This study assesses whether a person's self-concept as a "chronic kidney patient" differentially moderates the psychosocial impact of illness intrusiveness--illness-induced lifestyle disruptions--across the life span. Renal transplant (n = 52) and maintenance dialysis patients (n = 49) completed the illness Intrusiveness Ratings Scale, a semantic-differential self-concept measure, and structured interviews measuring psychosocial well-being and emotional distress. Across ages, distress rose with increasing illness intrusiveness when self-concept was similar, but not dissimilar, to the chronic kidney patient stereotype. The relation between illness intrusiveness and psychosocial well-being differed significantly between younger and older respondents depending on whether they construed themselves as similar versus dissimilar to the chronic kidney patient. Although self-definition moderates the psychosocial impact of chronic disease, this varies across the life span and across affect states.

Background: The relation between knowledge structure and diagnostic performance is unclear. Similarly, variables affecting knowledge structure are poorly understood.Purpose: The 1st objective was to examine the relation between concepts in knowledge structure and diagnostic performance. The 2nd objective was to examine the relation between the use of diagnostic schemes by small-group preceptors and knowledge structure of medical students.Methods: This was a cross-sectional study of 1st-year medical students in 4 clinical presentations: hyponatremia, hyperkalemia, metabolic acidosis, and metabolic alkalosis. The 1st dependent variable was diagnostic success with the number of expert-type concepts in knowledge structure (determined by concept sorting), diagnostic scheme use by preceptors, and clinical presentation as independent variables. The 2nd dependent variable was the number of expert-type concepts in knowledge structure with diagnostic scheme use by preceptors and clinical presentation as independent variables. Data were analyzed using multiple logistic and linear regression.Results: Thirty 1st-year medical students participated. After adjusting for clinical presentation and scheme use by preceptors, the number of expert-type concepts in knowledge structure was associated with increased odds of diagnostic success (odds ratio 1.18 [1.03, 1.35], p =.016). After adjustment for clinical presentation, scheme use by preceptors was associated with increased number of expert-type concepts in knowledge structure (2.22 vs. 1.86, p =.01, d = 0.23).Conclusions: The number of expert-type concepts in knowledge structure is associated with increased odds of diagnostic success. Scheme use by small-group preceptors is associated with an increased number of expert-type concepts in knowledge structure.

Background Previous studies have suggested an association between reasoning strategies and diagnostic success, but the influence on this relationship of variables such as question format and task difficulty, has not been studied. Our objective was to study the association between question format, task difficulty, reasoning strategies and diagnostic success. Methods Study participants were 13 Internal Medicine residents at the University of Calgary. Each was given eight problem-solving questions in four clinical presentations and were randomized to groups that differed only in the question format, such that a question presented as short answer (SA) to the first group was presented as extended matching (EM) to the second group. There were equal numbers of SA/EM questions and straightforward/difficult tasks. Participants performed think-aloud during diagnostic reasoning. Data were analyzed using multiple logistic regression. Results Question format was associated with reasoning strategies; hypothetico-deductive reasoning being used more frequently on EM questions and scheme-inductive reasoning on SA questions. For SA question, non-analytic reasoning alone was used more frequently to answer straightforward cases than difficult cases, whereas for EM questions no such association was observed. EM format and straightforward task increased the odds of diagnostic success, whereas hypothetico-deductive reasoning was associated with reduced odds of success. Conclusions Question format and task difficulty both influence diagnostic reasoning strategies and studies that examine the effect of reasoning strategies on diagnostic success should control for these effects. Further studies are needed to investigate the effect of reasoning strategies on performance of different groups of learners.

