title: Divergence in student and educator conceptual structures during auscultation training.
abstract: BACKGROUND
  Simulation-based medical education allows trainees to engage in self-regulated learning (SRL), yet research aimed at elucidating the mechanisms of SRL in this context is relatively absent. We compared 'unguided' SRL with 'directed' SRL (DSRL), wherein learners followed an expert-designed booklet.
  
  
  METHODS
  Year 1 medical students (n = 37) were randomly assigned to practise identifying seven cardiac murmurs using a simulator and video only (SRL group) or a simulator and video plus the booklet (DSRL group). All participants completed a 22-item test 3 weeks later. To compare interventions, we analysed students' diagnostic accuracy. As a novel source of evidence, we documented how participants autonomously sequenced the seven murmurs during initial and delayed practice sessions. In addition, we surveyed clinical educators (n = 17) to find out how they would sequence their teaching of these murmurs.
  
  
  RESULTS
  The DSRL group used 50% more training time than the SRL group (p < 0.001). The groups' diagnostic accuracy, however, did not differ significantly on the post-test, retention test or transfer test items (p > 0.12). Despite practising with the expert-defined 'timing-based' approach to murmur diagnosis (i.e. systolic versus diastolic), 84% of DSRL participants implemented a location-based approach (i.e. practising aortic murmurs separately from mitral murmurs) during a second, unguided practice session. Notably, most SRL participants used that same approach spontaneously. By contrast, clinical educators were split in their use of the timing-based (n = 10) and the location-based (n = 6) approaches. Chi-squared analyses suggested educators' conceptions for organising murmurs differed significantly from students' conceptions.
  
  
  CONCLUSIONS
  Contrary to our predictions, directing students' SRL produced no additional benefit and increased their practice time. Our findings suggest one potential source of these results was a divergence between student and educator conceptions for structuring the practice of cardiac auscultation skills. This phenomenon has not been well articulated in the medical education literature, and may have important implications in many (especially technology-mediated) educational contexts.
authors: Department of Medicine, University of Toronto, Toronto, Ontario, Canada. ryan.brydges@utoronto.ca
authors: Ryan
authors: R
authors: Brydges
authors: Adam
authors: A
authors: Peets
authors: S Barry
authors: SB
authors: Issenberg
authors: Glenn
authors: G
authors: Regehr
mesh_terms: D003198:Computer Simulation; D004501:Education, Medical / Q000379:methods*; D004521:Educational Measurement / Q000379:methods; D005260:Female; D006326:Heart Auscultation; D006337:Heart Murmurs / Q000175:diagnosis; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012927:Social Control, Informal; D013337:Students, Medical / Q000523:psychology*