PURPOSE:Current clinical reasoning assessments rely mostly on outcome-based rather than process-based indicators, which fails to account for early reasoning processes that impact overall diagnostic accuracy. Between 2022 and 2024, the National Board of Medical Examiners collaborated with medical school faculty members to develop a formative objective structured clinical examination for clinical reasoning (OSCE-CR), which used standardized patient encounters to assess observed student behaviors in three clinical reasoning process subdomains. This study evaluates the psychometric properties of scores from a large-scale pilot study to inform the utility of OSCE-CR as a formative assessment in undergraduate medical education. METHOD:The large-scale pilot study was conducted in fall 2023 and included 76 clerkship students across four different U.S. medical schools. All students completed four different standardized patient cases, and two trained faculty raters scored videos of each case-student combination on the three clinical reasoning process subdomains. Multivariate generalizability theory (G-theory) was used to evaluate score reliabilities (at the subdomain and composite levels), and generalized linear mixed modeling (GLMM) was used to evaluate the predictive utility of the subdomain scores on diagnostic accuracy. RESULTS:The multivariate G-theory results demonstrated acceptable subdomain (mean Φ coefficient = 0.466) and composite reliability estimates (mean Φ coefficient = 0.738). Reliability estimates were most influenced by number of cases, with the addition of more cases to the assessment yielding substantially higher reliability estimates, particularly at the subdomain level. The GLMM results indicated composite scores were a significant positive predictor of diagnostic accuracy (0.605; 95% CI, 0.053-1.157; P = .03). CONCLUSIONS:The results provide initial psychometric evidence for use of OSCE-CR to measure and provide feedback on relevant clinical reasoning processes linked to diagnostic accuracy. By moving beyond outcome-based indicators, OSCE-CR enables students to practice these process-related behaviors to improve their clinical reasoning and reduce future diagnostic errors.

BACKGROUND:Limited data exist on the long-term impact of invasive meningococcal disease (IMD) contracted during adolescence and early adulthood. This study aimed to determine the long-term outcomes on neurocognitive, psychological and quality of life (QoL) outcomes in adolescents and young adults. METHODS:IMD survivors 15-25 years old (2-10 years post-IMD hospitalization) and non-IMD age-matched control participants were recruited across mainland Australian states (2016-2023) and completed neurocognitive, psychological, QoL and physical assessments. RESULTS:A total of 41 IMD cases (93% serogroup B and 73% females) and 51 control participants (57% females) were enrolled in the study. There was no clinically significant difference in Full-Scale IQ between IMD cases (106, SD 11) and control participants [109, SD 14, adjusted difference -4, (95% confidence interval, -10 to 3), P = 0.2]. Mean QoL scores for IMD cases (0.80, SD 0.21) and control participants (0.90, SD 0.09) were similar [adjusted difference -0.06, (95% confidence interval, -0.13 to 0.02), P = 0.2]. Mathematical reasoning was poorer in cases than in controls ( P = 0.02). IMD cases had significantly higher rates of psychological symptoms than controls (58% vs. 31%, P = 0.01), including posttraumatic stress disorder symptoms (10% vs. 0%, P = 0.03) and alcohol dependence (18% vs. 2%, P = 0.04). Physician-assessed physical sequelae were present in 15% of IMD survivors (50% severe). CONCLUSIONS:While long-term outcomes for adolescents and young adult IMD survivors show no significant impact on intellectual functioning or overall QoL, they experienced substantial psychological and physical sequelae. The impact on mental health underscores the need for comprehensive postdischarge psychological follow-up and care for IMD survivors, in addition to care for physical sequelae.

