You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Background {#Sec1}
==========

In recent decades, there has been a dramatic increase in the levels of scientific knowledge, diagnostic expertise and overall competence that orthopaedic surgery residents must master during their training. This growing amount of information creates a need for objective and standardized assessment methods to assess residents' learning throughout their education, and especially at the end of their residency programs. In the United States of America, the Orthopaedic In-Training Examination (OITE), a national test taken annually by orthopaedic residents that evaluates knowledge of the most important subjects in orthopaedic surgery, has been assessed in several studies \[[@CR1]--[@CR4]\]. However, almost no information is available in the medical literature about similar evaluations for orthopaedic surgery residents in Latin America.

In Chile, the rising expectations of patients, combined with the country's economic growth and its aging population, have required that more new physicians be trained in different specialties. In response to this demand, the number of orthopaedic surgery residency programs throughout the country has grown during the last decade. As a result, the number of orthopaedic surgeons graduating each year in Chile has also increased significantly. The Chilean Society of Orthopaedic Surgery (SCHOT) plays an active role in the continuing education of orthopaedic surgeons and residents in Chile, and many of the Society's active members serve as certifying experts to ensure the quality of training programs. This is similar to the other medical societies in Latin America, which have played an active role in quality assurance for specialty training \[[@CR5]--[@CR7]\].

To determine whether individual residents are meeting minimal knowledge standards at the end of their training programs, the SCHOT developed the EMNOT, an acronym for "Examen Medico Nacional de Ortopedia y Traumatologia" (National Medical Examination in Orthopaedic Surgery). The EMNOT is a multiple-choice exam covering the areas of general orthopaedics (including basic sciences); musculoskeletal trauma; pediatric orthopaedics; spine; shoulder and elbow; hand; hip and pelvis; knee and sports medicine; foot and ankle; and musculoskeletal oncology. The EMNOT was first administered in 2009, and, to date, a total of 279 final-year residents have taken the test.

In this study, we analyzed this educational tool by assessing the examination's distribution of questions in the different subspecialties of orthopaedics, its question taxonomy, and its difficulty and discrimination indices.

Methods {#Sec2}
=======

For this study, we first obtained institutional board approval from the President and the Board of Directors of the SCHOT and its ethics committee. The information we analyzed did not include the examinees' and institutions' identifying data.

We retrospectively assessed the 7-year period during which the examination has been administered (2009--2015). The total number of residents taking the EMNOT (each year and during the entire period) was recorded. All questions were categorized using the taxonomic classification described by Buckwalter et al. \[[@CR8]\]. A question was defined as Type 1 (pure knowledge) when it required the recall of facts but no interpretation; as Type 2 (diagnosis) if it required interpretation of information provided (including images); and as Type 3 (evaluation/decision-making) if the resident needed to decide on a treatment plan using the data provided. Any discrepancies regarding the categorization of any question were discussed in a joint review and resolved based on consensus.

Each question was also classified into one of ten areas: general orthopaedics (including basic sciences); musculoskeletal trauma; pediatric orthopaedics; spine; shoulder and elbow; hand; hip and pelvis; knee and sports medicine; foot and ankle; and musculoskeletal oncology. The percentage of questions from each area as a fraction of the entire EMNOT was established. Residents' performance on the complete examination, as well as on each taxonomic type of question, was recorded.

The Difficulty Index (P) was determined as described by Crocker and Algina \[[@CR9]\]. P refers to the percentage of correct responses to the test item; it was calculated using the formula *P* = R/T, where R is the number of correct responses and T is the total number of responses (i.e., correct + incorrect + blank responses). Levels of P were established as proposed by Backhoff et al. \[[@CR10]\], with values \< 5 % considered difficult; 5 -- 25 % considered medium-hard difficulty; 26 -- 75 % considered medium difficulty; 76 -- 95 % considered medium-low difficulty and \> 95 % considered low difficulty.

Finally, we calculated the Discrimination Index (D). D refers to the capacity of an item to discriminate between high-ability examinees and low-ability examinees. We first scored each examinee\'s test and rank-ordered the test scores; next, the top 50 % of students (high-ability examinees) and the bottom 50 % (low-ability examinees) were separated for analysis. D for each question is the number of examinees in the upper group who answered the item correctly minus the number of examinees in the lower group who answered the item correctly, divided by 50 % of the number of students taking the test each year. Levels of D were established as proposed by Ebel and Frisbie \[[@CR11]\], with D values 0.00--0.20 considered poor discrimination; 0.20--0.29 considered fair discrimination; 0.30--0.39 considered good discrimination and \> 0.39 considered excellent discrimination.

