搜索结果：Evaluation & the health professions

Many researchers and educators have identified self-assessment as a vital aspect of professional self-regulation.1,2,3 This rationale has been the expressed motivation for a large number of studies of self-assessment ability in medical education, health professional education, and professions education generally. Unfortunately, the outcome of most studies would seem to cast doubt on the capacity for self-assessment, with the majority of authors concluding that self-assessment is, in fact, quite poor.4 In a recent article, Ward and colleagues suggested that this conclusion must be questioned because the methodologies used to evaluate self-assessment are fraught with methodological weaknesses.4 However, even studies that have attempted to address the weaknesses within the methodological paradigm have produced little evidence for effective self-assessment.5 Thus, the health professional education community is left with a conundrum that can only be resolved by deciding either that the conclusions of the studies are wrong, or that a critical premise underlying the concept of "self-regulation" in the professions is unsupportable. The current paper addresses this conundrum by arguing that there is a problem with the literature on self-assessment, and that this problem is more fundamental than a list of easily correctable methodological flaws. Rather, the roots of the problem in the self-assessment literature involve a failure to effectively conceptualize the nature of self-assessment in the daily practice of health care professionals, and a failure to properly explicate the role of self-assessment in a self-regulating profession. Until such an articulation of self-assessment is elaborated, it is difficult to know even which literatures might be informative in addressing this issue, and impossible to develop programs of research that operationalize the concept of self-assessment ability in a form that can be effectively studied. Thus, we will begin with a brief reflection on the various functions of self-assessment for a practicing health care professional and the manner in which these functions operate. The Purposes of Self-Assessment in Practice Self-assessment has been defined broadly as the involvement of learners in judging whether or not learner-identified standards have been met.6 While attractive due to their concise and encompassing nature, we fear that such simple definitions risk being misleading as they can cause underappreciation of the complexities of the construct. Self-assessment functions both as a mechanism for identifying one's weaknesses and as a mechanism for identifying one's strengths. Each of these mechanisms can be considered to have distinct, albeit complementary, functions. As a mechanism for identifying weaknesses or gaps in one's skills and abilities, self-assessment serves several potential functions. First, in daily practice, the identification of one's weaknesses allows the professional to self-limit in areas of limited competence. For example, in many circumstances the professional can quickly reject certain plans of action because she recognizes that she is unlikely to be able to complete the component tasks necessary to enact the plan. In other circumstances, a professional might recognize that he is "over his head" in a particular case and decide that it is time to recruit additional resources: to "look this up," to obtain a consultation, to recruit additional support, or to refer the problem to another individual who is more competent in this domain. Second, in reflecting on one's practice in general, the ability to identify weaknesses can serve the function of helping the professional set appropriate learning goals. That is, the traditional model of self-regulated continuing professional development presumes that an individual will select ongoing learning activities that fill professional gaps, but this presumes that the professional can effectively self-assess. Thus, in this role, the identification of weakness can help a professional to decide what must be learned. As a corollary to this, effective self-assessment is vital for setting realistic expectations of oneself, to avoid setting oneself up for failure. Thus, the identification of weakness also helps the self-regulating professional to decide what not to try learning, what should be accepted as forever outside one's scope of competent practice. There is a complementary set of functions served by the ability to accurately self-assess one's strengths. First, in daily practice, having a clear and accurate sense of one's strengths allows the professional to act with appropriate confidence. For example, knowing one's strengths provides the professional with the confidence to move forward on a fitting plan of action without inappropriate hesitation or trepidation. Similarly, it ensures that the individual will choose to persist on an appropriate plan of action in the face of initially negative feedback. The right path is not always smooth even if it is right, and early abandonment of an appropriate plan of action is as costly as selecting an inappropriate plan in the first place. Second, when reflecting on one's practice in general, an appropriate assessment of one's strengths ensures that one can set appropriately challenging learning goals, pushing the edges of one's knowledge rather than choosing professional development courses that merely reiterate what one already knows. At the same time, by knowing one's strengths, a professional can select learning objectives that are within her grasp, and therefore will be able to enjoy the motivational influence of attaining her goals and experience the satisfaction of a job well done. Together, then, the ability to accurately assess one's weaknesses and one's strengths generates a capacity for finding an effective balance both in daily practice and in setting personal learning goals. In daily practice, it generates a balance of confidence and caution, of persistence and flexibility, of experimentation and safety, and of independence and collaboration. In establishing learning goals, it generates a balance of learning enough but not too much, of starting neither too high nor too low, of knowing what to tackle and what to abandon. And in reflecting on accomplishments, it generates a balance of satisfaction and incentive, of self reward without self delusion. In order to fulfill these various functions, it seems that self-assessment must be effectively enacted in three forms: summatively, predictively, and concurrently. Enacting self-assessment summatively, a professional must reflect on completed performances both for the purposes of assessing the specific performance and for the purposes of assessing his abilities generally. When evaluating performance on a particular task, the professional can often assess the overall quality of the completed job as a question that may come in various forms. That is, the individual might ask how good this performance was relative to what she could have done; relative to what her peers might typically do; relative to the best that could have been done (a gold standard); or relative to some minimally acceptable standard. Alternatively, there are some situations where the mechanisms for objectively assessing the outcome are not immediately available, in which case the professional might ask herself how confident she is in the conclusion or outcome generated (is it right? will it stand up? could there have been a better solution given the situation?). The professional might then use her assessment of the specific task to draw summative conclusions about herself or her abilities in this domain generally. Again, such conclusions may be in absolute terms (am I good enough in this domain? am I minimally competent?) or in relative terms (am I average, above average, or below average, and against whom should I be comparing myself?). In drawing general conclusions about her abilities from a particular performance, the professional must also make determinations about whether this particular episode should be taken as an appropriate reflection of her general skills: were there extenuating circumstances that led to a particularly poor (or good) performance that might lead one to discount this outcome as reflective of overall ability? In addition to these summative functions, self-assessment must be used predictively. Professionals are constantly required to assess their likely ability to manage newly arising situations and challenges. In this predictive role, self-assessment leads to questions such as: Am I up to this challenge? Should I be starting this task (now, alone, in this way)? What are realistic goals for accomplishment in this context (what would I consider to be a good or acceptable outcome for me)? How much better might I imagine performing with some additional preparation and is the increased preparation worth the anticipated increase in performance? What additional resources should I recruit (either internally or from the outside) to complement my strengths and shore up my weaknesses? Finally, self-assessment plays a vital role in its concurrent mode of functioning. In this concurrent mode, self-assessment acts as an ongoing monitoring process during the performance of a task. It is self-assessment in its concurrent mode that leads to questions such as: Is this coming out the way I expected? Am I still on the right track? Am I in trouble? Should I be doing anything differently? Should I persist in the face of negative feedback from the situation (that things are not going the way I thought they would or as easily as I thought they would)? Do I need to recruit additional resources (internal resources such as attention or external resources such as advice/assistance)? Do I need to reassess my original goal or my original plan? Thus, self-assessment is a complicated, multifaceted, multipurpose phenomenon that involves a number of interacting cognitive processes. It functions as a monitor, a mentor, and a motivator through processes such as evaluation, inference, and prediction. Given this elaborated description of self-assessment, it is unlikely that simplistic questions such as "are health professional trainees effective self-assessors?" will lead to insightful discoveries about the nature and value of self-assessment. Rather, researchers must ask questions such as: On what basis do individuals make these decisions? What factors affect their reasoning? How fine tuned does the assessment need to be in order to be useful? A first step toward addressing these questions must be to determine who is already asking them and what insights we may borrow from their discoveries and reflections. Our search has led us to several literatures that seem particularly relevant: self-efficacy and self-concept; cognitive and metacognitive theory; social cognition; models of expert performance and the development of expertise; and the concept of reflective practice. In the following sections we will briefly touch on each of these literatures and suggest how they might inform our understanding of self-assessment. Our intent here is not to provide a systematic review of each literature, but to provide an overview of questions being addressed by researchers outside medical education that should inform our conception of self-assessment as a regulatory strategy. For each new literature we will define the area, provide examples of the issues under consideration, and then summarize the implications for self-assessment in the professions. We will end with a proposal for a program of research that has the potential to move the field beyond our current paradigm of repeatedly concluding that self-assessment is generically poor. Self-Efficacy and Self-Concept In studying the accuracy of self-assessments, education researchers in the health professions have tended to focus conceptually on what we have labeled the summative function – the ability to draw general conclusions about one's skills or knowledge in specific domains: How well do I understand endometriosis? Am I able to communicate effectively with other members of the health care team? Practically, this has usually been operationalized in research studies as a request that students try to estimate how well they will/did perform on an immediately following/preceding task. Yet, there is an important distinction between general assessments of one's ability in an area and the more specific question of how one did on a particular task. Researchers in the field of personality theory, for example, usefully distinguish between judgments of self-efficacy and the development of self-concept. Self-efficacy is the belief in one's capabilities to recruit the resources and execute the actions required to manage prospective situations. Self-concept is the relatively sweeping cognitive appraisal of oneself that is integrated across various dimensions.7 Thus, self-concept beliefs are context free, generalized judgments of self-worth that involve cognitive self-appraisals independent of a specific task or goal (but not necessarily independent of domain). By contrast, self-efficacy is a context specific assessment of competence to perform a specific task or range of tasks in a given domain (i.e., an individual's judgment of her capabilities to complete a given goal). Self-efficacy is, by its very nature, driven by an interaction between self-concept beliefs about one's skills or abilities and the specific context in which those skills or abilities will be applied for the attainment of the particular goal. It is concerned with the contextually embedded orchestration of skills that lead to performance. Self-efficacy differs importantly from the concept of self-assessment as currently envisioned in the health professions education literature in that self-efficacy is not only influenced by direct and indirect feedback, but also influences the future performance of tasks (the choices we make, the effort we put forth, how long we persist when confronted with obstacles or in the face of failure). Thus, there is an important reciprocity between self-efficacy and success. Not only will success lead to a strong sense of self-efficacy, but self-efficacy will also lead to an increased likelihood of success. Self-efficacy beliefs are not merely passive reflections of performance, but part of a self-fulfilling prophecy that affects performance. As a result, there is an advantage to high self-efficacy beliefs even in circumstances where such beliefs may not be warranted by past performance. Clearly there is a logical disadvantage to continually overestimating one's abilities, but this obvious disadvantage must be balanced with the value of believing that one can achieve more than one has in the past and that one can manage the challenges that one will face.8 As a result, researchers in the field of self-efficacy appear to be less worried about the "accuracy of self-assessment" and more worried about its impact on impending problem solving situations. They unconcernedly alter the situational self-efficacy of study participants through manipulations such as: varying the order in which people consider hypothetical levels of future performance,9 having subjects contemplate various positive or negative performance-related factors,10 altering the "anchor" values representing high or low levels of performance,11 or providing false performance feedback.12 Such manipulations regularly alter subjects' expectations of success on future events within the context of the study, suggesting that subjects will take contextual information into account when judging (either explicitly or implicitly) the likelihood of future success on tasks within that context. Again, for researchers engaged in the study of self-efficacy, the important point to be taken from these studies is that "trivial" factors alter self-efficacy and can affect future performance.13 For them, the fact that one can radically alter an individual's self-assessment of future performance appears to be simply taken for granted, rendering the question of "accuracy" somewhat nonsensical. Early on, Bandura provided a taxonomy of origins from whence information that would influence self-efficacy could be received.14 It included personal experience, vicarious experience, verbal persuasion, and physiological state. In addition, Cervone has argued that fundamental cognitive mechanisms (including common heuristics, as will be discussed in the next section) will influence the extent to which information from any given source will be weighed.13 In general, Cervone argues that self-efficacy judgments are not simply driven by an active, motivated distortion of facts in the service of ego protection ("hot cognition"), but rather that fundamental cognitive processes (i.e., those regularly used for a wide variety of judgment tasks – "cold cognition") influence self-efficacy beliefs quite independently. Overall then, it appears that researchers in the self-efficacy literature offer several theoretical and methodological approaches that can inform research in self-assessment. They acknowledge, in fact presume, the instability and situational specificity of self-reflective judgments, they examine and explicitly manipulate the factors that affect these judgments, and they concern themselves with the consequences of these judgments for future behavior. Cognitive and Metacognitive Theory In contrast to the focus on "accuracy" in the self-assessment literature and the focus on "consequences" in the self-efficacy literature, cognitive psychologists interested in metacognition (knowledge of one's own knowledge) tend to focus on delineating the mechanisms that allow us to mentally supervise and control the way in which we process information. Of particular interest for our purposes are questions of how people form metacognitive judgments, and what cues influence people's judgments of how well they have learned something. It is a fundamental assumption of this work that we do not have direct introspective access to our own memories or knowledge base. Rather, just as we must infer others' level of knowledge and motivations from their behaviors and other cues, so too we must use peripheral cues to make inferences about our own level of knowledge and learning. In fact, it is argued that our judgments of our own abilities are often based on the same inferential cognitive strategies, or heuristics, that we use to judge others. For example, the easier it is to process a piece of information, the more likely we are to judge that we will remember that information later (a fluency heuristic).15 Such heuristics are cognitive short-cuts that make us extremely effective and efficient at operating within a complex world despite our limited mental resources. However, they can also bias us in a way that leaves us susceptible to errors in decision making and, when applied to ourselves, errors in trying to identify our own strengths and weaknesses. Studies from this field suggest that, when trying to judge one's ability in a domain or when trying to judge the likelihood of success on a task, the accuracy of these metacognitive judgments is dependent on the extent to which the apparent difficulty of learning mimics the actual difficulty of eventually retrieving the learned material from memory. For example, research demonstrates that, when people are trying to learn a piece of information (such as a list of words) for later recall, several factors affect their judgments of having succeeded in their learning efforts. Metacognitive judgments are more accurate if the repetitions of each word are spaced apart and interspersed with other words than if repetitions of each word are blocked together.16 People appear to use the cue of fluency (i.e., ease of understanding) in judging the extent to which they have learned material and, as such, overestimate the amount they have learned when fluency is increased by blocking repetitions together. Similarly, metacognitive judgments are more accurate when there is a delay between study of the words and efforts to during practice. In general, people overestimate their learning if the words are blocked or if too on study of the because these of the task are easier than the actual task they will eventually be to perform a long The the task during the learning the better the of the amount of learning that merely the list and during practice are often to metacognition if people are left to their own during learning. That is, in order to recognize one's to the words it is necessary to try to them and make in these errors as feedback, people to overestimate their ability to the participants are unlikely to in themselves the that better judgments of learning. For example, judgments of learning tend to be more accurate participants are to provide a and the word than if they are to This that, without external to do the participants did not try and but rather simply did not and in doing an important cue that they might have used to their This finding is with the between performance and self-assessment in the health professions literature when judgments are relative to as a the from this literature the of beyond questions of people self-assess to that explicitly focus on the various factors that affect judgments of learning or knowledge or In the of direct access to our mental we are to make metacognitive judgments based on a variety of and external Metacognitive judgments tend to be more accurate when these cues accurately reflect the factors that affect but there are many in which the cues used for judgments of learning predictive or systematic between performance and actual A better understanding of which cues are used and which should be used in health professional education well as the impact these cues have on study might better and our understanding of the concept of into the of cues that are often misleading in world situations for the of into the inappropriate use of specific has been from researchers in the field of social the focus of the next in social has led many to that much of what we to know about outside of Each of us an that much of our and This part of the is labeled because we have access to the and of we do not enjoy such access to the mental processes that are We have a to for our but these are often and more than are about the of our This is because there are to people themselves to be more a better than the While it is impossible that we are above average, at the individual level such positive can be in individuals who such are less likely to be and more likely to persist at difficult and of the the we will to a sense of well and How we is somewhat but as one example, a number of mechanisms some in fundamental cognitive by which people can develop and many of which are to an of what is required to accurately self-assess one's own strengths and As one example, and evidence that the common belief that they can the because they or their On the focus more attention on their and remember them better than They the belief that they are by the on the they should have if not for some the being As a result, come to of as and the belief that they can the likely themselves in a It is very to an of one's own ability by making the but the question or I a in to that This to discount information, with the of feedback the likelihood that in will be Given that the goal of self-assessment is to avoid such of oneself, social psychologists suggest that it is necessary to at one's own and how to it rather than simply reflecting When reflecting on our knowledge and abilities we have a of information to us that is not to but our capacity for that do not with our of can the of that additional information in a misleading of confidence in the accuracy of our of such a we have to more than on and being more likely than external to situational influences on our the to do so being broadly as the fundamental This a for self-regulating in that it one must and the of and in order to develop an accurate of question the of are also to but the more the of information, the less susceptible our self-concept might be to search for This that self-assessment is for the of accurate self-concept is with the finding that peers tend to be better of performance than do individuals both in health and social This questions about self-assessment quite from the simple question of accuracy that has self-assessment researchers in professional what extent do health care out assessments from What them to do How can we with the of to a and appropriate sense of what extent is for such to be This question has been a focus in the of expert performance. of and the of social psychologists have argued that the is a the serves more as a fact this is also with current models of a being as the of approaches to both a of new and a more (i.e., of specific In the current the question of interest is what role, if does this or process of in the development and of In the study of on performance, and colleagues have been able to on in the of practice – on specific tasks by practice is from the of as up reflective and work to social to its is the of an who can students beyond their current ability by to or approaches that are likely to if one on In fact, by its in of the health professions is an on learning. to the role of early and

