OBJECTIVE: The objective of our IAEA-coordinated international study was to assess CT practices and radiation doses from multiple hospitals across several African countries.
METHODS: The study included 13 hospitals from Africa which contributed information on minimum of 20 consecutive patients who underwent head, chest, and/or abdomen-pelvis CT. Prior to the data recording step, all hospitals had a mandatory one-hour training on the best practices in recording the relevant data elements. The recorded data elements included patient age, weight, protocol name, scanner information, acquisition parameters, and radiation dose descriptors including phase-specific CT dose index volume (CTDIvol in mGy) and dose length product (DLP in mGy.cm). We estimated the median and interquartile range of body-region specific CTDIvol and DLP and compared data across sites and countries using the Kruskal-Wallis H Test for non-normal distribution, analysis of variance.
RESULTS: A total of 1061 patients (mean age 50 ± 19 years) were included in the study. 16 % of CT exams had no stated clinical indications for CT examinations of the head (32/343, 9 %), chest (50/281, 18 %), abdomen-pelvis (67/243, 28 %), and/or chest-abdomen-pelvis CT (24/194, 12 %). Most hospitals used multiphase CT protocols for abdomen-pelvis (9/11 hospitals) and chest CT (10/12 hospitals), regardless of clinical indications. Total median DLP values for head (953 mGy.cm), chest (405 mGy.cm), and abdomen-pelvis (1195 mGy.cm) CT were above the UK, German, and American College of Radiology Diagnostic Reference Levels (DRLs).
CONCLUSIONS: Concerning variations in CT practices and protocols across several hospitals in Africa were demonstrated, emphasizing the need for better protocol optimization to improve patient safety.

Background and objectives There is a crucial need to embrace modern methodologies for enhancing medical education in disciplines such as Family Medicine. The study introduces the SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, and Select) model, a six-step mnemonic representing a learner-centered case presentation approach that streamlines fact reporting while encouraging clinical reasoning, aiming to evaluate the effectiveness of the SNAPPS method as compared to the traditional model of case presentation in Family Medicine outpatient clinics and to gain insights into how students and preceptors perceive it. Methods A randomized controlled trial was conducted in Family Medicine outpatient clinics in Erbil, Iraq, from March 15, 2023, to August 30, 2023. Using convenience sampling, all Family Medicine board residents (n=30) in Erbil and six preceptors from the Community and Family Medicine department/College of Medicine/Hawler Medical University were randomly assigned into two groups by using the RAND function in Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States). The SNAPPS method was introduced to the SNAPPS group employing approved tools and methods, while no intervention was needed in the control group. Subsequently, 30 cases were presented in each group with a total of 60 case presentations; the case presentations served as the units for data analysis. Feedback and data were gathered after each presentation using validated data recording sheets. Results The study showed a significant advantage for the SNAPPS group over the control group in terms of time efficiency, number of basic clinical attributes covered, and justified diagnoses (P value < 0.001). In the SNAPPS group, 90% of the students sought clarification and information, surpassing 30% in the control group (P-value < 0.001). Almost all SNAPPS group students (96.7%) discussed case-related topics, compared to 43.3% in the controls (P-value<0.001). The SNAPPS group received superior overall ratings from both preceptors and students. Conclusion The SNAPPS method enhances clinical diagnostic reasoning in Family Medicine outpatient clinics. It is time-efficient and encourages students to articulate uncertainties, pose questions, and identify case-related topics for self-study.