Background During evolution from novice to expert, knowledge structure develops into an abridged network organized around pathophysiological concepts. The objectives of this study were to examine the change in knowledge structure in medical students in one year and to investigate the association between the use of a conceptual framework (diagnostic scheme) and long-term knowledge structure. Methods Medical students' knowledge structure of metabolic alkalosis was studied after instruction and one year later using concept-sorting. Knowledge structure was labeled 'expert-type' if students shared ≥ 2 concepts with experts and 'novice-type' if they shared < 2 concepts. Conditional logistic regression was used to study the association between short-term knowledge structure, the use of a diagnostic scheme and long-term knowledge structure. Results Thirty-four medical students completed the concept-sorting task on both occasions. Twenty-four used a diagnostic scheme for metabolic alkalosis. Short-term knowledge structure was not a correlate of long-term knowledge structure, whereas use of a diagnostic scheme was associated with increased odds of expert-type long-term knowledge structure (odds ratio 12.6 [1.4, 116.0], p = 0.02). There was an interaction between short-term knowledge structure and the use of a diagnostic scheme. In the group who did not use a diagnostic scheme the number of students changing from expert-type to novice-type was greater than vice versa (p = 0.046). There was no significant change in the group that used the diagnostic scheme (p = 0.6). Conclusion The use of a diagnostic scheme by students may attenuate the loss of expert-type knowledge structure.

Evolution from novice to expert is associated with the development of expert-type knowledge structure. The objectives of this study were to examine reliability and validity of concept sorting (ConSort©) as a measure of static knowledge structure and to determine the relationship between concepts in static knowledge structure and concepts used during diagnostic reasoning.

Abstract Background The influence of intended and informal curricula on examination preparation has not been extensively studied. This study aims to firstly describe how students utilized components of intended and informal curricula to guide examination preparation, and secondly to study the relationship between examination preparation and performance. Methods Students received a pre-examination questionnaire to identify components from the intended curriculum (objectives and examination blueprint), and informal curriculum (content emphasised during lectures and small groups), used during examination preparation. Multiple logistic regression was used to study the relationship between these variables and student performance (above versus at or below average). Results Eighty-one students participated. There was no difference in the proportions using the examination blueprint, content emphasised during lectures, and content emphasised during small groups (87 – 93%) but fewer students used objectives (35%, p < 0.001). Objectives use was associated with reduced odds of above average examination performance (adjusted odds ratio 0.27 [0.07, 0.97], p = 0.04). Conclusion When preparing for the renal course examination, students were influenced at least as much by the informal as the intended curriculum. Of the two intended curriculum components, the examination blueprint appeared to be more widely used than the course objectives. This decreased use of objectives on examination preparation did not appear to have a detrimental effect on student performance.

CONTEXT:A major goal of any evaluation is to demonstrate content validity, which considers both curricular content as well as the ability expected of learners. Whether evaluation blueprints should be published and the degree of blueprint transparency is controversial.OBJECTIVES:To examine the effect of blueprint publication on students' perceptions of the validity of the evaluation process.METHODS:This study examined students' attitudes towards the Renal Course evaluation before and after blueprint publication. There was no significant change in the course objectives, blueprint or evaluation between the two time periods. Students' attitudes were evaluated using a questionnaire containing four items related to evaluation. Also collected were the overall course ratings, minimum performance level (MPL) for evaluations and students' performance on each exam.RESULTS:There were no significant differences in the MPL or evaluation scores between the two time periods. A significantly greater proportion of students perceived that the Renal Course evaluation was a fair test and was reflective of both important subject matter and the delivered curriculum. The increased satisfaction process did not appear to be a reflection of their overall satisfaction with the course as there was a trend towards reduced overall satisfaction with the course.CONCLUSIONS:Publication of the evaluation blueprint appears to improve students' perceptions of the validity of the evaluation process. Further studies are required to identify the reasons for this attitude change. We propose that blueprint transparency drives both instructors teaching and student learning towards key educational elements.

BACKGROUND:Pencil-and-paper examination formats, and specifically the standard, five-option multiple-choice question, have often been questioned as a means for assessing higher-order clinical reasoning or problem solving. This study firstly investigated whether two paper formats with differing number of alternatives (standard five-option and extended-matching questions) can test problem-solving abilities. Secondly, the impact of the alternatives number on psychometrics and problem-solving strategies was examined.METHODS:Think-aloud protocols were collected to determine the problem-solving strategy used by experts and non-experts in answering Gastroenterology questions, across the two pencil-and-paper formats.RESULTS:The two formats demonstrated equal ability in testing problem-solving abilities, while the number of alternatives did not significantly impact psychometrics or problem-solving strategies utilized.CONCLUSIONS:These results support the notion that well-constructed multiple-choice questions can in fact test higher order clinical reasoning. Furthermore, it can be concluded that in testing clinical reasoning, the question stem, or content, remains more important than the number of alternatives.