Ten per cent of the world's school-aged children are estimated to be carrying excess body fat (Fig. 1), with an increased risk for developing chronic disease. Of these overweight children, a quarter are obese, with a significant likelihood of some having multiple risk factors for type 2 diabetes, heart disease and a variety of other co-morbidities before or during early adulthood. The prevalence of overweight is dramatically higher in economically developed regions, but is rising significantly in most parts of the world. Prevalence of overweight and obesity among school-age children in global regions. Overweight and obesity defined by IOTF criteria. Children aged 5–17 years. Based on surveys in different years after 1990. Source: IOTF (1). In many countries the problem of childhood obesity is worsening at a dramatic rate. Surveys during the 1990s show that in Brazil and the USA, an additional 0.5% of the entire child population became overweight each year. In Canada, Australia and parts of Europe the rates were higher, with an additional 1% of all children becoming overweight each year. The burden upon the health services cannot yet be estimated. Although childhood obesity brings a number of additional problems in its train – hyperinsulinaemia, poor glucose tolerance and a raised risk of type 2 diabetes, hypertension, sleep apnoea, social exclusion and depression – the greatest health problems will be seen in the next generation of adults as the present childhood obesity epidemic passes through to adulthood. Greatly increased rates of heart disease, diabetes, certain cancers, gall bladder disease, osteoarthritis, endocrine disorders and other obesity-related conditions will be found in young adult populations, and their need for medical treatment may last for their remaining life-times. The costs to the health services, the losses to society and the burdens carried by the individuals involved will be great. The present report has been written to focus attention on the issue and to urge policy-makers to consider taking action before it is too late. Specifically, the report: reviews the measurement of obesity in young people and the need to agree on standardized methods for assessing children and adolescents, and to compare populations and monitor trends; reviews the global and regional trends in childhood obesity and overweight and the implications of these trends for understanding the factors that underlie childhood obesity; notes the increased risk of health problems that obese children and adolescents are likely to experience and examines the associated costs; considers the treatment and management options and their effectiveness for controlling childhood obesity; emphasizes the need for prevention as the only feasible solution for developed and developing countries alike. This document reflects contributions from experts working in a wide range of circumstances with a diversity of approaches, but with many shared opinions. The report has been endorsed by the Federation of International Societies for Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) and the International Paediatric Association (IPA). Health professionals are aware that the rising trends in excess weight among children and adolescents will put a heavy burden on health services (for example, 10% of young people with type 2 diabetes are likely to develop renal failure by the time they enter adulthood, requiring hospitalization followed by life-long dialysis treatment (2). Health services, especially in developing countries, may not easily bear these costs, and the result could be a significant fall in life expectancy. In industrially developed countries, children in lower-income families are particularly vulnerable because of poor diet and limited opportunities for physical activity. There may also be an ethnic component; for example, in the USA the prevalence of overweight among children aged 4–12 years rose twice as fast in Hispanic and African–American groups compared with white groups over the period 1986–1998 (3). In developing nations child obesity is most prevalent in wealthier sections of the population. However, child obesity is also rising among the urban poor in these countries, possibly due to their exposure to Westernized diets co-inciding with a history of undernutrition. Such rapid changes in the numbers of obese children within a relatively stable population indicate that genetic factors are not the primary reason for change. Some migration of populations may account for a proportion of the epidemic, but cannot account for it all. Although studies of twins brought up in separate environments have shown that a genetic predisposition to gain weight could account for 60–85% of the variation in obesity (4), for most of these children the genes for overweight are expressed where the environment allows and encourages their expression. These obesity-promoting environmental factors are sometimes referred to as ‘obesogenic’ (or ‘obesigenic’). Put graphically, a child's genetic make-up ‘loads the gun’ while their environment ‘pulls the trigger’ (5). A genetic predisposition to accumulate weight is a significant element in the equation, but its importance might best be viewed from another perspective: the genes that predispose for obesity are likely to be commonplace, with only a small proportion of children able to resist gaining weight in an obesogenic environment. The changing nature of the environment towards greater inducement of obesity has been described in WHO Technical Report (6) on chronic disease as follows: ‘Changes in the world food economy have contributed to shifting dietary patterns, for example, increased consumption of energy-dense diets high in fat, particularly saturated fat, and low in unrefined carbohydrates. These patterns are combined with a decline in energy expenditure that is associated with a sedentary lifestyle—motorized transport, labour-saving devices at home, the phasing out of physically demanding manual tasks in the workplace, and leisure time that is preponderantly devoted to physically undemanding pastimes.’ (pp. 1–2) This emphasis on the environmental causes of obesity leads to certain conclusions: first that the treatment for obesity is unlikely to succeed if we deal only with the child and not with the child's prevailing environment, and second that the prevention of obesity – short of genetically engineering each child to resist weight gain – will require a broad-based, public health programme. A doctor presented with an obese child must nevertheless attempt some form of remedial intervention to prevent the child's health deteriorating. The aim is to stabilize and hopefully reduce that child's accumulation of body fat, using a range of approaches discussed in the next few paragraphs. For a great majority of obese patients, the first point of contact is with a primary care physician or a public health nurse. Yet the relevant training in bariatric methods (methods related to the assessment, prevention and treatment of obesity) at the undergraduate level remains inadequate. Two national surveys in the USA conducted over 10 years, indicated that paediatric obesity was the most wanted topic for continuing medical education (7). For children who are moderately overweight, measures to prevent further weight gain, combined with normal growth in height, can be expected to lead to a decrease in BMI – i.e. children may be able to ‘grow into’ their weight. For the more seriously obese child, treatment regimes are largely palliative and designed to manage and control rather than resolve the problem. Weight control and improved self-esteem may be achieved, but the child is likely to remain seriously overweight and at risk of chronic disease throughout his or her life. The clinical management of obese children may require an extended amount of time and the assembly of a professional team including a dietitian, exercise physiologist and psychologist in addition to the physician. As paediatric obesity becomes more common, patient management may not be restricted to obesity clinics and other forms of management may be developed. Obesity clinics may be necessary for morbid obesity, but less severe forms of obesity may be better managed in primary care settings by a range of health practitioners. Obesity control in adults relies on a range of options: improvements in nutritional habits, raised levels of physical activity, behavioural modification and psychotherapy, pharmaceutical treatment and as a last resort, surgery. These options can be used alone or in combination. For children, neither surgery nor drug therapy can currently be recommended unless within a closely monitored research study (8). Of the remaining choices, no single method will ensure success, although some consensus exists. For example, reducing the time engaged in sedentary activities (such as watching television or playing computer and video games) has been shown to facilitate better treatment outcome (9). Dietary interventions in combination with exercise programmes have been reported to have better outcomes than dietary modulation alone. Exercise programmes alone without dietary modification are unlikely to be effective, because increased energy expenditure is likely to be matched by increased energy intake (10). A whole-family approach also appears vital, with several studies showing that outcomes are improved if the parents are engaged in the process, or even are the key instigators of the process, at least for younger children (11). Very strict dietary limitations were reported to have better short-term results than moderate dietary limitations. However, strictly modified diets cannot be maintained for long periods of time. More marked rebound effects are observed after the discontinuation of strict diets than after moderate dietary modifications. Two additional concerns regarding strict dietary limitations are: (1) the risk of not meeting basic nutrient requirements and thus adversely affecting growth; and (2) the risk of inducing adverse psychological effects, including appetite or eating disorders, feelings of stigmatization, anxiety and low self-esteem, especially if the intervention is not successful or the child has prior psychological problems (12, 13). Many questions regarding what constitutes the best treatment remain unanswered: there have been few sufficiently large multicentre clinical trials to test the efficacy and safety of well-defined obesity treatment programmes. Such trials may reveal which non-pharmacological and non-surgical interventions can help manage obesity over the long term. Losing weight over the short term, but then experiencing a rebound gain in weight, remains the usual experience for the majority of obese children and adolescents. The importance of further research cannot be over stated, but it is not uncommon for research and treatment to compete for limited financial resources, with research frequently being more successful in securing financial support. The lack of paediatric obesity clinics at many well-respected academic institutions illustrates this point. If the current approach to treatment is largely aimed at bringing the problem under control, rather than effecting a cure, and if this aim is only successful when a multi-disciplinary and intensive regimen is mounted, then managing the obesity epidemic will be vastly expensive and probably unaffordable for most countries. Pharmaceutical approaches may assist, but cannot replace, the multi-disciplinary management of obesity. Prevention is the only feasible option and is essential for all affected countries. Yet effective techniques for prevention have also proved elusive. Programmes to prevent obesity in children may start by identifying those children at greatest risk, but there are problems with this approach. Although screening for obesity potential may help target resources where they are most needed, such screening also creates stigma among the children identified if they are singled out for special attention. Furthermore, genetic studies suggest that most children are at risk of weight gain, and that strategies to prevent obesity in a child population – such as encouraging healthful diets and plentiful physical activity – will benefit the health of all children, whether at risk of obesity or not. The most logical settings for preventive interventions are school settings and home-based settings. A number of interventions have been tried at these levels, and these are reviewed in the present report, but success has been hard to demonstrate. A Cochrane review of those trials of sufficient duration to detect the effects of intervention concluded that there was little evidence of success (14). It suggested that a more reliable evidence base is needed in order to determine the most cost-effective and health promoting strategies that have sustainable results and can be generalized to other situations. As shown in the present report, there are several examples of interventions designed to prevent the rising levels of obesity – such as the school-based ‘Trim and Fit’ programme in Singapore and the ‘Agita Sao Paulo’ programme in Sao Paulo, Brazil. Favourable outcomes have been shown with small-scale interventions, modifying children's TV watching behaviour and promoting consumption of healthier foods by establishing a price differential. Although the beneficial results of such interventions may be detectable and significant, they are small compared with the size of the problem. Moreover, the improvements tend to decline after the intervention ends. It must be concluded that interventions at the family or school level will need to be matched by changes in the social and cultural context so that the benefits can be sustained and enhanced. Such prevention strategies will require a co-ordinated effort between the medical community, health administrators, teachers, parents, food producers and processors, retailers and caterers, advertisers and the media, recreation and sport planners, urban architects, city planners, politicians and legislators. This report highlights the underlying social changes that have led to rising levels of obesity in both the adult and child populations. These underlying factors, as listed below, are often a part of, or a consequence of social development and urbanization. Such development based on economic growth to enhance consumption is generally regarded in a positive light and, especially in developing countries as they emerge from poverty, may be aspired to. Increase in use of motorized transport, e.g. to school. Increase in traffic hazards for walkers and cyclists. Fall in opportunities for recreational physical activity. Increased sedentary recreation. Multiple TV channels around the clock. Greater quantities and variety of energy dense foods available. Rising levels of promotion and marketing of energy-dense foods. More frequent and widespread food purchasing opportunities. More use of restaurants and fast food stores. Larger portions of food offering better ‘value’ for money. Increased frequency of eating occasions. Rising use of soft drinks to replace water, e.g. in schools. Changes in these social trends may require increased awareness by countries of the health consequences of the pattern of consumption as the first step in a strategy to promote healthier diets and more active lives. Several authors 15-18) have suggested that efforts to prevent obesity should include measures involving a wide range of social actions, such as: public funding of quality physical education and sports facilities; the protection of open urban spaces, provision of safer pavements, parks, playgrounds and pedestrian zones, creation of more cycling paths; taxes on unhealthy foods and subsidies for the promotion of healthy, nutritious foods; dietary standards for school lunch programmes; elimination or displacement of soft drinks and confectionery from vending machines in schools and offering healthier choices (i.e. low-fat dairy products, fruits and vegetables); clear food labelling and controls on inconsistent health messages; controls on the political contributions given by the food industry; restrictions or bans on the advertising of foods to children; limits on other forms of marketing of foods to children; assessment of food industry initiatives to improve formulations and marketing strategies. It is clear from these suggestions that policies and actions will be needed at a variety of levels, some local and individually based, some national or internationally based. All of them will require the support and involvement of departments across the broad range of government and may include education, social and welfare services, environment and planning, transport, food production and marketing, advertising and media, and international trading and standard-setting bodies. Obesity prevention will involve work at all levels of the obesogenic environment. As Fig. 2illustrates, attempts to improve the environment at one level, for example the school, may be undermined by a failure to improve the environment at another level, be it below in the home, or above in the social and cultural context involving food marketing and advertising, lost recreational facilities or unsafe streets. The opportunities for influencing a child's environment. Children are vulnerable to the social and environmental pressures that raise the risk of obesity. Although they can be encouraged to increase their self-control in the face of temptation, and although they can be given knowledge and skills to help understand the context of their choices, children cannot be expected to bear the full burden of responsibility for preventing excess weight gain. The prevention of childhood obesity requires: improving the family’s ability to support a child in making changes, which in turn needs support from the school and community, for example . . . ensuring the school has health-promoting policies on diet and physical activity, and that peer group beliefs are helping the child, which in turn requires that . . . the cultural norms, skills and traditional practices transmitted by the school are conducive to health promotion, and that the community a environment, such as . . . policies for and and recreation and ensuring to food which in turn requires that . . . at and regional level are such e.g. for and improved food through and that . . . national and international that standards and services are encouraging better public and practices promote choices, which in turn may require . . . and support to ensure that strategies for obesity are and and control measures are and that these are not by other government and that . . . government and activities in all including education, transport, the environment and social welfare policies are for their health and food e.g. for for the and schools and other involved in public are with health and The present report is to health social and in a to at national and international level, by a to the problems and an of the policies needed to It is written in the context of the Health work on the prevention of chronic and the development of strategies to promote physical activity and The document (6) the development of with health with other and to develop relevant programmes and The document for positive such as measures to support the greater of nutrient dense to reduce on motorized transport, to increase to recreation facilities and to ensure health is and easily and health are relevant and The WHO has the restrictions on countries by international such as those that and marketing The WHO can a in public health when these This upon political which in part upon from the medical and from The present report is designed to to that The International Obesity upon the WHO to countries to develop Obesity and to childhood obesity prevention within those of might be clear and e.g. on food food to more nutritious foods for children; develop for advertising that healthier improve and of facilities and local schools to and physical activity medical and health professionals to in the development of public health programmes. The International Obesity is to the WHO in developing these childhood obesity will require and but the world's children no suggest that of body fat should be in its of body with small measurement in of and of to the and with further that all these of in children and adolescents in a range of using a range of In this both and methods for assessing and are described and the and of these different methods used for population and clinical are measures of body an of body fat and of Such techniques include or and energy The methods are used for research and in care but may be used as a to measures of body the measures of or are and other and from and weight such as or the and All to some on the of the and their as a of must be a of The primary for overweight and obesity are to health and to between populations. with a need to be that where should that best these For the have been based on with and BMI being the most used both and in population Although not health weight for have a of assessing populations of children, especially those aged under years, and are used to both and weight for is and low weight for is found as a consequence of disease. A high weight for is overweight and high weight for is The use of weight for has the of not requiring knowledge of the child's which may be hard to in less developed but it should not be used as a for for or weight for as all measures different in In the use of weight for was recommended by WHO for children below the of 10 years, but a WHO review found that use of the for Health should not be recommended especially as it not account of between and children The WHO may consider standards based on studies of children showing growth The weight for is on a based on a which a based on the between the observed and the of a standardized the of the population. a of is to the or a of is to the and a of is The use of a weight for allows a more of an or a and between populations can also be and trends over time can be the in an require skills or programmes. In of overweight and obese the are based only on rather than a health In a study of young people aged 5–17 years, that fat as by was associated with an adverse and A high has also been shown to Although have been described for the for high or low health have not been may be in clinical as a of a child or to weight control In it may be used to a population in of fat and to determine the prevalence of risk cannot be used to a child as being at a high or low As suggested in 2 BMI is significantly associated with in childhood and and is the most of BMI with and It during the first after after the first and around the of this second is sometimes referred to as examples of childhood BMI by and A given of BMI needs to be and Several countries, including the and the have developed their using local In the USA, by from in the early have been used and were recommended for children years or by a WHO in More the for Health has based on from national health from although to an of the weight and BMI from the most were for children over the of years The of using is that a child can be described as being above or below certain (for example the or which can be in a clinical are from a single and an as overweight or obese that the is to that population. Furthermore, may the as an when the may in from a population with a high prevalence of obesity, such as the USA The that those children with a BMI greater than or to the be as and those children with a BMI between the and be as risk of In some children at or above the are referred to as and in to children above the As with the use of measures compared with populations, BMI can be compared with a and reported as A BMI is