BACKGROUND: Versatile large language models (LLMs) have the potential to augment diagnostic decision-making by assisting diagnosticians, thanks to their ability to engage in open-ended, natural conversations and their comprehensive knowledge access. Yet the novelty of LLMs in diagnostic decision-making introduces uncertainties regarding their impact. Clinicians unfamiliar with the use of LLMs in their professional context may rely on general attitudes towards LLMs more broadly, potentially hindering thoughtful use and critical evaluation of their input, leading to either over-reliance and lack of critical thinking or an unwillingness to use LLMs as diagnostic aids. To address these concerns, this study examines the influence on the diagnostic process and outcomes of interacting with an LLM compared with a human coach, and of prior training vs no training for interacting with either of these \'coaches\'. Our findings aim to illuminate the potential benefits and risks of employing artificial intelligence (AI) in diagnostic decision-making.
METHODS: We are conducting a prospective, randomised experiment with N=158 fourth-year medical students from Charité Medical School, Berlin, Germany. Participants are asked to diagnose patient vignettes after being assigned to either a human coach or ChatGPT and after either training or no training (both between-subject factors). We are specifically collecting data on the effects of using either of these \'coaches\' and of additional training on information search, number of hypotheses entertained, diagnostic accuracy and confidence. Statistical methods will include linear mixed effects models. Exploratory analyses of the interaction patterns and attitudes towards AI will also generate more generalisable knowledge about the role of AI in medicine.
BACKGROUND: The Bern Cantonal Ethics Committee considered the study exempt from full ethical review (BASEC No: Req-2023-01396). All methods will be conducted in accordance with relevant guidelines and regulations. Participation is voluntary and informed consent will be obtained. Results will be published in peer-reviewed scientific medical journals. Authorship will be determined according to the International Committee of Medical Journal Editors guidelines.

BACKGROUND: In EDs, triage ensures that patients whose condition requires immediate care are prioritized while reducing overcrowding. Previous studies have described the manifestation of caregivers\' moral judgements of patients in EDs. The equal treatment of patients in clinical practice presents a major issue. Studying the impact of prejudice on clinical practice in the ED setting provides an opportunity to rethink clinical tools, organizations and future training needs. Our study sought to describe the moral judgements expressed by triage nurses during admission interviews in emergency departments and to assess their impact on patient management.
METHODS: An exploratory sequential mixed-method study was performed. The study was conducted between January 1, 2018, and February 18, 2018, in the EDs of three French hospitals. Five hundred and three patients and 79 triage nurses participated in the study. Audio recordings, observations and written handover reports made by nurses during admission triage interviews were analyzed with a view to discerning whether moral judgements were expressed in them. We studied the impact of moral judgements on patient management in the emergency department.
RESULTS: Abstract Moral judgements were made in 70% of the triage situations studied (n=351/503). They could be classified in seven categories. Patients were more likely to be subjected to moral judgements if they were over 75 years old, visibly disabled or if they had visible signs of alcohol intoxication. Being subjected to moral judgement was associated with differential treatment, including assignment of a triage score that differed from the theoretical triage score.
CONCLUSIONS: More than two thirds of patients admitted to EDs were triaged using moral criteria. Patients who were morally judged at the admission interview were more likely to be treated differently.

