective simulation‐based instructional design.