Background: Data on the health-related quality of life (HRQoL) for invasive meningococcal disease (IMD) survivors, particularly among adolescents and young adults (AYAs), are limited. This study aimed to investigate the in-depth experiences and impacts of IMD on AYAs. Methods: Participants were recruited from two Australian states, Victoria and South Australia. We conducted qualitative, semi-structured interviews with 30 patients diagnosed with IMD between 2016 and 2021. The interview transcripts were analyzed thematically. Results: Of the participants, 53% were aged 15–19 years old, and 47% were aged 20–24. The majority (70%) were female. Seven themes relating to the participants’ experience of IMD were identified: (1) underestimation of the initial symptoms and then rapid escalation of symptoms; (2) reliance on social support for emergency care access; (3) the symptoms prompting seeking medical care varied, with some key symptoms missed; (4) challenges in early medical diagnosis; (5) traumatic and life-changing experience; (6) a lingering impact on HRQoL; and (7) gaps in the continuity of care post-discharge. Conclusion: The themes raised by AYA IMD survivors identify multiple areas that can be addressed during their acute illness and recovery. Increasing awareness of meningococcal symptoms for AYAs may help reduce the time between the first symptoms and the first antibiotic dose, although this remains a challenging area for improvement. After the acute illness, conducting HRQoL assessments and providing multidisciplinary support will assist those who require more intensive and ongoing assistance during their recovery.

Abstract Although most students complete Step 1 before clerkships, some institutions delay the exam until after clerkships. The change to pass/fail grading adds additional complexity that should be considered when deciding about exam timing. Both early and late administration may affect learning outcomes, learner behavior, student well-being, and residency match success. Step 1 completion before clerkships promotes learning outcomes (e.g., integration and mastery of foundational material), may encourage students to focus on the curriculum, and may better prepare students for clinical science exams (CSEs). However, delaying the exam ensures that students maintain foundational knowledge and may encourage clinical educators to demonstrate basic science illustrations. An early Step 1 may affect learner behavior by allowing clerkship students to focus on clinical learning. The associated National Board of Medical Examiners performance report may also be used for Step 2 and CSE preparation. However, delaying Step 1 allows greater scheduling flexibility based on developmental milestones. Administration of Step 1 before clerkships removes a significant stressor from the clinical year and decompresses the residency application period. However, a delayed Step 1 reduces the pressure on students to engage in numerous extracurricular and research activities to distinguish themselves due to the pass/fail change. An early Step 1 exam may also lead to improved CSE performance, which is often linked to clerkship honors criteria, an increasingly valuable distinction for residency match success after the change to pass/fail. In contrast, delaying Step 1 is associated with higher first-time pass rates, which may be especially important for students at risk for failure. Medical educators and students should collaboratively approach the question of Step 1 timing, considering these factors within the context of the medical school program, curricular constraints and priorities, and students’ individual needs and goals.

Honest signalling theory suggests that humans and chimpanzees can extract socially relevant information relating to personality from the faces of their conspecifics. Humans are also able to extract information from chimpanzees' faces. Here, we examine whether personality characteristics of chimpanzees, including measures of psychopathy, can be discerned based purely on facial morphology in photographs. Twenty-one chimpanzees were given naïve and expert personality ratings on the Ten Item Personality Inventory (TIPI) and the Chimpanzee Triarchic Model of Psychopathy (CHMP-Tri) before and following behavioural observations. Characteristics relating to openness, conscientiousness, extraversion, and disinhibition could be distinguished from the faces of chimpanzees. Individuals higher on disinhibition have lower scores on conscientiousness and emotional stability and higher scores on extraversion, while those higher on meanness have lower conscientiousness and agreeableness. Facial expressions are linked to personality traits present in the TIPI and CHMP-Tri models: the Relaxed Face and the Grooming Face were displayed more by chimpanzees higher on agreeableness, whereas the Compressed Lips Face was observed more in those individuals higher on boldness, and the Full Open Grin was displayed more by chimpanzees higher on extraversion but lower on emotional stability and conscientiousness. Facial expressions were also found to be associated with particular behavioural contexts, namely the Grooming Face in affiliative contexts and the Relaxed and Relaxed Open Mouth Faces in neutral contexts. Dominant chimpanzees display higher levels of boldness and more Compressed Lips Faces, Relaxed Open Mouth Faces, and Grooming Faces than subordinate individuals. These findings support and extend evidence for an honest signalling system and a personality structure shared between humans and chimpanzees. Future research could further explore how personality is conveyed through the face, perhaps through more than just singular aspects of character, and maybe reflecting what chimpanzees themselves are able to do.