Errors in reasoning are the main causes of poor decision-making in clinical practice. To remedy this, many studies highlight the importance of supervising clinical reasoning during medical internships. Although decision-making is an ongoing process at all key moments of the perioperative period, there are no studies on the supervision of clinical reasoning during student nurse anesthetist internships. The objective of this study was to identify the characteristics of the supervision of clinical reasoning by anesthesia professionals with student nurse anesthetists.
A multicenter qualitative study was carried out using observations and individual interviews with five nurse anesthetists and five students.
Three themes are identified : the characteristics of the learner’s and supervisor’s posture ; the teaching methods used ; and the specificities of clinical reasoning.
The nurse anesthetists question clinical reasoning only when they detect difficulties in the student. However, no traceability is carried out. Students spontaneously verbalize their clinical reasoning when unexpected events occur.
The results will be used as a basis for a new tool for tracing learning during internships.
Les erreurs de raisonnement sont les principales causes de mauvaise prise de décision en clinique. Pour y remédier, de nombreuses études montrent l’importance de la supervision du raisonnement clinique pendant les stages en médecine. Bien que la prise de décision soit permanente lors de tous les moments clés de la période péri-opératoire, il n’existe aucune étude sur la supervision du raisonnement clinique durant les stages des étudiants infirmiers anesthésistes. L’objectif de cette étude est d’identifier les caractéristiques de la supervision du raisonnement clinique par les professionnels d’anesthésie auprès des étudiants infirmiers anesthésistes.
Une étude qualitative multicentrique a été réalisée à l’aide d’observations et d’entretiens individuels auprès de cinq infirmiers anesthésistes et cinq étudiants.
Les trois thèmes identifiés sont les caractéristiques de la posture de l’apprenant et du superviseur, les méthodes pédagogiques utilisées et les spécificités du raisonnement clinique.
Les infirmiers anesthésistes questionnent le raisonnement clinique uniquement quand ils détectent des difficultés chez l’étudiant ; cependant, aucune traçabilité n’est réalisée. Les étudiants verbalisent spontanément leur raisonnement clinique lors d’événements imprévus.
Les résultats serviront de base à un nouvel outil de traçabilité des apprentissages en stage.

BACKGROUND: There is a discussion among general practitioners and psychiatrists regarding over-diagnosing versus under-reporting of psychiatric diagnoses. A deeper understanding of this topic is relevant for providing reasonable health care and for planning future studies. A crucial factor to understanding this discussion is the difference in the prevalence of a disease in each sector. One way to attain knowledge about such prevalences is the analysis of routine care data of the sector in question. However, diagnosis-related data might be modified by several additional influencing factors.
OBJECTIVE: This study aims to explore what kind of motives and modifying factors play a role for or against giving psychiatric diagnoses in psychiatric and general medical settings.
METHODS: Twenty-six semi-structured interviews were conducted with German physicians in the fields of general medicine and psychiatry. Interviews were analysed using content analysis.
RESULTS: The analysis revealed three major motivational categories for finding a diagnosis: (1) \"objective matters\" such as \"categorisation for research\"; (2) \"functional and performance-related factors\" such as \"requirement for medication\", \"billing aspects\" that go with certain diagnoses or \"access to adequate care\" and (3) \"Individual factors\" such as the \"personality of a physician\". Similarly, factors emerged that lead to not making psychiatric diagnoses like \"fear of stigmatization among patients\" or \"detrimental insurance status with psychiatric diagnosis\". Additionally participants mentioned other reasons for \"not diagnosing a psychiatric diagnosis\", such as \"coding of other clinical pictures\".
CONCLUSIONS: The diagnostic process is a complex phenomenon that goes far beyond the identification of medical findings. This insight should be considered when processing and interpreting secondary data for designing health care systems or designing a study.

BACKGROUND: The consensus that clinical reasoning should be explicitly addressed throughout medical training is increasing; however, studies on specific teaching methods, particularly, for preclinical students, are lacking. This study investigated the effects of an illness script worksheet approach in flipped learning on the development of clinical reasoning abilities in preclinical students. It also explored whether the impact of this intervention differed depending on clinical reasoning ability after dividing the students into high and low groups based on their pre-diagnostic thinking inventory (DTI) scores.
METHODS: This study used a one-group pre-post test design and convenience sampling. Forty-two second-year medical students were invited to participate in this study. The course, \"clinical reasoning method,\" was redesigned as an illness script worksheet approach in flipped learning. The course was an eight-week long program. The students met once or twice per week with a different professor each time and engaged with 15 clinical cases in small groups in one classroom. Each time, one professor facilitated seven groups in a single classroom. The effectiveness of the intervention was measured using DTI before and after the intervention. A learning experience survey was conducted with post-DTI assessment.
RESULTS: Thirty-six students participated in the survey and their data were analyzed. The mean pre-DTI score was 170.4, and the mean post-DTI score was 185.2, indicating an 8.68% increase (p < .001). Significant differences were also found in both high and low groups between the pre- and post-DTI assessments. However, the low group improved much more than the high group and exhibited a significant increase in one of the DTI subscales as well. The overall average score on the learning experience survey was 3.11 out of 4.
CONCLUSIONS: The findings indicated that the intervention was an effective instructional method for the development of clinical reasoning in preclinical students and was more beneficial for students with a low level of clinical reasoning ability. This study demonstrated that the intervention can be a feasible and scalable method to effectively and efficiently train clinical reasoning in preclinical students in a classroom.