Background: When the University of Calgary implemented the clinical presentation (CP) curriculum in 1994, it was prospectively decided to administer the National Board of Medical Examiner's Comprehensive Basic Science Exam (CBSE) as a measure of students' basic science knowledge retention. Purpose: The exam performance from 2 classes (1995, 1996) of the previous system-based (SB) curriculum was compared to exam performance of 2 classes (2000, 2002) of the CP curriculum. Methods: Data analyses employed 2 statistical models (covariate multiple linear regression and hierarchical mixed effects), and effect sizes were computed. Results: Differences between CBSE mean scores produced by students from the SB and CP curricula showed a curricular effect on students' retention of basic science knowledge. However, preexisting differences between groups were found to be in the small-to-medium range. Conclusion: Evidence supporting the potential of schemes within a CP curriculum and their relation to basic science knowledge retention was observed. Effect size for the CP curriculum on students' retention of basic science knowledge was substantial; however, a notable part of that difference can be accounted for by extraneous and confounding factors. Further research utilizing more rigorous designs to investigate the relation between schemes and basic science retention is warranted.

Purpose Cognitive psychology research supports the notion that experts use mental frameworks or 'schemes', both to organize knowledge in memory and to solve clinical problems. The central purpose of this study was to determine the relationship between problem-solving strategies and the likelihood of diagnostic success.Methods Think-aloud protocols were collected to determine the diagnostic reasoning used by experts and non-experts when attempting to diagnose clinical presentations in gastroenterology.Results Using logistic regression analysis, the study found that there is a relationship between diagnostic reasoning strategy and the likelihood of diagnostic success. Compared to hypothetico-deductive reasoning, the odds of diagnostic success were significantly greater when subjects used the diagnostic strategies of pattern recognition and scheme-inductive reasoning. Two other factors emerged as independent determinants of diagnostic success: expertise and clinical presentation. Not surprisingly, experts outperformed novices, while the content area of the clinical cases in each of the four clinical presentations demonstrated varying degrees of difficulty and thus diagnostic success.Conclusions These findings have significant implications for medical educators. It supports the introduction of 'schemes' as a means of enhancing memory organization and improving diagnostic success.

We evaluated a health rating for renal failure patients that was completed by patients, nurses, and nephrologists. The study was a prospective inception-cohort follow-up design. Measurements were taken before initiating dialysis (n=206) or at the initiation of dialysis (n=200) and at 18 (n=225), 30 (n=181), 42 (n=162), 54 (n=137), and 66 (n=112) months after initiating dialysis. Patients, nurses, and nephrologists independently rated patients' health at each measurement occasion. Objective measures of health status, abstracted from the medical record, included emergency and non-emergency admissions, smoking, diabetes mellitus, pulmonary edema, history and number of myocardial infarctions (MI), basal rales, comorbid illnesses, and uremic symptoms. Simultaneous multiple regression analyses examined the correspondence between objective measures of health status and subjective health ratings separately for each rater and measurement occasion. Health ratings were averaged and submitted to the same analyses. Raters showed good agreement (average Pearson r=.43 overall), although agreement was higher between nephrologists and nurses (average r=.64) than between health professional and patients (average r=.34 and .31, respectively). All three ratings and the combined rating corresponded significantly to objective measures of health status. Uremic symptoms, emergency hospital admissions, diabetes mellitus, and recent MI correlated uniquely and most consistently with subjective health ratings. Despite overall convergence, objective measures of health status related to the groups' ratings in a complementary fashion. The health rating is reliable and relates to the current status of the patient. Performance was superior for the combined score that incorporated ratings by patients, nurses, and nephrologists.

