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If there are two things that scare medical students right out of their boots, it is board exams and not having enough information. Bad news for those who like good news in this case, as the USMLE Step 1 and Step 2 have expanded questions about communication skills and ethics. Medical school curriculum does not typically spend a lot of time teaching and reviewing communication skills, so oftentimes it comes down to the individual student to fill in this hole.
The OPICAN study used a uniform screening and study protocol, and it received approval from a university or hospital ethics research board in each of the 5 cities. Subjects confirmed their eligibility through responses to a screening questionnaire, provided informed consent and were offered treatment, health and social service referrals if necessary. The study protocol consisted of an interviewer-administered questionnaire covering social, health and drug-use information; a depression assessment (Composite International Diagnostic Interview Short Form for Major Depression41); and an immunoassay antibody screening test of oral fluid for HIV, hepatitis C and hepatitis B. Assessments were performed on an anonymous basis (with each participant identified by a study code rather than by name), and all data were treated confidentially. Each subject received $20 compensation for undergoing the assessment and all have been invited for follow-up assessments. For the analysis presented here, 28 cases were missing or excluded because of ambiguous responses; therefore, data for only 651 subjects were available for analysis.
In June 2016, 88 medical students worked on eight cases with the chief complaint dyspnea in a laboratory setting using an electronic learning platform, in summary 704 processed cases. The diagnostic steps of the students were tracked and analyzed. Furthermore, after each case the participants stated their presumed diagnosis and explained why they came to their diagnostic conclusion. The content of these explanations was analyzed qualitatively.
First, the students completed a socio-demographic questionnaire and a test on content-specific pre-knowledge. Then they worked within the electronic case simulation platform CASUS  on eight clinical cases in Internal Medicine (diagnoses see Fig. 1) with dyspnea as chief complaint. Each case consisted of a medical history, a physical examination and an electronic patient record (contents see Fig. 1). Participants could freely select the number and sequence of information from the electronic learning platform that they regarded as important to diagnose the case. The information from the history and the physical examination and the number of selected technical examinations was not restricted and the students could choose as many examinations as they wanted. However, this was restricted to the amount of information that was available in the electronic learning platform. The amount of available information was quite extensive: The history provided the following information in each case: sex, age, pre-existing conditions, medication, alcohol- and nicotine-abuse, history of present illness, symptoms. The physical examination included information regarding the vital signs, the general and nutrition condition, an examination of the cardiovascular-system, the abdomen, the lung, the lymph nodes and a neurological examination. The 10 technical examinations are listed in Fig. 1. Also, the sequence in which the students assessed the history, the physical examination and the technical examinations was completely up to them. Additionally, they were allowed to go back to any of this information as often as they wanted. In the end, they were required to state their final diagnosis. No feedback was given on their diagnoses. After each case, participants had to write an explanation why they had chosen their diagnosis. Importantly, in the case scenarios developed for this study the diagnostic knowledge and clinical reasoning abilities as well as the diagnostic skills of the participants (such as interpretation of electrocardiograms, lung function tests and x-rays) were examined, and thus allowing for a more specific assessment of diagnostic errors.
88 (58 female) participants processed all cases and their diagnoses were analysed. The mean age was 24.6 years (SD = 0.48) and they had on average spent 14.9 weeks (SD = 0.48) on clerkships and block placements. There were not significant differences between the participants form the two Munich medical faculties regarding any of the following results.
A lack of diagnostic skills such as the correct interpretation of an electrocardiogram or an x-ray was identified as a major cause of diagnostic errors. The results do not differ between the two medical schools although the curricula substantially differ (data not shown). Not only medical students but junior doctors as well show poor competence in the interpretation of x-rays [21, 22]. We were able to replicate these findings; evidently, these skills - or at least the application of these skills in clinical cases - are not sufficiently trained in medical school. Students need to learn these skills through a lot of repetitive practice. Furthermore, there might be a gap between the clinical skills as taught and daily clinical practice. At some point, students should be confronted with more complex and atypical results of technical examinations and not only with classic textbook cases. A more structured approach or checklists might help to improve the diagnostic skills .
A limitation of the study is that we, like in the study of Graber et al. , only used Internal Medicine cases. Further studies are needed to analyze whether the categories can be transferred to other medical disciplines. Also, our study included 8 different cases and it remains unclear whether the same error categories can be found in a sample of more cases. Though, we investigated a large sample size, thus gaining greater range of answers, all students were recruited from only two medical school. This might have led to a bias with respect to the curriculum related knowledge base.
NutriStem with LN-511, TeSR2 with human recombinant laminin (LN-511), and RegES with human foreskin fibroblasts (HFFs) are commonly used xeno-free culture systems . There are many organizations and international initiatives, such as the National Stem Cell Bank, that provide stem cell lines for treatment or medical research . 2b1af7f3a8