Remy M. J. P. Rikers

How expertise develops in medicine: knowledge encapsulation and illness script formation

Context  For over 30 years, research has focused on the question of how knowledge is organised in the doctor’s mind. The development of encapsulated knowledge, followed by the formation of illness scripts, may both be considered as important stages in the development of medical expertise.

Instructional Design for Advanced Learners: Establishing Connections between the Theoretical Frameworks of Cognitive Load and Deliberate Practice

Cognitive load theory (CLT) has been successful in identifying instructional formats that are more effective and efficient than conventional problem solving in the initial, novice phase of skill acquisition. However, recent findings regarding the “expertise reversal effect” have begun to stimulate cognitive load theorists to broaden their horizon to the question of how instructional design should be altered as a learners knowledge increases. To answer this question, it is important to understand how expertise is acquired and what fosters its development. Expert performance research, and, in particular, the theoretical framework of deliberate practice have given us a better understanding of the principles and activities that are essential in order to excel in a domain. This article explores how these activities and principles can be used to design instructional formats based on CLT for higher levels of skills mastery. The value of these formats for e-learning environments in which learning tasks can be adaptively selected on the basis of online assessments of the learners level of expertise is discussed.

Dynamic problem selection in air traffic control training : A comparison between performance, mental effort and mental efficiency

The differential effects on training and training outcome of four methods of problem selection were investigated in a computer-based training for air traffic control. In one method, training problems were given to the participants in a fixed predetermined sequence, from simple to complex. In the other methods, problems were selected dynamically, based on three different learner variables. These were mental effort, performance and mental efficiency, which is a variable that combines mental effort and performance measures to determine problem efficiency. After the training, transfer was measured. The hypothesis that dynamic problem selection would lead to more efficient training than non-dynamic problem selection was confirmed. The second hypothesis, that dynamic problem selection based on mental efficiency would lead to more efficient training and better transfer than dynamic problem selection based on performance or mental effort alone was not supported. However, the efficiency measures of the three variables were distorted by the differential effects of these variables on the acquisition phase. A possible explanation for the results is that selection based on performance stimulates rule automation, whereas selection based on mental effort or mental efficiency leads to schema acquisition.

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert.

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices’ decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases.

The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modeling approach.

Purpose To examine four theories on the role of basic science knowledge and clinical knowledge in diagnostic reasoning. Method In 2000–01, the authors tested the basic science and clinical knowledge and diagnostic performances of 59 family physicians and 184 second- to sixth-year medical students at Maastricht University, The Netherlands. Structural equation modeling was used to analyze the data. Four theoretical models were tested. In the first model only basic science knowledge is involved in diagnostic reasoning; in the second model only clinical knowledge is related to diagnostic reasoning; in the third model, clinical knowledge is related to diagnostic reasoning, but basic science knowledge is integrated in clinical knowledge; and in the fourth model, both basic science knowledge and clinical knowledge independently influence diagnostic reasoning. Results Forty-four (75%) of the family physicians and 184 (100%) of the students responded. The results indicated that the third model, which is based on the knowledge encapsulation theory, provided the best fit to the data, whereas the models that had directly related basic science knowledge with diagnostic performance did not fit the data adequately. Conclusion The results generally supported the third model by Schmidt and Boshuizen of knowledge encapsulation theory suggesting that basic science knowledge is activated in expert diagnostic reasoning through its relation with clinical knowledge.

The effects of deliberate practice in undergraduate medical education

Introduction  Ericsson and colleagues introduced the term ‘deliberate practice’ to describe training activities that are especially designed to maximise improvement. They stressed that how much one practises is as important as how one practises. Essential aspects of deliberate practice are the presence of well defined tasks, informative feedback, repetition, self‐reflection, motivation and endurance. Deliberate practice is often difficult, laborious, and even unpleasant. Previous studies in the fields of sports and music have shown a positive relation between deliberate practice and level of expertise.

Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning

Context  Two modes of case processing have been shown to underlie diagnostic judgements: analytical and non‐analytical reasoning. An optimal form of clinical reasoning is suggested to combine both modes. Conditions leading doctors to shift from the usual mode of non‐analytical reasoning to reflective reasoning have not been identified. This paper reports a study aimed at exploring these conditions by investigating the effects of ambiguity of clinical cases on clinical reasoning.

The role of encapsulated knowledge in clinical case representations of medical students and family doctors

Background  Previous studies on the development of medical expertise, predominantly using measures of free recall and pathophysiological explanations, have shown ambiguous results concerning the relationship between expertise level and encapsulated knowledge.

Reflection as a strategy to foster medical students' acquisition of diagnostic competence

Medical Education 2012: 46: 464–472

Students' Conceptions of Distinct Constructivist Assumptions.

The present studies were conducted to investigate students’ conceptions of distinct constructivist assumptions. To that end, a questionnaire was developed containing statements about four constructivist assumptions: The importance of knowledge construction, cooperative learning, self-regulation, and the use of authentic problems together with self-perceived inability to learn and motivation to learn. The studies demonstrate that the questionnaire was able to unearth students’ conceptions of the distinctiveness of constructivist assumptions. Students were able to identify the six factors underlying the questionnaire, as indicated by the fit of the hypothesized model. The test for measurement invariance showed that factor loadings were equivalent across groups and that the questionnaire’s underlying factor structure gave evidence of cross-validation. Testing alternative models with one and three latent factors resulted in poor model fits, supporting the questionnaire’s latent factor structure. The questionnaire developed appeared an adequate instrument to investigate students’ conceptions of constructivist assumptions of learning and students acknowledge the importance of these assumptions as distinct influences on their learning process.RésuméLes études en question ont été menées afin d’examiner les conceptions des étudiants quant aux principes constructivistes. Le questionnaire, mis au point a cette fin, contient quatre piliers de conceptions constructivistes: l’importance de la construction cognitive, l’apprentissage cooper-off, l’autorégulation, et l’emploi de problèmes authentiques conjointement avec l’incertitude de l’apprentissage et la motivation d’étudier. Ces études démontrent que le questionnaire était capable de mettre en évidence les conceptions que se faisaient les étudiants a propos du caractère distinctif des principes constructifs. Les étudiants étaient capables d’identifier les six facteurs sous-jacents au questionnaire, comme la forme du modèle d’hypothèses l’indique. Le test visant à mesurer la constance a révélé que les analyses factorielles (le poids des facteurs) étaient équivalentes entre les groupes et que la structure des facteurs implicite du questionnaire a mis en évidence la validation croisée. Le modèle a six facteurs a été mis a l’épreuve vis-à-vis des modèles d’un facteur versus trois facteurs. Les analyses factorielles confirment que le modèle a six facteurs révèle la solution la plus optimale et que les autres modèles révèlent des solutions sub-optimales.Apparentement, le question naire permet de développer un instrument utile pour étudier la conception qu’ont les étudiants a propos des principes constructivistes de l’apprentissage. De même, les étudiants comprennent l’importance de ces suppositions en les considérants comme des influences directes de leur processus d’apprentissage.