Editorials20 June 2000The Informationist: A New Health Profession?Frank Davidoff, MD and Valerie Florance, PhDFrank Davidoff, MD and Valerie Florance, PhDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-132-12-200006200-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Physicians have always had a professional obligation to base their decisions on the best available information, an assumption now explicitly embodied in the concept of evidence-based medicine (1). For decades, when physicians wanted information from the published literature, they relied heavily on medical librarians or office assistants to do the searches. The advent of computer-based indexes such as MEDLINE promised to change all that by putting the basic information retrieval tools directly into physicians' hands. The disappointing reality, however, is that physicians still don't regularly search the medical literature themselves, nor do they ask for professional help in searching nearly ...References1. Davidoff F. In the teeth of the evidence: the curious case of evidence-based medicine. Mt Sinai J Med. 1999;66:75-83. MedlineGoogle Scholar2. Smith R. What clinical information do physicians need? BMJ. 1996;313:1062-8. CrossrefMedlineGoogle Scholar3. Ely JW, Osheroff JA, Ebell MH, Bergus GR, Levy BT, Chambliss ML, Evans ER. Analysis of questions asked by family physicians regarding patient care. BMJ. 1999;319:358-61. CrossrefMedlineGoogle Scholar4. Funk ME, Reid CA. Indexing consistency in MEDLINE. Bull Med Libr Assoc. 1983;71:176-83. MedlineGoogle Scholar5. Purcell GP, Rennels GD, Shortliffe EH. Development and evaluation of a context-based document representation for searching the medical literature. International Journal on Digital Libraries. 1997;1:288-96. CrossrefGoogle Scholar6. McKibbon KA, Haynes RB, Dilks CJ, Ramsden MF, Ryan NC, Baker L, Flemming T, et al . How good are clinical MEDLINE searches? A comparative study of clinical end-user and librarian searches. Comput Biomed Research. 1990;23:583-93. CrossrefMedlineGoogle Scholar7. Medical School Graduation Questionnaire. All Schools Report. Question 20. Association of American Medical Colleges, 1999. www.aamc.org/meded/gq. Accessed 6 March 2000. Google Scholar8. Florance V. Clinical extracts of biomedical literature for patient-centered problem solving. Bull Med Libr Assoc. 1996;84:375-85. MedlineGoogle Scholar9. Sackett DL, Straus SE. Finding and applying evidence during clinical rounds: the “evidence cart.”. JAMA. 1998;280:1336-8. CrossrefMedlineGoogle Scholar10. Cimino JJ, Elhanan G, Zeng Q. Supporting infobuttons with terminological knowledge. Proc AMIA Annu Fall Symp. 1997;:528-32. MedlineGoogle Scholar11. Lamb G. A decade of clinical librarianship. Clinical Librarian Quarterly. 1982;1:2-4. Google Scholar12. Scura G, Davidoff F. Case-related use of the medical literature. Clinical librarian services for improving patient care. JAMA. 1981;245:50-2. CrossrefMedlineGoogle Scholar13. Marshall JG. The impact of the hospital library on clinical decision making: the Rochester study. Bull Med Libr Assoc. 1992;80:169-78. MedlineGoogle Scholar14. Veenstra RJ. Clinical medical librarian impact on patient care: a one-year analysis. Bull Med Libr Assoc. 1992;80:19-22. MedlineGoogle Scholar15. Giuse NB, Kafantaris SR, Miller MD, Wilder KS, Martin SL, Sathe NA, et al . Clinical medical librarianship: the Vanderbilt experience. Bull Med Libr Assoc. 1998;86:412-6. MedlineGoogle Scholar16. Giuse NB. Advancing the practice of clinical medical librarianship. Bull Med Libr Assoc. 1997;85:437-8. MedlineGoogle Scholar17. Dodson S. A clinical medical librarian program into the next millennium. healthlinks.washington.edu/hsl/liaisons/dodson. Accessed 2 March 2000. Google Scholar18. van Walraven C, Naylor CD. Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits. JAMA. 1998;280:550-8. CrossrefMedlineGoogle Scholar19. Crenner CW. Introduction of the blood pressure cuff into U.S. medical practice: technology and skilled practice. Ann Intern Med. 1998;128:488-93. LinkGoogle Scholar20. Clinical Evidence: A Compendium of the Best Available Evidence for Effective Health Care. London: BMJ; Issue 2, December 1999. Google Scholar Author, Article, and Disclosure InformationAuthors: Frank Davidoff, MD; Valerie Florance, PhDAffiliations: Corresponding Author: Frank Davidoff, MD, American College of Physicians–American Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106.Current Author Addresses: Dr. Davidoff: American College of Physicians–American Society for Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106.Dr. Florance: Association of American Medical Colleges, 2450 N Street NW, Room 419, Washington, DC 20037. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Informationist Deborah B. Root Jorgensen The Informationist Stephen Sandroni The Informationist Bruce Houghton and Eugene C. Rich The Informationist Michael J. Schott The Informationist Frank Davidoff and Valerie Florance Metrics Cited byDeveloping a Competency-Based Curriculum for Clinical InformationistsPromoting new and expanded roles for librarians and information specialistsTranslating Liaison Librarians to the Scientific CommunitySkills and key education needed for clinical librarians: an exploratory study from the librarians' perspectivesClinical Informationist Services Challenges: A Qualitative Content Analysis of the LiteratureThe Presence of a Clinical Informationist on Ward Rounds: An Action Research StudyHealth Information Work: A Scoping ReviewInformacionista de Pesquisa: oportunidades para bibliotecários na era do big dataAccessTraining for Research Careers in Biomedical Informatics and Data Science Supported by the National Library of MedicineTranslating Clinical Questions by Physicians Into Searchable Queries: Analytical Survey StudyDeveloping Specialized Graduate Curricula for Health Information Professionals: Integrated Findings of a Scoping Review and an Employer SurveyThe clinical informationist as a new member of clinical teamWelServe: The DBMS for Capturing and Tracking Welch Medical Library’s Embedded Informationist Service Delivery at Johns Hopkins Medical InstitutionsInvolving Clinical Librarians in Clinical Settings: Skills, Roles, Advantages and BarriersHealth Libraries and Information Services in Tanzania: A Strategic AssessmentDisaster and Digital Libraries in Developing CountriesThrough the eyes of the Informationist: Identifying information needs of the Breast Imaging Service at a tertiary medical center specializing in cancerA Librarian’s Role in Improving Rigor in Research—AlzPED: Alzheimer’s Disease Preclinical Efficacy DatabaseAn Embedded Librarian Program: Eight Years OnLibrarians in the Lab: Toward Radically Re-Engineering Data Curation Services at the Research CoalfaceBarriers to the use of the library service amongst clinical staff in an acute hospital setting: an evaluationDisaster and Digital Libraries in Developing CountriesA study comparing public and medical librarians’ perceptions of the role and duties of health information-providing librariansIntegrating an Informationist Into Graduate Education: Case Study With Preliminary ResultsA review of competencies needed for health librarians - a comparison of Irish and international practiceEnvisioning the Academic Library: A Reflection on Roles, Relevancy and RelationshipsReferencesResearch Embedded Health Librarianship: The Canadian LandscapeAdapting an Embedded Model of Librarianship, College by CollegeEstablishing a New Clinical Informationist Role in an Academic Health Sciences CenterRetaining students by embedding librarians into undergraduate research experiences‘Personalised evidence’ for personalised healthcare: integration of a clinical librarian into mental health services – a feasibility studyExploring New Roles for LibrariansEvolving academic library specialtiesSustaining Librarian Vitality: Embedded Librarianship Model for Health Sciences LibrariesBoredom among psychiatric in-patients: does it matter?Bridging Paradigms: Hybrid Mechanistic-Discriminative Predictive ModelsHow Work-Related and Personal Motivated Information Needs Shape Trust Towards Government-Sponsored Medical Information Sources?Information professionals' participation in interdisciplinary research: a preliminary study of factors affecting successful collaborationsThe Disaster Information Specialist: An Emerging Role for Health LibrariansHealth education for Somali Bantu refugees via home visitsPlugging the “whole”: librarians as interdisciplinary facilitatorsExpert searching in health librarianship: a literature review to identify international issues and Australian concernsEffectiveness of bibliographic searches performed by paediatric residents and interns assisted by librarians. A randomised controlled trialInformation Needs and Barriers to Accessing Electronic Information: Hospital-Based Physicians Compared to Primary Care PhysiciansTechnology MediatorHospital clinicians’ information behaviour and attitudes towards the ‘Clinical Informationist’: an Irish surveyEvaluating clinical librarian services: a systematic reviewThe Informatics Imperative in Veterinary Medicine: Collaboration across DisciplinesClinical librarians as facilitators of nurses’ evidence-based practiceThe Informationist: Ten Years LaterCompetency-based continuing professional developmentClinical Library Services: Outreach to Enhance Patient CareWelServe: The DBMS for Capturing and Tracking Welch Medical Library's Embedded Informationist Service Delivery at Johns Hopkins Medical InstitutionsA clinical librarian pilot project in psychiatryResearch Support in an Academic Medical CenterInformation Takeout and Delivery: A Case Study Exploring Different Library Service Delivery ModelsHealth Sciences Librarians in Academic Libraries: A Brief Review of Their Developing RoleBuilding PROMIS item banks: librarians as co-investigatorsEvaluation of a New Clinical Librarian ServiceKnowledge Workers, Librarians, and SafetyAnalysis of queries sent to PubMed at the point of care: Observation of search behaviour in a medical teaching hospitalDeveloping research capacity in health librarians: a review of the evidenceInformationist EducationDo bibliotecário médico ao informacionista: traços semânticos de seus perfis e competênciasInformationist programme in support of biomedical research: a programme description and preliminary findings of an evaluationKorean medical libraries and professional associations: changing services and rolesA Randomized Effectiveness Trial of a Clinical Informatics Consult Service: Impact on Evidence-based Decision-making and Knowledge ImplementationBuilding a statewide knowledge network for clinicians in intensive care units: Knowledge brokering and the NSW Intensive Care Coordination and Monitoring Unit (ICCMU)Education for information scienceThe potential role of ILS schools in educating medical informationists 1The perioperative librarian: luxury or necessity?Informationists or Information Specialists in Context (ISIC): six years after conceptionThe education and training needs of health librarians?the generalist versus specialist dilemmaIntegrating Knowledge-Based Resources into the Electronic Health RecordCollaborative information synthesis II: Recommendations for information systems to support synthesis activitiesWhat do clinicians want from us? An evaluation of Brighton and Sussex University Hospitals NHS Trust clinical librarian service and its implications for developing futureworking patternsSignposting best evidence: a role for information professionalsOpportunity for change in the future roles for the health library and information professional: meeting the challenges in NHS ScotlandA web-based library consult service for evidence-based medicine: Technical developmentTechnology mediator: a new role for the reference librarian?Use of the Internet by parents of paediatric patientsThe Clinical Librarian/InformationistAdvancing practice inquiry: Research foundations of the practice doctorate in nursingA Clinical Librarian Program at an Urban Teaching HospitalWorking towards the informationistWho are the Informaticians? What We Know and Should KnowLibrarians, Surgeons, and KnowledgeEvidence-Based Resources and the Role of Librarians in Developing Evidence-Based Practice CurriculaFacilitating Patient Centeredness Through Information WorkInformation needs of United Kingdom primary care clinicians1Promoting Informed Choice: Transforming Health Care To Dispense Knowledge for Decision MakingSteven H. Woolf, MD, MPH, Evelyn C.Y. Chan, MD, MS, Russell Harris, MD, MPH, Stacey L. Sheridan, MD, MPH, Clarence H. Braddock III, MD, MPH, Robert M. Kaplan, PhD, Alex Krist, MD, Annette M. O'Connor, RN, MScN, PhD, and Sean Tunis, MD, MScEffect of CPOE User Interface Design on User-Initiated Access to Educational and Patient Information during Clinical CareUndertaking an information-needs analysis of the emergency-care physician to inform the role of the clinical librarian: a Greek perspectiveManaging knowledge to support the patient journey in NHS Scotland: strategic vision and practical realityManaging and leveraging organizational knowledgeLibrarians, Informaticists, Informationists, and Other Information Professionals in Biomedicine and the Health SciencesThe John Eisenberg Lecture: Health Services Research as a Citizen in ImprovementA survey of UK clinical librarianship: February 2004Answering Physicians' Clinical Questions: Obstacles and Potential SolutionsUsing Information Technology To Transfer Knowledge: A Medical Institution Steps Up to the PlateRobert Badgett, MD and Cynthia Mulrow, MD, MSc, Deputy EditorLibrarians as Hidden Gems in a Clinical TeamFellowship Training at Johns HopkinsProviding Evidence-Based Answers to Complex Clinical Questions: Evaluating the Consistency of Article SelectionToward continuous medical educationClinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarianEffect of an evidence-based answering service on GPs and their patients: a pilot studyThe informationist in Australia: a feasibility studyThe InformationistInformationist? Internal Medicine Rounds with a Clinical Medical LibrarianWhy emerging roles for health sciences librarians?Clinical medical librarian to clinical informationistBioterrorism alert: reference and literature support for the CDC Director’s Emergency Operations Center (DEOC) and investigative field teamsPhysicians' Internet information-seeking behaviorsWeb-Enabled Medicine: The Challenge of Ensuring Quality Information and CareUsing Clinical Vignette Assignments to Teach Medical InformaticsClinical librarianship: a systematic review of the literatureThe role of the information specialist in the systematic review process: a health information case studyIncorporating the views of obstetric clinicians in implementing evidence-supported labour and delivery suite ward rounds: a case studyCase Studies from Morning ReportOp zoek naar bewijs; een vraag- en antwoorddienst voor de huisartsFinding your place in the information age libraryPerson-centered approach to care, teaching, and research in fibromyalgia syndrome: Justification from biopsychosocial perspectives in populationsThe Impact of Medical Informatics on LibrarianshipClinical focus and patient management in the XXI century within the context of the advances in medicineKnowledge Resources: Finding Answers to Primary Care QuestionsAplicación de la gestión por procesos a las unidades De atención al usuarioA clinical librarian can support clinical governanceFrom Artisan To Architect: The Specialist And Systems Of Provision Of Diabetes Care In 2001Clinical Medical LibrariansThe InformationistDeborah B. Root Jorgensen, PharmD CandidateThe InformationistStephen Sandroni, MDThe InformationistBruce Houghton, MD and Eugene C. Rich, MDThe InformationistMichael J. Schott, MS, MLSProgress in Health Sciences Librarianship: 1970–2005The Development and Impact of Digital Library Funding in the United StatesUbiquitous Information Therapy Service through Social Networking LibrariesUbiquitous Information Therapy Service through Social Networking Libraries 20 June 2000Volume 132, Issue 12Page: 996-998KeywordsClinical epidemiologyGraduate medical educationHealth careHealth informaticsHealth information technologyInformation retrievalInformation technologyLibrariesPatientsTechnicians ePublished: 15 August 2000 Issue Published: 20 June 2000 Copyright & PermissionsCopyright © 2000 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

