Researcher

NEXO's scientific research program on learning and diagnostic reasoning.

scientific@nexo.wiki.br

Learning architecture

Principles from learning science and clinical reasoning, put into practice and recorded with every case.

In the theory of gamified learning, game elements influence learning through the behavior they prompt. Here each element corresponds to a principle described in the literature and leaves a record, which makes it possible to test the effect of each one and to separate what sustains practice from what produces learning.

Landers, Simulation & Gaming, 2014

Diagnostic reasoning

  1. Progressive disclosure and hypothesis updatingMechanicClues revealed one at a time
    Lets you studyHow the hypothesis changes with each new piece of information, and how much weight each finding carries in that change.Bergus et al., Med Decis Making, 1998
  2. Pre-test probability and regional epidemiologyMechanicContinents
    Lets you studyHow geography changes what is considered likely.Tversky and Kahneman, Science, 1974
  3. Perceptual learningMechanicMultimedia: ECG, auscultation and imaging
    Lets you studyHow a test is read with and without a hypothesis already formed.LeBlanc, Brooks and Norman, Acad Med, 2002
  4. Time pressureMechanicAdrenaline, against the clock
    Lets you studySpeed versus accuracy, and how many hypotheses fit in the time available.ALQahtani et al., Acad Med, 2016

Feedback and reflection

  1. Graded feedbackMechanicICD proximity on five levels
    Lets you studyWhether the distance of the error shrinks with practice, and whether graded feedback teaches more than right or wrong.Hattie and Timperley, Rev Educ Res, 2007
  2. Scaffolding and help-seekingMechanicHints and clue skipping
    Lets you studyWhen help brings the correct answer forward and when it merely replaces it.Wood, Bruner and Ross, J Child Psychol Psychiatry, 1976
  3. Reflection after the diagnosisMechanicExplanation at the end of the case
    Lets you studyWhether reviewing one's own reasoning changes performance on similar cases.Mamede et al., JAMA, 2010

Memory

  1. Spaced practiceMechanicOne new case a day
    Lets you studyRetention over weeks and months, by specialty.Kerfoot et al., Med Educ, 2007
  2. Repeated testingMechanicArchive of past cases
    Lets you studyThe effect of returning to a case already played on memory of the diagnosis.Larsen, Butler and Roediger, Med Educ, 2009

Motivation

  1. Motivation and habitMechanicDaily streak
    Lets you studyWhether practice is sustained by interest or by fear of losing the streak.Ryan and Deci, Am Psychol, 2000
  2. Rewards and social comparisonMechanicXP, levels, achievements and leaderboard
    Lets you studyWhat each reward does to practice and to learning, for those at the top and for those at the bottom.Hanus and Fox, Comput Educ, 2015

Measurement

  1. Measurement equivalence across languagesMechanicSix languages
    Lets you studyWhether the same case measures the same thing after translation.International Test Commission, 2017

Research questions

  • Clinical reasoning

    Does the hypothesis change according to the weight of the new finding, or according to the order in which it arrives?

    Bergus et al., Med Decis Making, 1998

  • Which findings bring the guess closest to the diagnosis, and does that measured weight match the likelihood ratios in the literature?

    McGee, Evidence-Based Physical Diagnosis

  • Does a hypothesis already formed change how an ECG, a sound or an image that comes later is read?

    LeBlanc, Brooks and Norman, Acad Med, 2002

  • At what point in experience does the correct answer stop coming step by step and start coming from the first findings, as illness script theory predicts?

    Schmidt and Rikers, Med Educ, 2007

  • Diagnostic error and bias

    Can premature closure be measured as persistence with a wrong hypothesis after findings that contradict it?

    Croskerry, Acad Med, 2003

  • Does seeing a diagnosis a few days earlier raise the chance of proposing it in a similar case of a different disease?

    Mamede et al., JAMA, 2010

  • When the disease is rare, does the error land on a common disease in the same group because prevalence is used correctly, or because the specific finding is overlooked?

    Tversky and Kahneman, Science, 1974

  • Do near misses, in the same ICD group, and far misses, in another chapter, have different causes, such as lack of knowledge and faulty reasoning?

    Norman et al., Acad Med, 2017

  • Time and pressure

    Does time pressure reduce accuracy, or does it only bring forward decisions that would be the same without the rush?