The importance of clinical reasoning in patient care is well-recognized across all health professions. Validity evidence supporting high quality clinical reasoning assessment is essential to ensure health professional schools are graduating learners competent in this domain. However, through the course of a large scoping review, we encountered inconsistent terminology for clinical reasoning and inconsistent reporting of methodology, reflecting a somewhat fractured body of literature on clinical reasoning assessment. These inconsistencies impeded our ability to synthesize across studies and appropriately compare assessment tools. More specifically, we encountered: 1) a wide array of clinical reasoning-like terms that were rarely defined or informed by a conceptual framework, 2) limited details of assessment methodology, and 3) inconsistent reporting of the steps taken to establish validity evidence for clinical reasoning assessments. Consolidating our experience in conducting this review, we provide recommendations on key definitional and methodologic elements to better support the development, description, study, and reporting of clinical reasoning assessments.

Background: Completing an emergency medicine (EM) away rotation is integral to matching successfully into an EM residency program. The demand for EM away rotations (ARs) drives students to submit numerous applications without evidence-based recommendations to guide stakeholders on the approach or number to submit. Objectives: We conducted a survey study of EM-bound fourth-year medical students to gain insight into their AR application experiences, outcomes, and perceptions. Methods: We distributed a 40-item questionnaire to EM applicants in Fall 2018 via e-mail through the Clerkship Directors in Emergency Medicine, Council of Residency Directors in EM, and Emergency Medicine Residents' Association listservs. Responses were evaluated using quantitative and qualitative analysis. Primary outcomes were the number of AR applications submitted and AR offers received by students. Secondary outcomes were students' self-assessment of their competitiveness, differences in AR application numbers by degree type, sources of student advising, and student perceptions of the AR application process. Results: There were 253 respondents, consisting of 192 allopathic (MD) and 61 osteopathic (DO) medical students, who met the inclusion criteria, representing about 10% of the applicant pool. On average, students submitted 13.97 applications (95% confidence interval [CI] 11.59-16.35), received 3.25 offers (95% CI 3.01-3.49), and accepted 2.22 offers (95% CI 2.08-2.36). DO candidates submitted twice as many applications as MD candidates while experiencing a similar rate of offers received. Peer influence (n = 154, 61%), peer online advising networks (n = 83, 33%), and self-assessment (n = 114, 45%) were the most often reported causes of increased applications; cost (n = 104, 41%) and geographic limitations (n = 114, 45%) were the most often reported causes of decreased applications. Open-response analysis revealed frustration with lack of standardization (n = 44, 29.5%), insufficient transparency on available positions (n = 37, 24.8%), limited communication (n = 30, 20.1%), and cost (n = 12, 8.1%). Conclusions: This study showed that, as a whole, students received one away rotation offer for every four to five applications submitted. It clarified factors contributing to increased EM away rotation application submissions and associated stressors inherent in the application experience. Our findings offer insights to inform advising recommendations. They also suggest that stakeholders consider standardizing the process and improve communication over spot availability and application status. (c) 2021 Published by Elsevier Inc.

I would like to thank the organisers and the PIDE for giving me the honour to present this year’s Allama Iqbal Lecture on the subject of Child Poverty and Economic Growth and the opportunity to talk to such well-informed and distinguished audience. I believe that child poverty and economic growth is a subject that is rarely discussed but I think it is a crucial subject for the 21st century. I have only got a brief time to talk to you, so I will only be able to skim over the surface of many issues. If you want to go into a greater depth, there is a website for the Townsend Centre for International Poverty Research, where you can find more details about the issues to which I am going to talk.

Multiple studies around the world suggest that syphilis is re-emerging. Ocular syphilis - with a wide range of presentations, most of which are subtypes of uveitis - has become an increasingly common cause of ocular inflammation over the past 20 years. Its rising incidence, diagnostic complexity, and manifestations that have only recently been characterized make ocular syphilis relevant from the public health, clinical, and scientific perspectives. We review the demographics, epidemiology, clinical features, ocular imaging findings, diagnosis, and medical management of this condition.