PURPOSE:First, to evaluate "concept sorting" as a tool for assessing knowledge organization in the memories of first-year medical students, and second, to study the relationship between knowledge organization and examination performance.METHOD:During 2001, first-year medical students taking the Renal Course at the University of Calgary Faculty of Medicine were given a questionnaire on scheme use and were given a concept-sorting task in the domain of metabolic alkalosis. The sophistication of their concept sorting was graded using the number of physiology-based groups they formed. Review of the course's examination scores allowed correlation with concept-sorting scores. Statistical analyses used Fisher's exact test and the two-sample t-test. Pearson's correlation coefficient and the kappa statistic were used for correlation between raters.RESULTS:A total of 81 of 99 students completed the study. The concept-sorting score (mean +/- SEM) for students who used the scheme was higher than was the score for students who did not (2.5 +/- 0.14 versus 1.91 +/- 0.12, p =.016). Students who scored higher in the concept-sorting task, referred to as "deep learners," scored higher than did "surface learners" on exam questions on metabolic alkalosis (2.81 versus 2.29, p =.02). There was no difference in the overall examination performances between the two groups.CONCLUSIONS:Concept sorting may be a useful tool for studying the learning process. Scheme use by students produces a positive outcome on examination performance.

This essay outlines the development and evaluation of the Research Project Program (RPP) ten years after its introduction into the medical curriculum at the University of Calgary. The RPP consists of two mandatory for-credit courses. Students have the option of conducting either two smaller independent research projects or one larger project over the two years. At the end of the second-year course the students complete an evaluation of the RPP in which they are asked to assess and comment upon various aspects of the program. The authors compared data available from years one (the class of 1990) and ten (the class of 2000) and found significant differences between the two classes' approaches to the RPP. Most of the class of 2000 (89%) carried out two-year independent in-depth research projects spanning a wide range of topics. Half of these projects involved individual collection and analyses of data using experimental methods; this represented a 2.25-fold increase over the first year of the program. In the class of 2000, 44% of students presented their results at a newly implemented research symposium; an additional 22% of students presented their results at local, national, or international meetings. Further, 59% of the class of 2000 had either submitted or were planning to submit their research for peer-reviewed publication. In contrast, none of the students of the class of 1990 formally presented their research, and only 11% planned to submit their research findings for publication. The RPP has evolved in the ten years since its implementation, but the authors believe the program continues to foster independent learning and analytic and problem-solving skills.

Background The lecture is a much used and much criticized teaching method. Lecturalgia (painful lecture) is a frequent cause of morbidity for both teachers and learners. The etiology of lecturalgia is multifactorial and multiple lecturing pathologies frequently coexist. The 'Clinical Presentation' curriculum at the University of Calgary encourages the use of 'schemes' that provide a scaffolding for learning and a starting point for approaching (clinical) problems. Thus far this approach has not been used to tackle teaching or learning problems.Aim Our aim in this paper was to devise a schematic approach to diagnosing lecturing problems and to make evidence-based recommendations on how to resolve lecturing problems. We have suggested that causes of lecturalgia can be divided into three categories: poor judgement; poor organization; and poor delivery. Our proposed scheme is based upon these three categories that are then subcategorized.Results We have reviewed the medical education literature in an attempt to provide evidence-based recommendations for the remediation of lecturing problems within each subcategory.Conclsion Where trial evidence is lacking we have made recommendations that are consistent with cognitive theory or expert opinion. Finally, where expert opinion does not exist, we have taken the liberty (literary license) of providing nonexpert opinion!

