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Introduction Diagnostic errors remain prevalent across all specialties, driven largely by deficits in clinical reasoning (CR). Although CR is a core competency, most medical schools lack structured pre-clerkship CR training. Virtual patients (VPs) with automated feedback offer scalable, simulation-based training to improve diagnostic skills and reduce faculty workload. The aim of this study was to assess whether a CR curriculum using VPs with automated scoring and deliberate practice improves diagnostic accuracy and CR. Methods We conducted a multi-site observational study across five North American medical schools. First- and second-year students completed up to 20 diagnostic VP cases on TeachingMedicine.com, each with automated scoring to inform individualized feedback. We analyzed 1.55 million datapoints from 12,400 cases completed by 1,066 students to assess differences in CR performance between correctly and incorrectly diagnosed cases, associations between CR components and diagnostic accuracy, and learning gains over time. Results Misdiagnoses occurred in 20.1% of cases. Correct diagnoses were associated with higher diagnostic justification (DxJ) scores (+ 50%), better test ordering (+ 51%), and fewer cognitive errors (–89%). Multivariate analysis identified DxJ and cognitive errors as the strongest predictors of diagnostic accuracy. With repeated practice, students improved DxJ by 72%, test ordering by 40%, and reduced misdiagnoses threefold and cognitive errors by half, with no plateau observed after 20 cases. By end of pre-clerkship, first-year students who completed 20 cases outperformed second-year students who completed 10 in all CR metrics. All results were statistically significant with p  < 0.0001. Conclusions This curriculum shows that CR skills are highly trainable through deliberate practice. Improved DxJ and reduced cognitive errors are strongly associated with lower misdiagnosis rates. In contrast to a common misperception, training CR diagnostic skills is successful when started in the beginning of 1st year medical school prior to students’ acquisition of significant medical knowledge.

Purpose Diagnostic errors are a large burden on patient safety and improving clinical reasoning (CR) education could contribute to reducing these errors. To this end, calls have been made to implement CR training as early as the first year of medical school. However, much is still unknown about pre-clerkship students’ reasoning processes. The current study aimed to observe how pre-clerkship students use clinical information during the diagnostic process. Methods In a prospective observational study, pre-clerkship medical students completed 10–11 self-directed online simulated CR diagnostic cases. CR skills assessed included: creation of the differential diagnosis (Ddx), diagnostic justification (DxJ), ordering investigations, and identifying the most probable diagnosis. Student performances were compared to expert-created scorecards and students received detailed individualized formative feedback for every case. Results 121 of 133 (91%) first- and second-year medical students consented to the research project. Students scored much lower for DxJ compared to scores obtained for creation of the Ddx, ordering tests, and identifying the correct diagnosis, (30–48% lower, p < 0.001). Specifically, students underutilized physical exam data (p < 0.001) and underutilized data that decreased the probability of incorrect diagnoses (p < 0.001). We observed that DxJ scores increased 40% after 10–11 practice cases (p < 0.001). Conclusions We implemented deliberate practice with formative feedback for CR starting in the first year of medical school. Students underperformed in DxJ, particularly with analyzing the physical exam data and pertinent negative data. We observed significant improvement in DxJ performance with increased practice.

OBJECTIVE: To achieve national consensus on standards of training, quality assurance and maintenance of competence for critical care ultrasound for intensivists and critical care trainees in Canada using recently published international training statements. DATA SOURCES: Existing internationally endorsed guidelines and expert opinion. DATA SYNTHESIS: In November 2013, a day‐long consensus meeting was held with 15 Canadian experts in critical care ultrasound in which essential topics relevant to training ultrasound were discussed. CONCLUSIONS: Consensus was achieved to direct training curriculum, oversight, quality assurance and maintenance of competence for critical care ultrasound. In providing the first national guideline of its kind, these Canadian recommendations may also serve as a model of critical care ultrasound dissemination for other countries.

Medical decision-making requires years of experience in order to develop an adequate level of competence to successfully engage in safe practice. While diagnostic and technical skills are essential, an awareness of the extent and limits of our own knowledge and skills is critical. The present study examines clinicians’ subjective awareness in a diagnostic cardiac ultrasound task. Clinicians answered diagnostic and treatment related questions for a range of pathologies. Following these questions, clinicians indicated their level of confidence in their response. A comparison of response accuracy and confidence revealed that clinicians were generally overconfident in their responses. Critically, we observed that a clinician’s overconfidence was negatively correlated with prior experience: clinicians that had more prior experience expressed less overconfidence in their performance such that some clinicians were in fact underconfident. We discuss the implications for training in medical education and decision-making.