March 2021

posted in: 2021 Journal Clubs | 0

COMSEP Journal Club
March 2021
Editors: Karen Forbes, Randy Rockney and Jon Gold


The value of deliberate reflection

Exploring mechanisms underlying learning from deliberate reflection: An experimental study. Ribeiro LMC, Mamede S, de Brito EM, Moura AS, de Faria RMD, Schmidt HG.. Med Educ. 2021;55:404–412. medu.14410

Reviewed by Jon Gold


What was the study question?  

How does deliberate reflection on clinical cases help students with future learning tasks?


How was the study done?

101 5th-year medical students at a single Brazilian institution participated in a voluntary study.  First, they were given two clinical cases and asked to come up with a prioritized differential diagnosis.  Half were randomized to a ‘deliberate reflection procedure’ in which they were asked to type out possible diagnoses and possible supporting/refuting evidence for each before submitting a final diagnosis.  The other half were asked only to submit a differential diagnosis and final diagnosis.  Second, all students were asked to rate their knowledge gap and situational interest (a measure of ‘thirst for knowledge’) using standardized tools.  Third, the students were again randomized to study materials related to the cases in a restricted time frame (180 seconds) or for as long as they wanted.  Finally, all students completed a cued recall test to determine what they had learned from the study materials.


What were the results?

The group assigned to deliberate reflection reported higher levels of situational interest and more awareness of their knowledge gaps.  They also recalled more from the study materials than the other group.  There was no effect of study time on recall of study materials.


What are the implications?

The results of the cued recall tests suggest that structured reflection can improve future learning through cognitive mechanisms.   The situational interest test suggests that reflection can also improve motivation, but the improved motivation did not improve performance through more time on task.  Overall, this study supports the use of structured reflection activities to aid in learning.


Editor’s note: It should come as no surprise that a “deliberate reflection procedure” can be demonstrated to improve learning. I imagine this method could benefit any and all clinicians with the obvious caveat that such a procedure takes time. It would be of interest to know if students who are introduced to this idea persist in its employment beyond the terms of this study. i.e., might they make this method a habit. (RR)


If you see something, say…nothing?


Pediatric Trainees’ Speaking Up About Unprofessional Behavior and Traditional Patient Safety Threats. Etchegaray JM, Lehmann LS, Thomas EJ, Martinez W. Acad Pediatr. 2021 Mar;21(2):352-357.


Reviewed by: Karen Forbes


What was the study question?

What are the experiences, attitudes and anticipated behaviors of pediatric trainees when it comes to speaking up about unprofessional behavior and safety threats?


How was it done?

All residents and fellows at two large free-standing academic children’s hospitals were invited to complete an anonymous electronic survey. Participants were asked whether they had observed unprofessional behavior or a patient safety breach in their most recent inpatient block and whether they had discussed the observed events with the individual(s) involved. Further items were used to assess attitudes about perceived support for speaking up, psychological safety, and barriers and facilitators to speaking up. Two vignettes were provided where trainees reported perceived potential for harm and likelihood of speaking up, as well as assertiveness of communication.


What were the results?

Response rate was 44% (223 of 512 trainees), with most having received formal education on patient safety (96%), speaking up about safety concerns (90%), and speaking up about professional concerns (86%). Fifty-seven percent reported observing unprofessional behavior while 34% reported having observed a patient safety breach. Only 52% of respondents felt safe speaking up about unprofessional behavior compared to 78% who felt safe speaking up about a patient safety concern. Participants were significantly less likely to report speaking up to all levels of the hierarchy in the unprofessional behavior vignette compared to the traditional safety vignette, even when they perceived high potential for patient harm. The most common barrier to speaking up was fear of conflict or eliciting anger.


What are the implications?

Unprofessional behavior and patient safety breaches are commonly observed in the clinical learning environment. Trainees are less comfortable with and less likely to speak up about unprofessional behavior than patient safety concerns, although this survey suggests reluctance for both. Even if they perceived high risk of patient harm, very few trainees anticipated speaking up to an attending in a case describing unprofessional behavior. These findings are concerning not only in that such frequent events occur, but that the trainees remain reluctant to speak up.


Editor’s Note: The results of this study reinforce the sad news that medicine remains a hierarchical and tradition-bound profession.  Receiving formal education didn’t have a significant impact on trainees’ likelihood of speaking up.   Until we change the culture of medicine, it will be difficult to make significant progress. (JG)


Learners and End-of-Life Care


Pediatric Resident Perception and Participation in End-of-Life Care.  Niehaus JZ, Palmer M, LaPradd M, Haskamp A, et al. American Journal of Hospice and Palliative Medicine. 2020;37(11) 936-942.

DOI: 10.1177/1049909120913041

Reviewed by Alyssa Wohl


What was the study questions?

How do pediatric residents at one institution rate their personal efficacy and involvement in providing high-quality, end-of-life care (EOLC)?


How was the study done?

A cross-sectional survey was administered to all incoming PGY1, rising PGY2 and PGY3, and graduating residents (four years) over one academic year at a single institution. The Pediatric Palliative Care Questionnaire, a published and validated survey, was modified to include questions regarding self-reported passive (observational) and active participation in EOLC. The survey included both quantitative and qualitative data across 5 sections: demographics, self-reported comfort, medical education, EOLC participation, and themes. EOLC participation included eight domains of the process: discussions about goals of care, code status, Physician Order for Scope of Treatment form, the dying process, autopsy consents, EOLC symptom management, death pronouncement, and bereavement follow up with family. Most quantitative data was evaluated on a 5-point Likert scale. Open-ended questions were evaluated for thematic similarities.


What were the results?

68 of the 100 residents responded to the survey. Self-reported comfort was measured on a Likert-type scale, very uncomfortable to comfortable, and demonstrated a statistically significant increase in comfort as residency progressed. The mean score per question was 3.2 (+/- 1.3), indicating that residents on average were “neither comfortable nor uncomfortable” with EOLC.

Residents reported passive participation in an average of 4.05 aspects of EOLC and active participation in 3.63 aspects. Two residents reported observing none of the aspects and eight residents reported no active involvement in EOLC.

Eight themes were identified from the narrative responses. The two most common were lack of clinical experience and education.


What are the implications?

Pediatric residents neither receive enough didactic education nor hands-on experience to feel comfortable providing EOLC. The identified passive and educational deficits could be addressed via a formalized curriculum. Simulations, example videos, and resident-wide debriefs would give residents the opportunity to actively participate which may increase comfort levels.


Editor’s note: In the 1965 Akira Kurosawa film, Red Beard, an experienced physician played by Toshiro Mifune, mentors a younger physician in 19th century Japan. One principle enunciated by the former is that above all a physician needs to know how to care for the dying. Contemporary circumstances make it necessary for more deliberate preparatory medical education to achieve that goal. (RR)