BACKGROUND: Clinical reasoning (CR) is a crucial ability that can prevent errors in patient care. Despite its important role, CR is often not taught explicitly and, even when it is taught, typically not all aspects of this ability are addressed in health professions education. Recent research has shown the need for explicit teaching of CR for both students and teachers. To further develop the teaching and learning of CR we need to improve the understanding of students\' and teachers\' needs regarding content as well as teaching and assessment methods for a student and trainer CR curriculum.
METHODS: Parallel mixed-methods design that used web-surveys and semi-structured interviews to gather data from both students (nsurvey = 100; ninterviews = 13) and teachers (nsurvey = 112; ninterviews = 28). The interviews and surveys contained similar questions to allow for triangulation of the results. This study was conducted as part of the EU-funded project DID-ACT ( https://did-act.eu ).
RESULTS: Both the surveys and interview data emphasized the need for content in a clinical reasoning (CR) curriculum such as \"gathering, interpreting and synthesizing patient information\", \"generating differential diagnoses\", \"developing a diagnostic and a treatment plan\" and \"collaborative and interprofessional aspects of CR\". There was high agreement that case-based learning and simulations are most useful for teaching CR. Clinical and oral examinations were favored for the assessment of CR. The preferred format for a train-the-trainer (TTT)-course was blended learning. There was also some agreement between the survey and interview participants regarding contents of a TTT-course (e.g. teaching and assessment methods for CR). The interviewees placed special importance on interprofessional aspects also for the TTT-course.
CONCLUSIONS: We found some consensus on needed content, teaching and assessment methods for a student and TTT-course in CR. Future research could investigate the effects of CR curricula on desired outcomes, such as patient care.

Critical thinking is considered as the essential set of skills for medical practice, particularly during emergencies. However, there is lack of conceptual clarity around it and it was not explicitly included in the undergraduate medical curriculum in India. The present study has been planned to assess the critical thinking disposition and clinical reasoning skills among medical undergraduate students in a medical college in West Bengal, India. The perceived definition and attributes of critical thinking in medical education will be explored and the contexts where application of critical thinking skills may be crucial for medical practice will be identified. The content validity index, test-retest agreement; internal consistency and construct validity of the Critical Thinking Disposition Assessment Questionnaire (CTDAQ) will be assessed through step-by-step procedure. CTDAQ and the case-based objective-type questions for the clinical reasoning skills will be applied to around 200 medical undergraduate students. Their perception and experience on critical thinking in medical education will be assessed with structured open-ended questions. In-depth interviews with medical teachers of the second and third phases of undergraduate medical curriculum will be conducted to assess their perception and experiences on critical thinking. The quantitative analysis will be conducted with MS excel and R software using the relevant packages. The qualitative data will be transcribed and translated in English, close to the participants\' verbatim. The thematic analysis will be conducted with inductive coding and memoing. The study will be conducted maintaining ethical standards for epidemiological studies. The present study, one of the first a few studies in India, will help to meet the conceptual gap in understanding the attributes of critical thinking, its association with clinical reasoning and the contexts of preferred application in medical practice.

BACKGROUND: Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers.
METHODS: A pre-test post-test intervention study.
METHODS: Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital.
METHODS: The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback.
METHODS: Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods.
RESULTS: A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach\'s alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen\'s d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen\'s d=0.83).
CONCLUSIONS: This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.