Statistical analysis was conducted using Statistical Program for the Social Sciences (SPSS) version 18 (SPSS, Chicago, IL). Categorical variables were expressed as percentages. Fisher's exact test was used to analyze categorical variables. A p value less than 0.05 was considered statistically significant.

Results {#Sec3}
=======

A total of 279 residents finishing their orthopaedic surgery programs have taken the EMNOT since 2009; the number of examinees has increased each year, as shown in Table [1](#Tab1){ref-type="table"}.Table 1General description of the test from 2009 to 20152009201020112012201320142015Number of examinees23263238495556Number of questions90110120120120120120Number of questions with images00416363424Difficulty Index (median)66.071.655.852.762.465.965.2Discrimination Index (median)0.340.280.270.250.410.410.58

The number of questions increased from 90 in 2009 to 110 in 2010, and remained at 120 from 2011 to 2015. The number of questions containing some type of image has increased from zero questions containing images in 2009 and 2010 to a median of 34 questions containing images during the last three years (2013 -- 2015), *p* \< 0.01 (Table [1](#Tab1){ref-type="table"}).

The proportion of Type 1 questions has decreased significantly (from 77.8 % in 2009 to 59.2 % in 2015). There has also been a significant increase in Type 3 questions (from 5.6 % in 2009 to 22.5 % in 2015), *p* \< 0.05. Variations in the proportion of questions by taxonomy level are shown in Tables [2](#Tab2){ref-type="table"} and [3](#Tab3){ref-type="table"}.Table 2Percentage of questions according to taxonomic classificationYear2009201020112012201320142015Mean ± SDType 177.876.465.859.252.559.259.264.3 ± 9.6Type 216.717.325.825.022.521.718.321.0 ± 3.7Type 35.66.48.315.825.019.222.514.7 ± 8.0*SD* standard deviationTable 3Number of total questions according to taxonomic classification2009201020112012201320142015Type 170847971637171Type 215193130272622Type 3571019302327Total90110120120120120120

The most frequently tested areas have been pediatric orthopaedics (22.9 %), spine (13.8 %), general orthopaedics (13.8 %) and musculoskeletal trauma (9.9 %), as shown in Table [4](#Tab4){ref-type="table"}.Table 4Percentage of questions by areaAreaYear2009201020112012201320142015TotalHip/pelvis2.28.25.86.76.57.76.76.3Spine21.115.513.312.59.814.510.013.8General orthopaedics2.27.32.56.711.412.012.57.8Shoulder/elbow8.94.511.710.89.84.39.28.4Pediatric orthopaedics28.922.724.219.220.322.222.522.9Hand14.410.910.07.56.56.87.59.1Knee/Sports Medicine10.010.09.29.29.87.78.39.2Foot and Ankle2.28.25.86.77.38.57.56.6Musculoskeletal Trauma5.64.512.511.711.411.112.59.9Tumor4.48.25.09.27.35.13.36.1Total100100100100100100100100

The Difficulty Index of the test (median *P* = 65.2; range 52.7 -- 71.6) showed that the test has presented medium difficulty in each of the years it has been administered. The Discrimination Index (median D = 0.34; range 0.25 -- 0.58) showed good discrimination in 2009 but only fair discrimination from 2010 through 2012; D values increased to excellent discrimination from 2013 through 2015, as shown in Table [1](#Tab1){ref-type="table"}.

Discussion {#Sec4}
==========

The SCHOT has been administering the EMNOT since 2009 to assess whether residents finishing their orthopaedic surgery training programs are meeting minimal knowledge standards. Although a multiple-choice examination like the EMNOT cannot directly assess all the necessary competencies required of orthopaedic surgeons \[[@CR12]\], it serves as a standardized evaluation tool of cognitive competencies. This is an extremely important function given that medical knowledge influences the quality of patients' care \[[@CR13], [@CR14]\].

