Diagnostic errors contribute substantially to preventable medical error. 1 Cognitive error is among the leading causes and mostly results from faulty data synthesis. 2 Furthermore, reflecting on their confidence does not prevent physicians from committing diagnostic errors. 1 Diagnostic decisions usually are not made by individual physicians working alone. Our aim was to investigate the effect of working in pairs as opposed to alone on diagnostic performance.

Background Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context. Trial registration https://bmjopen.bmj.com/content/6/5/e011585 Electronic supplementary material The online version of this article (10.1186/s13049-019-0629-z) contains supplementary material, which is available to authorized users.

Objectives: This longitudinal study followed the language development of children who received the combination of early (5 to 18 months) and simultaneous bilateral cochlear implants (CIs) throughout the first 6 years after implantation. It examined the trajectories of their language development and identified factors associated with language outcomes. Design: Participants were 21 Norwegian children who received bilateral CIs between the ages of 5 and 18 mo and 21 children with normal hearing (NH) who were matched to the children with CIs on age, sex, and maternal education. The language skills of these two groups were compared at 10 time points (3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months after implantation) using parent reports and standardized measures of general language skills, vocabulary, and grammar. In addition, assessments were made of the effects of age at CI activation, speech recognition abilities, and mothers’ education on language outcomes 6 years after implantation. Results: During the first 4 years after implantation, the gap in general expressive and receptive language abilities between children with CIs and children with NH gradually closed. While at the initial five to six assessments (3 to 36 months after implantation), significant differences between children with CIs and children with NH were observed; at 4 years after implantation, there were no longer any significant group differences in general language skills and most children with CIs achieved scores within 1 SD of the tests’ normative means. From 2 to 3 years after implantation onward, expressive vocabulary and receptive grammar skills of children with CIs were similar to those of the reference group. However, from 4 years after implantation until the end of the observation period, 6 years after implantation, expressive grammar skills of children with CIs were lower than those of children with NH. In addition, a gap in receptive vocabulary appeared and grew increasingly larger from 4 to 6 years postimplantation. At the final assessment, the children with CIs had an average receptive vocabulary score around 1 SD below the normative mean. Regression analysis indicated that the children’s language outcomes at 6 years after implantation were related to their speech recognition skills, age at CI activation, and maternal education. Conclusions: In the first 4 years after implantation, the language performance of children with CIs became increasingly similar to that of their NH peers. However, between 4 and 6 years after implantation, there were indications of challenges with certain aspects of language, specifically receptive vocabulary and expressive grammar. Because these challenges first appeared after the 4-year assessment, the findings underline the importance of long-term language intervention to increase the chances of a continued language development comparable to that of NH peers. They also indicate that there is a need for com...

In medical education, the effect of the educational environment on student achievement has primarily been investigated in comparisons between traditional and problem-based learning (PBL) curricula. As many of these studies have reached no clear conclusions on the superiority of the PBL approach, the effect of curricular reform on student performance remains an issue. We employed a theoretical framework that integrates antecedents of student achievement from various psychosocial domains to examine how students interact with their curricular environment. In a longitudinal study with N = 1,646 participants, we assessed students in a traditional and a PBL-centered curriculum. The measures administered included students' perception of the learning environment, self-efficacy beliefs, positive study-related affect, social support, indicators of self-regulated learning, and academic achievement assessed through progress tests. We compared the relations between these characteristics in the two curricular environments. The results are two-fold. First, substantial relations of various psychosocial domains and their associations with achievement were identified. Second, our analyses indicated that there are no substantial differences between traditional and PBL-based curricula concerning the relational structure of psychosocial variables and achievement. Drawing definite conclusions on the role of curricular-level interventions in the development of student's academic achievement is constrained by the quasi-experimental design as wells as the selection of variables included. However, in the specific context described here, our results may still support the view of student activity as the key ingredient in the acquisition of achievement and performance.

Progress testing as a longitudinal method allows us to better understand the development of knowledge during formal undergraduate education. The main difference between traditional and problem-based medical education seems to be provoked by the high-stakes national examination undertaken in the traditional course (the Physikum).

Context The ability to self‐monitor one's performance in clinical settings is a critical determinant of safe and effective practice. Various studies have shown this form of self‐regulation to be more trustworthy than aggregate judgements (i.e. self‐assessments) of one's capacity in a given domain. However, little is known regarding what cues inform learners’ self‐monitoring, which limits an informed exploration of interventions that might facilitate improvements in self‐monitoring capacity. The purpose of this study is to understand the influence of characteristics of the individual (e.g. ability) and characteristics of the problem (e.g. case difficulty) on the accuracy of self‐monitoring by medical students. Methods In a cross‐sectional study, 283 medical students from 5 years of study completed a computer‐based clinical reasoning exercise. Confidence ratings were collected after completing each of six cases and the accuracy of self‐monitoring was considered to be a function of confidence when the eventual answer was correct relative to when the eventual answer was incorrect. The magnitude of that difference was then explored as a function of year of seniority, gender, case difficulty and overall aptitude. Results Students demonstrated accurate self‐monitoring by virtue of giving higher confidence ratings (57.3%) and taking a shorter time to work through cases (25.6 seconds) when their answers were correct relative to when they were wrong (41.8% and 52.0 seconds, respectively; p< 0.001 and d > 0.5 in both instances). Self‐monitoring indices were related to student seniority and case difficulty, but not to overall ability or student gender. Conclusions This study suggests that the accuracy of self‐monitoring is context specific, being heavily influenced by the struggles students experience with a particular case rather than reflecting a generic ability to know when one is right or wrong. That said, the apparent capacity to self‐monitor increases developmentally because increasing experience provides a greater likelihood of success with presented problems.

Participants in computer-based tests are not at a disadvantage in terms of their test results. The computer-based test required less processing time. The reason for the longer processing time when using the paper-pencil version might be due to the time needed to write the answer down, controlling for transferring the answer correctly. It is still not known why students using the computer version (particularly low-performing students) guess at a higher rate. Further studies are necessary to understand this finding.

AIMS OF THE STUDY While COVID-19 significantly overburdens emergency rooms (ERs) and hospitals in affected areas, ERs elsewhere report a marked decrease in patient numbers. This study aimed to investigate the assumption that patients with urgent problems currently avoid the ER. METHODS Electronic health records from the ER of a large Swiss university hospital were extracted for three periods: first, the awareness phase (ap) from the publication of the national government’s initiative “How to protect ourselves” on 1 March 2020 to the lockdown of the country on 16 March; second, the mitigation phase (mp) from 16–30 March; finally, patients presenting in March 2019 were used as a control group. We compared parameters including a critical illness as the discharge diagnosis (e.g., myocardial infarction, stroke, sepsis and ER death) using logistic and linear regression, as well as 15-day bootstrapped means and 95% confidence intervals for the control group. RESULTS In the three periods, a total of 7143 patients were treated. We found a 24.9% (42.5%) significant decline in the number of patients presenting during the ap (mp). Patients presenting during the mp were more likely to be critically ill. There was an increase of 233% and 367% (ap and mp, respectively) of ER deaths (none related to COVID-19) compared to the control period. Apart from polytrauma (increase of 5% in the mp), all other critical illnesses as discharge diagnosis showed a lower incidence in descriptive analysis. Significantly more patients died in the ER in both the ap and mp. CONCLUSIONS Barriers to seeking emergency care during COVID-19 pandemic may lead to higher morbidity and mortality. Healthcare authorities and hospitals must ensure low barriers to treatment and business as usual for all patients.