BACKGROUND: Case-based learning (CBL) is a long established pedagogical method, which is defined in a number of ways depending on the discipline and type of 'case' employed. In health professional education, learning activities are commonly based on patient cases. Basic, social and clinical sciences are studied in relation to the case, are integrated with clinical presentations and conditions (including health and ill-health) and student learning is, therefore, associated with real-life situations. Although many claims are made for CBL as an effective learning and teaching method, very little evidence is quoted or generated to support these claims. We frame this review from the perspective of CBL as a type of inquiry-based learning. AIM: To explore, analyse and synthesise the evidence relating to the effectiveness of CBL as a means of achieving defined learning outcomes in health professional prequalification training programmes. SELECTION CRITERIA: We focused the review on CBL for prequalification health professional programmes including medicine, dentistry, veterinary science, nursing and midwifery, social care and the allied health professions (physiotherapy, occupational therapy, etc.). Papers were required to have outcome data on effectiveness. SEARCH STRATEGIES: The search covered the period from 1965 to week 4 September 2010 and the following databases: ASSIA, CINAHL, EMBASE, Education Research, Medline and Web of Knowledge (WoK). Two members of the topic review group (TRG) independently reviewed the 173 abstracts retrieved from Medline and compared findings. As there was good agreement on inclusion, one went onto review the WoK and ASSIA EndNote databases and the other the Embase, CINAHL and Education Research databases to decide on papers to submit for coding. Coding and data analysis: The TRG modified the standard best evidence medical education coding sheet to fit our research questions and assessed each paper for quality. After a preliminary reliability exercise, each full paper was read and graded by one reviewer with the papers scoring 3-5 (of 5) for strength of findings being read by a second reviewer. A summary of each completed coding form was entered into an Excel spread sheet. The type of data in the papers was not amenable to traditional meta-analysis because of the variability in interventions, information given, student numbers (and lack of) and timings. We, therefore, adopted a narrative synthesis method to compare, contrast, synthesise and interpret the data, working within a framework of inquiry-based learning. RESULTS: The final number of coded papers for inclusion was 104. The TRG agreed that 23 papers would be classified as of higher quality and significance (22%). There was a wide diversity in the type, timing, number and length of exposure to cases and how cases were defined. Medicine was the most commonly included profession. Numbers of students taking part in CBL varied from below 50 to over 1000. The shortest interventions were two hours, and one case, whereas the longest was CBL through a whole year. Group sizes ranged from students working alone to over 30, with the majority between 2 and 15 students per group. The majority of studies involved single cohorts of students (61%), with 29% comparing multiple groups, 8% involving different year groups and 2% with historical controls. The outcomes evaluation was either carried out postintervention only (78 papers; 75%), preintervention and postintervention (23 papers; 22%) or during and postintervention (3 papers; <3%). Our analysis provided the basis for discussion of definitions of CBL, methods used and advocated, topics and learning outcomes and whether CBL is effective based on the evaluation data. CONCLUSION: Overwhelmingly, students enjoy CBL and think that it enhances their learning. The empirical data taken as a whole are inconclusive as to the effects on learning compared with other types of activity. Teachers enjoy CBL, partly because it engages, and is perceived to motivate, students. CBL seems to foster learning in small groups though whether this is the case delivery or the group learning effect is unclear.