Our study shows that despite a decrease in the number of knowledge questions (Type 1) and an increase in the number of evaluation/decision-making questions (Type 3), the proportion of correct answers did not change during the administration period of the test (Table [5](#Tab5){ref-type="table"}). Therefore, the variation in the taxonomy of questions did not affect the performance of the examinees; similar results have been described in other studies evaluating orthopaedic tests \[[@CR1]\]. Accordingly, no significant differences in the Difficulty Index of the test were observed throughout its years of administration. This is important because Type 3 questions, as opposed to questions that require only the recall of data, better evaluate the competencies expected from a specialist.Table 5Percentage of correct answers according to taxonomic classificationYear2009201020112012201320142015Type 163.170.565.060.358.359.762.4Type 263.277.565.560.560.861.059.9Type 361.568.157.165.668.161.160.8

The EMNOT migrated from a paper-based exam to a computer-based exam in 2012. This change facilitated the inclusion of images, which resulted in an increased percentage of questions involving figures. There were no images in 2009 and 2010 and the test had a median of 34 questions with images from 2013 to 2015. This also helped with the development of type 2 and type 3 questions: the inclusion of radiographs, patient photos, and graphs has resulted in more intricate questions that require a more complex approach, requiring the examinee to provide diagnosis and treatment decisions.

This examination was developed as a comprehensive examination testing core knowledge in all areas of orthopaedic surgery. In this analysis, we found that not all sub-specialties were proportionately represented by the test; pediatric orthopaedics and spine surgery were the most represented sub-specialties. Similar results were also found by Papp et al. in their report on the OITE exam \[[@CR2]\]. In our results, pediatric questions represented 22.9 % of all questions; this proportion reflects the time allocated to this sub-specialty, which represents between 18 and 24 % of an orthopaedic residency, depending on the program. The high ratio of spine questions may be partly explained by the fact that all pediatric spinal deformity questions were labelled as spine questions; nevertheless, this over-representation has been corrected during the most recent years of the examination, as shown in Table [4](#Tab4){ref-type="table"}.

The test has evolved throughout the years, with an increase in the total number of questions, an increase in Type 2 and Type 3 questions, and a more homogeneous representation of the different sub-specialties. The Difficulty Index shows that the exam has had a medium difficulty level throughout all years of administration; the Discrimination Index shows that the test has increased its discrimination capacity in the last three years. While these results are encouraging, the EMNOT still faces the limitation that, as a multiple-choice examination, it only evaluates knowledge, diagnostic skills, and evaluation/decision-making skills. The assessment of surgical skills and attitudes of examinees still remains a challenge \[[@CR15], [@CR16]\].

Although beyond the scope of this article, the results of these exams have also helped to identify learning needs for the development of a more relevant continuing education program. Moreover, yearly reports are given to Residency Program Directors in Chile to aid in curriculum development.

In a recent review, Gurgacz et al. postulated that a socially useful credentialing process in surgical specialties should adhere to three main conditions: (a) only one institution should be responsible for the credentialing process, (b) best-practice standards for design, implementation, and monitoring of the examination should be used and (c) the organization should have a strong quality-improvement culture \[[@CR17]\]. The SCHOT develops the EMNOT with the help of experts in orthopaedic surgery and medical education. This exam has been evaluated yearly to improve its standards and to establish a certification process. We believe that future evaluations of the EMNOT should include national and international appraisals to ensure an external impartial verification of its quality level. The examination should also incorporate methods for the assessment of surgical skills and attitudes among graduating orthopaedic residents.

Conclusion {#Sec5}
==========

The EMNOT has evolved over several years to include higher quality questions, better discrimination, and a more representative distribution of questions covering the different orthopaedic sub-specialties. Thus, this examination developed and administered by the SCHOT represents an effective instrument for quality assurance of orthopaedic residency programs in Chile.

**Competing interests**

The authors have no financial competing interests.

Non-financial competing interests:

Dr. Julio Urrutia and Dr. Mario Orrego are members of the Board of Directors of the Chilean Society of Orthopaedic Surgery

Dr. Mario Orrego and Mrs. Ana C. Wright are members of the Commission that creates and administers the Chilean National Examination of Orthopaedic Surgery

**Authors' contributions**

JU conceived the study, and participated in its design and acquisition, analysis and interpretation of data, and drafted the manuscript. MO participated in the design of the study, acquisition, analysis and interpretation of data, and helped to draft the manuscript. ACW participated in the analysis and interpretation of data. DA participated in the analysis of data, and helped to draft the manuscript. All authors read and approved the final manuscript.

To the Sociedad Chilena de Ortopedia y Traumatologia for providing the information required to perform this study.