Cooperation can be difficult to sustain when there is a temptation to free-ride on the efforts of others. In experiments, peer punishment often stabilizes cooperation but fails to improve earnings because of the costs associated with punishment. In addition, antisocial use of punishment-punishing cooperators, counterpunishing, and feuding-often leads to lower cooperation and earnings. The current study investigated if powerful individuals-individuals who can punish without cost or who are immune from punishment-police the antisocial use of punishment, thus reducing the undesirable effects of punishment. In order to create ample opportunities for antisocial punishment and identify the motives for the use of punishment, our modified public goods game implemented fixed groups, fixed participant identifiers, 2 punishment stages, and full information about participant actions. The powerful participants with cost-free punishment or immunity punished low contributors more often, and immune participants also punished those who punished cooperators. Intriguingly, we found that whenever all participants could be punished-regardless of the cost of punishing or asymmetry in the cost-cooperation and net earnings reached very high levels. However, participants who were immune cooperated at a markedly low level, reducing earnings in the group. The results show that in an environment with repeated interactions, plenty of information, and everyone being accountable, even inefficient punishment can maintain high cooperation and earnings, but immunity of the powerful leads to corrupt behavior and reduced efficiency. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

While the COVID-19 pandemic has presented an immediate risk to human life around the world, climate change poses an arguably greater-although less immediate-threat to our species' survival. Within the framework of life-history theory (LHT), this pre-registered study investigated whether extrinsic risk (i.e., external factors that pose a risk to an individual's life, e.g., COVID-19) and existential risk (i.e., risks with outcomes that threaten the existence of humans as a species, e.g., climate change) had similar or different relationships with reproductive decision-making. A UK representative sample of 325 participants between 18 and 35 years of age was asked to indicate their ideal number of children, ideal age to start having children, and whether their desire for a child had recently changed. Participants were asked about their experiences of COVID-19 and given a series of scales with which to assess their beliefs about climate change. In support of LHT, the study found evidence that knowing people who had been hospitalized with or died of COVID-19 was associated with a greater ideal number of children. Conversely, there was no clear evidence of a relationship between climate change beliefs and reproductive decision-making. The repercussions for understanding how we interpret and respond to different forms of mortality risk are discussed.

Poverty and social exclusion are a gendered phenomenon. They are rooted deeply in the stereotypes, biases, prejudices, and discriminations against women, especially those suffering from poor living conditions. Unfortunately, gender inequality is manifested in most, if not all, major life domains. It is therefore important to understand the gender aspect of poverty and social exclusion through a psychological lens. We begin this chapter by introducing the concepts of multi-dimensional poverty and social exclusion with a sketch of the gender disparities displayed in these areas. We turn next to several mainstream psychological theories which have attempted to investigate and interpret the relationship between poverty and gender inequality from the dispositional, motivational, cognitive, and behavioural perspectives. Finally, we evaluate the reliability, objectivity, and generalisability of the reviewed theories and studies and offer suggestions for future research.

Background Clinical reasoning is at the core of health professionals’ practice. A mapping of what constitutes clinical reasoning could support the teaching, development, and assessment of clinical reasoning across the health professions. Methods We conducted a scoping study to map the literature on clinical reasoning across health professions literature in the context of a larger Best Evidence Medical Education (BEME) review on clinical reasoning assessment. Seven databases were searched using subheadings and terms relating to clinical reasoning, assessment, and Health Professions. Data analysis focused on a comprehensive analysis of bibliometric characteristics and the use of varied terminology to refer to clinical reasoning. Results Literature identified: 625 papers spanning 47 years (1968–2014), in 155 journals, from 544 first authors, across eighteen Health Professions. Thirty-seven percent of papers used the term clinical reasoning; and 110 other terms referring to the concept of clinical reasoning were identified. Consensus on the categorization of terms was reached for 65 terms across six different categories: reasoning skills, reasoning performance, reasoning process, outcome of reasoning, context of reasoning, and purpose/goal of reasoning. Categories of terminology used differed across Health Professions and publication types. Discussion Many diverse terms were present and were used differently across literature contexts. These terms likely reflect different operationalisations, or conceptualizations, of clinical reasoning as well as the complex, multi-dimensional nature of this concept. We advise authors to make the intended meaning of ‘clinical reasoning’ and associated terms in their work explicit in order to facilitate teaching, assessment, and research communication.