CONTEXT: For nearly 40 years, outcome-based models have dominated programme evaluation in health professions education. However, there is increasing recognition that these models cannot address the complexities of the health professions context and studies employing alternative evaluation approaches that are appearing in the literature. A similar paradigm shift occurred over 50 years ago in the broader discipline of programme evaluation. Understanding the development of contemporary paradigms within this field provides important insights to support the evolution of programme evaluation in the health professions. METHODS: In this discussion paper, we review the historical roots of programme evaluation as a discipline, demonstrating parallels with the dominant approach to evaluation in the health professions. In tracing the evolution of contemporary paradigms within this field, we demonstrate how their aim is not only to judge a programme's merit or worth, but also to generate information for curriculum designers seeking to adapt programmes to evolving contexts, and researchers seeking to generate knowledge to inform the work of others. DISCUSSION: From this evolution, we distil seven essential elements of educational programmes that should be evaluated to achieve the stated goals. Our formulation is not a prescriptive method for conducting programme evaluation; rather, we use these elements as a guide for the development of a holistic 'programme of evaluation' that involves multiple stakeholders, uses a combination of available models and methods, and occurs throughout the life of a programme. Thus, these elements provide a roadmap for the programme evaluation process, which allows evaluators to move beyond asking whether a programme worked, to establishing how it worked, why it worked and what else happened. By engaging in this process, evaluators will generate a sound understanding of the relationships among programmes, the contexts in which they operate, and the outcomes that result from them.