In reply: We greatly appreciate the response of Mandin, Harasym, and Woloschuk to our article,1 because it furthers the discussion of a topic that is (in our view) seriously under-addressed in medical education: how medical students learn to cope with complex clinical cases, and, more particularly, how they construct differential diagnoses for such cases. However, we want to start by clarifying some critical aspects of the method we advocate, which is called clinical problem analysis (CPA), and the article we published. First, we do not refer to the article by Mandin, Harasym, Eagle, and Watanabe2 as a “representative presentation of standard schemas for constructing a differential diagnosis”—at least, we did not intend to. In fact, we referred to this article as one of the few in the medical education literature that actually addresses (albeit tangentially) the construction of a differential diagnosis. We just wanted to emphasize that while schemes can be helpful in constructing differential diagnoses, there is also a risk associated with their use, namely that students learn them by heart and use them rather mindlessly, without checking whether the alternatives the schemes provide are correct and exhaustive. Furthermore, in our view, students should be trained to generate possible causes for diseases based on their knowledge of pathology, pathophysiology, nosology, and other basic sciences, rather than to instantiate a standard scheme. Nevertheless, we definitely do not think that authors who advocate such schemes would endorse students' using them mindlessly. Second, in their letter, Mandin et al. appear to interpret CPA as a completely content-independent method for solving clinical problems. However, when we claim that “CPA … makes optimal use of content-independent (methodical) aspects of problem solving,” we do not mean to imply that CPA is completely content-independent! Therefore, we fully agree with Mandin et al.'s statement that “diagnostic accuracy depends more on mastery of knowledge domain than problem solving strategy,” but, on the other hand, we do not believe that medical problem solving is completely content-dependent. What we do claim is that CPA makes optimal use of that part of problem solving that is not content-dependent. Even if one does not support CPA, one might still agree that a systematic approach to analyzing clinical problems might be advantageous. Moreover, a method can be called systematic only if it is to some extent content-independent (even though it is always applied to specific content). Part of CPA's systematicness is that it explicitly forces the diagnostician to take into consideration every symptom, sign, and patient complaint, and use his or her knowledge to account for them. We are convinced that novice diagnosticians often miss relevant diagnostic hypotheses because they either neglect particular features or misinterpret them. Thus, though CPA may be problem-independent, it is not, as Mandin et al. appear to think, knowledge-independent. In addition, we also emphasize that CPA aims not only at developing students' diagnostic competency, also at identifying treatment. Although we think that the clinical presentation curriculum, as presented in the literature by Mandin et al.,2,3 is an interesting innovation in medical education, we do have some questions concerning the approach. In their letter to Academic Medicine, the authors state that “In the clinical presentation model, all possible patient presentations are identified and listed beforehand.” We doubt whether this is possible. For example, in practice, one should always be aware of comorbidity (which theoretically increases the number of clinical presentations from N to N2, even if the comorbidity of only two diseases is taken into account). Even more importantly, the medication a patient currently takes (e.g., for a chronic disease) often interacts with a new, acute illness, not to mention all kinds of drug—drug interactions. Are they all covered in a clinical presentation curriculum? In addition, it is also not quite clear what Mandin et al.2,3 actually mean by a scheme. On the one hand, the term apparently refers to a procedure to be followed for solving a clinical problem (e.g., “students are given opportunity to practice utilizing schemes in problem solving issues…,”2,p. 189), whereas on the other hand, it appears to refer to a compiled knowledge structure in the mind of the student or physician (“a mental categorization of knowledge”3,p. 173; it is also described this way in the letter to Academic Medicine). Apart from lack of theoretical clarity, a problematic consequence of this view is that it is all too easy to assume that students learn to solve clinical problems by emulating experts' behavior: apparently, the scheme an expert uses reflects the knowledge structure in his or her mind. In most areas of expertise development, however, watching and mimicking experts is not the optimal way to acquire expertise, for much of what experts actually do has become implicit. Therefore, in our view, students should initially learn clinical problem solving by following CPA's guidelines, that is, by explicitly working through and elaborating upon a complex case. By repeated application of the method, as well as by accumulation of clinical experience, students gradually develop finely tuned knowledge structures (e.g., illness scripts) that they learn to apply when appropriate—that is, when a clinical case is relatively simple, with one disease or condition responsible for all signs, symptoms, and complaints. Only in such cases is it appropriate to take shortcuts; in more complex cases, an explicit approach will be necessary to fully resolve a clinical problem, including deciding on treatment. The fact that experts are able to use illness scripts (or compiled knowledge structures, or prototypes, or “patterns”) in routine cases is, in our view, a consequence—may be even an epiphenomenon—of their acquired expertise; thus, encouraging inexperienced students to use such knowledge structures, which they possess only in a very rudimentary form, is not a fruitful way to develop clinical expertise. In sum, we think that CPA and the clinical presentation curriculum basically are not incompatible, for the clinical presentations Mandin et al. (1995, 1997) describe can be used by students to practice applying CPA. As the clinical presentations are probably representative of the full domain of clinical problems, repeated application of CPA to these presentations may foster students' development of illness scripts for a broad and representative sample of patients. Thus, CPA and the use of clinical presentations do not by necessity lead to completely different curricular structures, as Mandin et al. state in their letter. In our view, CPA definitely has some advantages: it explicitly addresses comorbidity and drug—drug interactions, it is geared to treatment, it takes into account not only the causes but also the consequences of the current condition of the patient, and it can be used in all cases, including those yet unsolved. Presently, it is not clear to us whether the clinical presentation curriculum has the same potential. We look forward to future contributions by Mandin and colleagues in which these issues are addressed.