    ALQahtani et al., Acad Med, 2016

  • On the same case, are those who answer quickly right more or less often than those who take their time?

    Sherbino et al., Acad Med, 2012

  • Learning and memory

    Does meeting a diagnosis again days apart lead to better retention than seeing it several times in a row, and for how long?

    Kerfoot et al., Med Educ, 2007

  • Does switching specialties from one case to the next help tell similar diagnoses apart, as interleaved practice did in ECG interpretation?

    Hatala, Brooks and Norman, Adv Health Sci Educ, 2003

  • Gamification and motivation

    Which game element sustains practice and which produces learning, if the two effects can be separated?

    Sailer and Homner, Educ Psychol Rev, 2020

  • Does feedback graded by proximity teach more than right-or-wrong feedback?

    Shute, Rev Educ Res, 2008

  • Does the leaderboard motivate those at the top and drive away those at the bottom?

    Hanus and Fox, Comput Educ, 2015

  • People, places and languages

    Do people who live far from endemic areas recognize a neglected tropical disease later in the case, and does the difference come from knowledge or from the probability they assign to it?

    WHO, road map for neglected tropical diseases 2021 to 2030

  • Do the patient's sex and age change when the correct answer comes, in diseases that present differently across groups?

    Chapman, Kaatz and Carnes, J Gen Intern Med, 2013

  • Does reasoning in a foreign language reduce bias, as in decisions studied outside medicine, or does it only slow down the diagnosis?

    Keysar, Hayakawa and An, Psychol Sci, 2012

  • Measurement and artificial intelligence

    Does the same case have the same difficulty in all six languages, or does translation change what it measures?

    International Test Commission, 2017

  • Can the clue at which the answer is reached become an ordinal difficulty scale, calibrated with item response theory?

    Samejima, Psychometrika, 1969

  • Do language models and students go wrong on the same cases and at the same points in the ICD, or do they fail in different ways?

    Kanjee, Crowe and Rodman, JAMA, 2023

Data and ethics

  • Ethics approval firstNo data is extracted or analyzed before the study is approved by a research ethics committee.
  • TransparencyAny use of player data in research is disclosed in NEXO's privacy policy before it happens.
  • Aggregated by defaultThe default is synthetic data or aggregated tables, with a minimum number of people per group. Replacing an identifier with a code does not make data anonymous.
  • No raw databaseNames, email addresses, account identifiers, payment data and security logs do not leave NEXO, and no one receives the whole database.
  • The minimum for each questionEach study receives only what it needs, under terms that prohibit re-identifying people, linking with other databases and passing data to third parties.
  • Optional participationWhen a study requires consent, that consent is separate, specific, optional and revocable. Using NEXO never depends on agreeing to take part in research.
  • MinorsStudies are designed with added protection for minors, for example, by enrolling only adults who consent.
  • IndependenceNEXO reviews results only for privacy, security and confidential information, and does not veto unfavorable, neutral or negative results. NEXO's ties and conflicts of interest are declared in any publication.

Authorship

Authorship follows the four criteria of the ICMJE (International Committee of Medical Journal Editors): substantial contributions to the conception or design of the work, or to the acquisition, analysis or interpretation of data; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; and accountability for all aspects of the work. Contributors who meet fewer than all four criteria are acknowledged.

In the program, providing data, funding, general supervision or taking part in a NEXO program is not enough for authorship. Authors, roles and the publication plan are set in writing at the start of each study.

What it is not

  • It is not an open database, and it does not sell or hand over data.
  • It does not use patient data. NEXO cases are fictional, built from classic presentations described in the literature.
  • It does not assess anyone's professional competence. Results describe performance in a training game with fictional cases.
  • Being part of the program does not, by itself, come with payment, the Max plan, a badge, authorship or access to data.
  • Taking part in another NEXO program, such as Creators, Curator or Closer, does not give access to data.

How to take part

If you are a researcher affiliated with a teaching or research institution, you can propose a study by writing to scientific@nexo.wiki.br with:

  • Your name, institution, position and a link to your CV (ORCID or equivalent)
  • Your research question in one paragraph
  • Whether your institution already has a principal investigator for the study and an ethics committee that would review it

Sending a proposal does not give access to data. Access depends on the study's ethics approval and follows the rules on this page.