The coronavirus disease (COVID-19) pandemic has had a significant impact on undergraduate medical education with limitation of patient care activities and disruption to medical licensing examinations. In an effort to promote both safety and equity, the emergency medicine (EM) community has recommended no away rotations for EM applicants and entirely virtual interviews during this year's residency application cycle. These changes affect the components of the EM residency application most highly regarded by program directors - Standardized Letters of Evaluation from EM rotations, board scores, and interactions during the interview. The Council of Residency Directors in Emergency Medicine Application Process Improvement Committee suggests solutions not only for the upcoming year but also to address longstanding difficulties within the process, encouraging residency programs to leverage these challenges as an opportunity for disruptive innovation.

PURPOSE:An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore the existing menu of CR assessments. METHOD:Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were sorted by assessment methods and reviewed by pairs of authors. Extracted data were used to construct descriptive appendixes, summarizing each method, including common stimuli, response formats, scoring, typical uses, validity considerations, feasibility issues, advantages, and disadvantages. RESULTS:A total of 377 articles were included in the final synthesis. The articles broadly fell into three categories: non-workplace-based assessments (e.g., multiple-choice questions, extended matching questions, key feature examinations, script concordance tests); assessments in simulated clinical environments (objective structured clinical examinations and technology-enhanced simulation); and workplace-based assessments (e.g., direct observations, global assessments, oral case presentations, written notes). Validity considerations, feasibility issues, advantages, and disadvantages differed by method. CONCLUSIONS:There are numerous assessment methods that align with different components of the complex construct of CR. Ensuring competency requires the development of programs of assessment that address all components of CR. Such programs are ideally constructed of complementary assessment methods to account for each method's validity and feasibility issues, advantages, and disadvantages.

Clinical reasoning is an essential component of a health professional's practice. Yet clinical reasoning research has produced a notably fragmented body of literature. In this article, the authors describe the pause-and-reflect exercise they undertook during the execution of a synthesis of the literature on clinical reasoning in the health professions. Confronted with the challenge of establishing a shared understanding of the nature and relevant components of clinical reasoning, members of the review team paused to independently generate their own personal definitions and conceptualizations of the construct. Here, the authors describe the variability of definitions and conceptualizations of clinical reasoning present within their own team. Drawing on an analogy from mathematics, they hypothesize that the presence of differing "boundary conditions" could help explain individuals' differing conceptualizations of clinical reasoning and the fragmentation at play in the wider sphere of research on clinical reasoning. Specifically, boundary conditions refer to the practice of describing the conditions under which a given theory is expected to hold, or expected to have explanatory power. Given multiple theoretical frameworks, research methodologies, and assessment approaches contained within the clinical reasoning literature, different boundary conditions are likely at play. Open acknowledgment of different boundary conditions and explicit description of the conceptualization of clinical reasoning being adopted within a given study would improve research communication, support comprehensive approaches to teaching and assessing clinical reasoning, and perhaps encourage new collaborative partnerships among researchers who adopt different boundary conditions.

Juniors doctors self confidence and knowledge to clinically use the antibiotic vancomycin.

“Moralistic” punishment of free riders can provide a beneficial reputation, but the immediate behavior is costly to the punisher. In Study 1, we investigated whether variation in status would be perceived to offset or mitigate the costs of punishment. One hundred and nineteen participants were presented with a vignette describing a punishment scenario. Participants predicted whether punishment would occur, how successful it would be, and indicated their attitude to the punisher. Participants believed only intervention by a high-status (HS) individual would be successful and that low-status (LS) individuals would not intervene at all. HS individuals predicted to punish successfully were seen as more formidable and likable. Study 2 investigated whether punishment was necessary to maintain an HS position. One hundred and seventeen participants were presented with a vignette describing a punishment scenario. Participants were asked to indicate whether they wished to be led by the punisher. HS individuals who did not punish were less likely to be chosen as leaders compared to HS punishers, whereas LS individuals who punished were no more or less likely to be chosen than nonpunishers. The results of both studies suggest that only HS individuals are expected to punish, likely because such a position offsets some of the costs of punishment. As a result, only HS individual can access the reputation benefits from punishment. Furthermore, an HS position may be dependent on the willingness to punish antisocial behavior. The ramifications that these results may have for the evolution of moralistic punishment are discussed.