INTRODUCTION: In an effort to increase the rigour of evaluation in health professions education (HPE), a range of evaluation approaches are used. These largely focus on outcome evaluation as opposed to programme evaluation. We aim to review and critique the use of outcome evaluation models, using the Kirkpatrick Model as an example given its wide acceptance and use, and advocate for the use of programme evaluation models that help us understand how and why outcomes are occurring. METHODS: We systematically searched OVID medline, Scopus, CINAHL and Pubmed, and hand searched six leading HPE journals to provide an overview of the use of the Kirkpatrick Model as well as a range of programme evaluation models in HPE. In addition to this, we synthesised the existing critiques of the Kirkpatrick Model as an example of outcome evaluation, to highlight the limitations of such models. RESULTS: The use of the Kirkpatrick Model in HPE is widespread and increasing; however, studies focus on categorising outcomes, rather than explaining how and why they occur. The main criticisms of the model are as follows: it is outcomes focused and fails to consider factors that can impact training outcomes; it assumes positive casual linkages between the levels; there is an assumption that the higher-level outcomes are more important; and unintended impacts are not considered. The use of the Kirkpatrick Model by the MERSQI, BEME and WHO contribute to the myth that the Kirkpatrick Model is the gold standard for programme evaluation. DISCUSSION: Moving forward, evaluations of HPE interventions must shift from focusing largely on measuring outcomes of interventions with little consideration for how and why these outcomes are occurring to programme evaluation that investigates what contributes to these outcomes. Other models that facilitate the evaluation of the complex processes that occur in HPE should be used instead of Kirkpatrick's.