In an era of increasing professional accountability, there is a need for both medical educators and licensing bodies to identify attributes expected of medical graduates. Once these attributes are identified, educators must translate them into meaningful learning objectives. Because educators in many countries are in the process of defining (or have defined) attributes and competencies expected of their graduates, a review of the conceptual basis for writing curricular and examination objectives is relevant and constructive. The authors compare the principles of a conceptual model for identifying educational objectives and those used in the creation of the second (and most current) edition of the Objectives for the Qualifying Examination of the Medical Council of Canada (MCC). In developing these objectives, extensive and careful collaboration between licensing bodies, medical schools, the practicing profession, learners, and the MCC was critical. The process illustrates that the goals for the education of medical students can be consistent whether they are elaborated by medical schools or licensing bodies. The authors present the method and principles used by the MCC, including the clinical presentation model. The basic steps in the process are described: identifying the attributes, identifying the basic educational philosophy, assigning priority to problem-solving principles, and deducing learning objectives from desirable practice-related behaviors. The authors conclude with a consideration of the need and feasibility of defining the scientific underpinnings of competency-based learning objectives.

CONTEXT:The University of Calgary has implemented a new curriculum which is organized according to 120 ways in which patients may present to a physician. Students are taught scheme-based problem solving rather than the more typical hypothetico-deductive or search and scan approach to problem resolution.OBJECTIVE:This study sought to determine the extent to which faculty and students were implementing and utilizing scheme-based problem solving.METHOD:All classes taught within the new clinical presentation curriculum were surveyed at the year end. Participants included four classes of first-year students and three classes of second-year students. Using a 5-point scale, students responded to survey items regarding scheme implementation and utilization.RESULTS:Data were analysed using MANOVA (multivariate analysis of variance) and revealed significant differences among classes in both first- and second-year students. Increments in scheme implementation and utilization by instructors and students were observed, although instructors' utilization of schemes lagged behind that of students. A levelling effect to the benefits of schemes for problem solving was also evident. First-year students reported schemes to be very useful for learning and organizing new information.CONCLUSION:Although it has taken time to implement curriculum change, the student response to schemes has been favourable. Faculty development and further generation of pictorial/spatial representations for all schemes, to ensure that all clinical presentations provide pathways that students can use for both learning and problem solving are recommended. Whether students who utilize schemes are more successful problem solvers is not yet known but will be the subject of study as soon as scheme delivery is predominant.

Background/Aims: Early identification and predialysis psychoeducation are gaining acceptance. Although research supports the immediate value of predialysis interventions, long-term benefits remain unknown. We examined long-term knowledge retention following a psychoeducational intervention. Methods: 47 progressive renal failure patients completed the Kidney Disease Questionnaire at baseline and 18, 30, 42, and 54 months after initiating renal replacement therapy (RRT; the ‘longitudinal’ sample). A larger cohort provided data at one or more of these points (n = 132, 117, 101, and 70 at 18, 30, 42, and 54 months, respectively; the ‘cross-sectional’ sample). Results: Initial knowledge gains among psychoeducation recipients were followed by a significant knowledge advantage for three groups throughout follow-up. Patients who received predialysis psychoeducation either before or after starting dialysis demonstrated superior Kidney Disease Questionnaire scores as compared with those identified before the initiation of RRT who received the usual standard of practice. Patients identified after the initiation of RRT and who received standard education, however, demonstrated the same level of knowledge retention as produced by psychoeducation. The results were identical across the longitudinal and cross-sectional samples. Conclusions: Patient education produces important benefits in end-stage renal disease, but the incremental value of early intervention remains to be demonstrated.