PROBLEM: Program evaluation approaches that center the achievement of specific, measurable, achievable, realistic, and time-bound goals are common in health professions education (HPE) but can be challenging to articulate when evaluating emergent programs. Principles-focused evaluation is an alternative approach to program evaluation that centers on adherence to guiding principles, not achievement of goals. The authors describe their innovative application of principles-focused evaluation to an emergent HPE program. APPROACH: The authors applied principles-focused evaluation to the Children's Hospital of Philadelphia Medical Education Collaboratory, a works-in-progress program for HPE scholarship. In September 2019, the authors drafted 3 guiding principles. In May 2021, they used feedback from Collaboratory attendees to revise the guiding principles: Advance Excellence , Build Bridges , and Cultivate Learning . OUTCOMES: In July 2021, the authors queried participants about the extent to which their experience with the Collaboratory adhered to the revised guiding principles. Twenty of the 38 Collaboratory participants (53%) responded to the survey. Regarding the guiding principle Advance Excellence , 9 respondents (45%) reported that the Collaboratory facilitated engagement in scholarly conversation only by a small extent, and 8 (40%) reported it facilitated professional growth only by a small extent. Although some respondents expressed positive regard for the high degree of rigor promoted by the Collaboratory, others felt discouraged because this degree of rigor seemed unachievable. Regarding the guiding principle Build Bridges , 19 (95%) reported the Collaboratory welcomed perspectives within the group. Regarding the guiding principle Cultivate Learning , 19 (95%) indicated the Collaboratory welcomed perspectives within the group and across disciplines, and garnered collaboration. NEXT STEPS: Next steps include improving adherence to the principle of Advancing Excellence , fostering a shared mental model of the Collaboratory's guiding principles, and applying a principles-focused approach to the evaluation of multi-site HPE programs.

Background: Virtual reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice. Objective: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction. Methods: We performed a systematic review of the effectiveness of VR in pre- and postregistration health professions education following the gold standard Cochrane methodology. We searched 7 databases from the year 1990 to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data, and assessed risk of bias, and then, we compared the information in pairs. We contacted authors of the studies for additional information if necessary. All pooled analyses were based on random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to rate the quality of the body of evidence. Results: A total of 31 studies (2407 participants) were included. Meta-analysis of 8 studies found that VR slightly improves postintervention knowledge scores when compared with traditional learning (standardized mean difference [SMD]=0.44; 95% CI 0.18-0.69; I2=49%; 603 participants; moderate certainty evidence) or other types of digital education such as online or offline digital education (SMD=0.43; 95% CI 0.07-0.79; I2=78%; 608 participants [8 studies]; low certainty evidence). Another meta-analysis of 4 studies found that VR improves health professionals’ cognitive skills when compared with traditional learning (SMD=1.12; 95% CI 0.81-1.43; I2=0%; 235 participants; large effect size; moderate certainty evidence). Two studies compared the effect of VR with other forms of digital education on skills, favoring the VR group (SMD=0.5; 95% CI 0.32-0.69; I2=0%; 467 participants; moderate effect size; low certainty evidence). The findings for attitudes and satisfaction were mixed and inconclusive. None of the studies reported any patient-related outcomes, behavior change, as well as unintended or adverse effects of VR. Overall, the certainty of evidence according to the GRADE criteria ranged from low to moderate. We downgraded our certainty of evidence primarily because of the risk of bias and/or inconsistency. Conclusions: We found evidence suggesting that VR improves postintervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness, and clinical practice or behavior change.

BACKGROUND: Knowledge translation (KT) aims to close the research-practice gap in order to realize and maximize the benefits of research within the practice setting. Previous studies have investigated KT strategies in nursing and medicine; however, the present study is the first systematic review of the effectiveness of a variety of KT interventions in five allied health disciplines: dietetics, occupational therapy, pharmacy, physiotherapy, and speech-language pathology. METHODS: A health research librarian developed and implemented search strategies in eight electronic databases (MEDLINE, CINAHL, ERIC, PASCAL, EMBASE, IPA, Scopus, CENTRAL) using language (English) and date restrictions (1985 to March 2010). Other relevant sources were manually searched. Two reviewers independently screened the titles and abstracts, reviewed full-text articles, performed data extraction, and performed quality assessment. Within each profession, evidence tables were created, grouping and analyzing data by research design, KT strategy, targeted behaviour, and primary outcome. The published descriptions of the KT interventions were compared to the Workgroup for Intervention Development and Evaluation Research (WIDER) Recommendations to Improve the Reporting of the Content of Behaviour Change Interventions. RESULTS: A total of 2,638 articles were located and the titles and abstracts were screened. Of those, 1,172 full-text articles were reviewed and subsequently 32 studies were included in the systematic review. A variety of single (n = 15) and multiple (n = 17) KT interventions were identified, with educational meetings being the predominant KT strategy (n = 11). The majority of primary outcomes were identified as professional/process outcomes (n = 25); however, patient outcomes (n = 4), economic outcomes (n = 2), and multiple primary outcomes (n = 1) were also represented. Generally, the studies were of low methodological quality. Outcome reporting bias was common and precluded clear determination of intervention effectiveness. In the majority of studies, the interventions demonstrated mixed effects on primary outcomes, and only four studies demonstrated statistically significant, positive effects on primary outcomes. None of the studies satisfied the four WIDER Recommendations. CONCLUSIONS: Across five allied health professions, equivocal results, low methodological quality, and outcome reporting bias limited our ability to recommend one KT strategy over another. Further research employing the WIDER Recommendations is needed to inform the development and implementation of effective KT interventions in allied health.

BACKGROUND: Microlearning, the acquisition of knowledge or skills in the form of small units, is endorsed by health professions educators as a means of facilitating student learning, training, and continuing education, but it is difficult to define in terms of its features and outcomes. OBJECTIVE: This review aimed to conduct a systematic search of the literature on microlearning in health professions education to identify key concepts, characterize microlearning as an educational strategy, and evaluate pedagogical outcomes experienced by health professions students. METHODS: A scoping review was performed using the bibliographic databases PubMed (MEDLINE), CINAHL, Education Resources Information Center, EMBASE, PsycINFO, Education Full Text (HW Wilson), and ProQuest Dissertations and Theses Global. A combination of keywords and subject headings related to microlearning, electronic learning, or just-in-time learning combined with health professions education was used. No date limits were placed on the search, but inclusion was limited to materials published in English. Pedagogical outcomes were evaluated according to the 4-level Kirkpatrick model. RESULTS: A total of 3096 references were retrieved, of which 17 articles were selected after applying the inclusion and exclusion criteria. Articles that met the criteria were published between 2011 and 2018, and their authors were from a range of countries, including the United States, China, India, Australia, Canada, Iran, Netherlands, Taiwan, and the United Kingdom. The 17 studies reviewed included various health-related disciplines, such as medicine, nursing, pharmacy, dentistry, and allied health. Although microlearning appeared in a variety of subject areas, different technologies, such as podcast, short messaging service, microblogging, and social networking service, were also used. On the basis of Buchem and Hamelmann's 10 microlearning concepts, each study satisfied at least 40% of the characteristics, whereas all studies featured concepts of maximum time spent less than 15 min as well as content aggregation. According to our assessment of each article using the Kirkpatrick model, 94% (16/17) assessed student reactions to the microlearning (level 1), 82% (14/17) evaluated knowledge or skill acquisition (level 2), 29% (5/17) measured the effect of the microlearning on student behavior (level 3), and no studies were found at the highest level. CONCLUSIONS: Microlearning as an educational strategy has demonstrated a positive effect on the knowledge and confidence of health professions students in performing procedures, retaining knowledge, studying, and engaging in collaborative learning. However, downsides to microlearning include pedagogical discomfort, technology inequalities, and privacy concerns. Future research should look at higher-level outcomes, including benefits to patients or practice changes. The findings of this scoping review will inform education researchers, faculty, and academic administrators on the application of microlearning, pinpoint gaps in the literature, and help identify opportunities for instructional designers and subject matter experts to improve course content in didactic and clinical settings.

Mental health is fundamental to health, according to Mental Health: A Report of the Surgeon General, the first Surgeon General’s report ever to focus exclusively on mental health. That report of two years ago urged Americans to view mental health as paramount to personal well-being, family relationships, and successful contributions to society. It documented the disabling nature of mental illnesses, showcased the strong science base behind effective treatments, and recommended that people seek help for mental health problems or disorders. The first mental health report also acknowledged that all Americans do not share equally in the hope for recovery from mental illnesses. This is especially true of members of racial and ethnic minority groups. That awareness galvanized me to ask for a supplemental report on the nature and extent of disparities in mental health care for racial and ethnic minorities and on promising directions for the elimination of these disparities. This Supplement documents that the science base on racial and ethnic minority mental health is inadequate; the best available research, however, indicates that these groups have less access to and avail-ability of care, and tend to receive poorer quality mental health services. These disparities leave minority communities with a greater disability burden from unmet mental health needs. A hallmark of this Supplement is its emphasis on the role that cultural factors play in mental health. The cultures from which people hail affect all aspects of mental health and illness, including the types of stresses they confront, whether they seek help, what types of help they seek, what symptoms and concerns they bring to clinical attention, and what types of coping styles and social supports they possess. Likewise, the cultures of clinicians and service systems influence the nature of mental health services.

BACKGROUND: There is a worldwide shortage of health workers, and this issue requires innovative education solutions. Serious gaming and gamification education have the potential to provide a quality, cost-effective, novel approach that is flexible, portable, and enjoyable and allow interaction with tutors and peers. OBJECTIVE: The aim of this systematic review was to evaluate the effectiveness of serious gaming/gamification for health professions education compared with traditional learning, other types of digital education, or other serious gaming/gamification interventions in terms of patient outcomes, knowledge, skills, professional attitudes, and satisfaction (primary outcomes) as well as economic outcomes of education and adverse events (secondary outcomes). METHODS: A comprehensive search of MEDLINE, EMBASE, Web of Knowledge, Educational Resources Information Centre, Cochrane Central Register of Controlled Trials, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature was conducted from 1990 to August 2017. Randomized controlled trials (RCTs) and cluster RCTs were eligible for inclusion. Two reviewers independently searched, screened, and assessed the study quality and extracted data. A meta-analysis was not deemed appropriate due to the heterogeneity of populations, interventions, comparisons, and outcomes. Therefore, a narrative synthesis is presented. RESULTS: A total of 27 RCTs and 3 cluster RCTs with 3634 participants were included. Two studies evaluated gamification interventions, and the remaining evaluated serious gaming interventions. One study reported a small statistically significant difference between serious gaming and digital education of primary care physicians in the time to control blood pressure in a subgroup of their patients already taking antihypertensive medications. There was evidence of a moderate-to-large magnitude of effect from five studies evaluating individually delivered interventions for objectively measured knowledge compared with traditional learning. There was also evidence of a small-to-large magnitude of effect from 10 studies for improved skills compared with traditional learning. Two and four studies suggested equivalence between interventions and controls for knowledge and skills, respectively. Evidence suggested that serious gaming was at least as effective as other digital education modalities for these outcomes. There was insufficient evidence to conclude whether one type of serious gaming/gamification intervention is more effective than any other. There was limited evidence for the effects of serious gaming/gamification on professional attitudes. Serious gaming/gamification may improve satisfaction, but the evidence was limited. Evidence was of low or very low quality for all outcomes. Quality of evidence was downgraded due to the imprecision, inconsistency, and limitations of the study. CONCLUSIONS: Serious gaming/gamification appears to be at least as effective as controls, and in many studies, more effective for improving knowledge, skills, and satisfaction. However, the available evidence is mostly of low quality and calls for further rigorous, theory-driven research.

Background: Virtual patients are interactive digital simulations of clinical scenarios for the purpose of health professions education. There is no current collated evidence on the effectiveness of this form of education. Objective: The goal of this study was to evaluate the effectiveness of virtual patients compared with traditional education, blended with traditional education, compared with other types of digital education, and design variants of virtual patients in health professions education. The outcomes of interest were knowledge, skills, attitudes, and satisfaction. Methods: We performed a systematic review on the effectiveness of virtual patient simulations in pre- and postregistration health professions education following Cochrane methodology. We searched 7 databases from the year 1990 up to September 2018. No language restrictions were applied. We included randomized controlled trials and cluster randomized trials. We independently selected studies, extracted data, and assessed risk of bias and then compared the information in pairs. We contacted study authors for additional information if necessary. All pooled analyses were based on random-effects models. Results: A total of 51 trials involving 4696 participants met our inclusion criteria. Furthermore, 25 studies compared virtual patients with traditional education, 11 studies investigated virtual patients as blended learning, 5 studies compared virtual patients with different forms of digital education, and 10 studies compared different design variants. The pooled analysis of studies comparing the effect of virtual patients to traditional education showed similar results for knowledge (standardized mean difference [SMD]=0.11, 95% CI −0.17 to 0.39, I2=74%, n=927) and favored virtual patients for skills (SMD=0.90, 95% CI 0.49 to 1.32, I2=88%, n=897). Studies measuring attitudes and satisfaction predominantly used surveys with item-by-item comparison. Trials comparing virtual patients with different forms of digital education and design variants were not numerous enough to give clear recommendations. Several methodological limitations in the included studies and heterogeneity contributed to a generally low quality of evidence. Conclusions: Low to modest and mixed evidence suggests that when compared with traditional education, virtual patients can more effectively improve skills, and at least as effectively improve knowledge. The skills that improved were clinical reasoning, procedural skills, and a mix of procedural and team skills. We found evidence of effectiveness in both high-income and low- and middle-income countries, demonstrating the global applicability of virtual patients. Further research should explore the utility of different design variants of virtual patients.

BACKGROUND: The articulation of learning goals, processes and outcomes related to health humanities teaching currently lacks comparability of curricula and outcomes, and requires synthesis to provide a basis for developing a curriculum and evaluation framework for health humanities teaching and learning. This scoping review sought to answer how and why the health humanities are used in health professions education. It also sought to explore how health humanities curricula are evaluated and whether the programme evaluation aligns with the desired learning outcomes. METHODS: A focused scoping review of qualitative and mixed-methods studies that included the influence of integrated health humanities curricula in pre-registration health professions education with programme evaluate of outcomes was completed. Studies of students not enrolled in a pre-registration course, with only ad-hoc health humanities learning experiences that were not assessed or evaluated were excluded. Four databases were searched (CINAHL), (ERIC), PubMed, and Medline. RESULTS: The search over a 5 year period, identified 8621 publications. Title and abstract screening, followed by full-text screening, resulted in 24 articles selected for inclusion. Learning outcomes, learning activities and evaluation data were extracted from each included publication. DISCUSSION: Reported health humanities curricula focused on developing students' capacity for perspective, reflexivity, self- reflection and person-centred approaches to communication. However, the learning outcomes were not consistently described, identifying a limited capacity to compare health humanities curricula across programmes. A set of clearly stated generic capabilities or outcomes from learning in health humanities would be a helpful next step for benchmarking, clarification and comparison of evaluation strategy.

CONTEXT: High-quality research into education costs can inform better decision making. Improvements to cost research can be guided by information about the research questions, methods and reporting of studies evaluating costs in health professions education (HPE). Our objective was to appraise the overall state of the field and evaluate temporal trends in the methods and reporting quality of cost evaluations in HPE research. METHODS: We searched the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, Business Source Complete and ERIC (Education Resources Information Centre) databases on 31 July 2017. To evaluate trends over time, we sampled research reports at 5-year intervals (2001, 2006, 2011 and 2016). All original research studies in HPE that reported a cost outcome were included. The Medical Education Research Study Quality Instrument (MERSQI) and the BMJ economic checklist were used to appraise methodological and reporting quality, respectively. Trends in quality over time were analysed. RESULTS: A total of 78 studies were included, of which 16 were published in 2001, 15 in 2006, 20 in 2011 and 27 in 2016. The region most commonly represented was the USA (n = 43). The profession most commonly referred to was that of the physician (n = 46). The mean ± standard deviation (SD) MERSQI score was 10.9 ± 2.6 out of 18, with no significant change over time (p = 0.55). The mean ± SD BMJ score was 13.5 ± 7.1 out of 35, with no significant change over time (p = 0.39). A total of 49 (63%) studies stated a cost-related research question, 23 (29%) stated the type of cost evaluation used, and 31 (40%) described the method of estimating resource quantities and unit costs. A total of 16 studies compared two or more interventions and reported both cost and learning outcomes. CONCLUSIONS: The absolute number of cost evaluations in HPE is increasing. However, there are shortcomings in the quality of methodology and reporting, and these are not improving over time.

BACKGROUND: Blended learning, defined as the combination of traditional face-to-face learning and asynchronous or synchronous e-learning, has grown rapidly and is now widely used in education. Concerns about the effectiveness of blended learning have led to an increasing number of studies on this topic. However, there has yet to be a quantitative synthesis evaluating the effectiveness of blended learning on knowledge acquisition in health professions. OBJECTIVE: We aimed to assess the effectiveness of blended learning for health professional learners compared with no intervention and with nonblended learning. We also aimed to explore factors that could explain differences in learning effects across study designs, participants, country socioeconomic status, intervention durations, randomization, and quality score for each of these questions. METHODS: We conducted a search of citations in Medline, CINAHL, Science Direct, Ovid Embase, Web of Science, CENTRAL, and ERIC through September 2014. Studies in any language that compared blended learning with no intervention or nonblended learning among health professional learners and assessed knowledge acquisition were included. Two reviewers independently evaluated study quality and abstracted information including characteristics of learners and intervention (study design, exercises, interactivity, peer discussion, and outcome assessment). RESULTS: We identified 56 eligible articles. Heterogeneity across studies was large (I(2) ≥93.3) in all analyses. For studies comparing knowledge gained from blended learning versus no intervention, the pooled effect size was 1.40 (95% CI 1.04-1.77; P<.001; n=20 interventions) with no significant publication bias, and exclusion of any single study did not change the overall result. For studies comparing blended learning with nonblended learning (pure e-learning or pure traditional face-to-face learning), the pooled effect size was 0.81 (95% CI 0.57-1.05; P<.001; n=56 interventions), and exclusion of any single study did not change the overall result. Although significant publication bias was found, the trim and fill method showed that the effect size changed to 0.26 (95% CI -0.01 to 0.54) after adjustment. In the subgroup analyses, pre-posttest study design, presence of exercises, and objective outcome assessment yielded larger effect sizes. CONCLUSIONS: Blended learning appears to have a consistent positive effect in comparison with no intervention, and to be more effective than or at least as effective as nonblended instruction for knowledge acquisition in health professions. Due to the large heterogeneity, the conclusion should be treated with caution.