Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough

BACKGROUND

An experimenter controlled form of reflection has been shown to improve the detection and correction of diagnostic errors in some situations; however, the benefits of participant-controlled reflection have not been assessed.

OBJECTIVE

The goal of the current study is to examine how experience and a self-directed decision to reflect affect the accuracy of revised diagnoses.

DESIGN

Medical residents diagnosed 16 medical cases (pass 1). Participants were then given the opportunity to reflect on each case and revise their diagnoses (pass 2).

PARTICIPANTS

Forty-seven medical Residents in post-graduate year (PGY) 1, 2 and 3 were recruited from Hamilton Health Care Centres.

MAIN MEASURES

Diagnoses were scored as 0 (incorrect), 1 (partially correct) and 2 (correct). Accuracies and response times in pass 1 were analyzed using an ANOVA with three factors-PGY, Decision to revise yes/no, and Case 1-16, averaged across residents. The extent to which additional reflection affected accuracy was examined by analyzing only those cases that were revised, using a repeated measures ANOVA, with pass 1 or 2 as a within subject factor, and PGY and Case or Resident as a between-subject factor.

KEY RESULTS

The mean score at pass 1 for each level was PGY1, 1.17 (SE 0.50); PGY2, 1.35 (SE 0.67) and PGY3, 1.27 (SE 0.94). While there was a trend for increased accuracy with level, this did not achieve significance. The number of residents at each level who revised at least one diagnosis was 12/19 PGY1 (63 %), 9/11 PGY2 (82 %) and 8/17 PGY3 (47 %). Only 8 % of diagnoses were revised resulting in a small but significant increase in scores from Pass 1 to 2, from 1.20/2 to 1.22 /2 (t = 2.15, p = 0.03).

CONCLUSIONS

Participants did engage in self-directed reflection for incorrect diagnoses; however, this strategy provided minimal benefits compared to knowing the correct answer. Education strategies should be directed at improving formal and experiential knowledge.

When less is more for the struggling clinical reasoner

Busy clinician-educators are often tasked with remediating medical students who have deficits in clinical reasoning. In this essay, we share our early experience with providing less feedback and more practice to these trainees. We suggest that front line teachers can streamline their feedback to struggling reasoners by focusing solely on the problem representation and prioritized differential diagnosis of the main problem in their oral presentations and then engaging in repeated loops of feedback until the student achieves competency in real time. By receiving feedback targeted to the assessment alone and employing deliberate practice, struggling students have the opportunity to make concrete improvement during short-term clinical assignments. This remediation approach is feasible for busy clinician-educators and warrants formal study.

Dual processing theory and experts' reasoning: exploring thinking on national multiple-choice questions

BACKGROUND

An ongoing debate exists in the medical education literature regarding the potential benefits of pattern recognition (non-analytic reasoning), actively comparing and contrasting diagnostic options (analytic reasoning) or using a combination approach. Studies have not, however, explicitly explored faculty's thought processes while tackling clinical problems through the lens of dual process theory to inform this debate. Further, these thought processes have not been studied in relation to the difficulty of the task or other potential mediating influences such as personal factors and fatigue, which could also be influenced by personal factors such as sleep deprivation. We therefore sought to determine which reasoning process(es) were used with answering clinically oriented multiple-choice questions (MCQs) and if these processes differed based on the dual process theory characteristics: accuracy, reading time and answering time as well as psychometrically determined item difficulty and sleep deprivation.

METHODS

We performed a think-aloud procedure to explore faculty's thought processes while taking these MCQs, coding think-aloud data based on reasoning process (analytic, nonanalytic, guessing or combination of processes) as well as word count, number of stated concepts, reading time, answering time, and accuracy. We also included questions regarding amount of work in the recent past. We then conducted statistical analyses to examine the associations between these measures such as correlations between frequencies of reasoning processes and item accuracy and difficulty. We also observed the total frequencies of different reasoning processes in the situations of getting answers correctly and incorrectly.

RESULTS

Regardless of whether the questions were classified as 'hard' or 'easy', non-analytical reasoning led to the correct answer more often than to an incorrect answer. Significant correlations were found between self-reported recent number of hours worked with think-aloud word count and number of concepts used in the reasoning but not item accuracy. When all MCQs were included, 19 % of the variance of correctness could be explained by the frequency of expression of these three think-aloud processes (analytic, nonanalytic, or combined).

DISCUSSION

We found evidence to support the notion that the difficulty of an item in a test is not a systematic feature of the item itself but is always a result of the interaction between the item and the candidate. Use of analytic reasoning did not appear to improve accuracy. Our data suggest that individuals do not apply either System 1 or System 2 but instead fall along a continuum with some individuals falling at one end of the spectrum.

Diseases, patients and the epistemology of practice: mapping the borders of health, medicine and care

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition.

Developing clinical reasoning in the classroom - analysis of the 4C/ID-model

OBJECTIVES

The purpose of this study is to provide a theoretical rationale for the implementation of the four-component instructional design model for complex learning (4C/ID-model) at the University of Pretoria with the aim of systematically developing the clinical reasoning of undergraduate dental students in a classroom setting.

METHODS

Recent literature provides a rationale for the use of the 4C/ID-model to teach clinical reasoning in terms of four strategic teaching and learning needs: (i) the need for authenticity in the learning process; (ii) the need to manage cognitive load during the learning process; (iii) the need for repeated practice; (iv) a need for valid assessment, feedback and reflection.

RESULTS AND DISCUSSION

The literature review indicated that the 4C/ID-model makes provision for teaching and learning in an authentic context and proposes systematically structured methods that could be practically applied to manage cognitive load during repetitive exercises. The model also makes provision for cognitive feedback following assessment in order to eliminate misconceptions about content and to develop the cognitive strategies of the learner.

CONCLUSIONS

On the basis of the literature review above, it is recommended that the 4C/ID-model be considered as a basis for classroom teaching and learning to develop competence in clinical reasoning in undergraduate dental students, even at pre-clinical level. The model may also have an application in medical education.

Can Medical Diagnosis Benefit from "Unconscious Thought"?

The unconscious thought theory argues that making complex decisions after a period of distraction can lead to better decision quality than deciding either immediately or after conscious deliberation. Two studies have tested this unconscious thought effect (UTE) in clinical diagnosis with conflicting results. The studies used different methodologies and had methodological weaknesses. We attempted to replicate the UTE in medical diagnosis by providing favorable conditions for the effect while maintaining ecological validity. Family physicians (N= 116) diagnosed 3 complex cases in 1 of 3 thinking modes: immediate, unconscious (UT), and conscious (CT). Cases were divided into short sentences, which were presented briefly and sequentially on computer. After each case presentation, the immediate response group gave a diagnosis, the UT group performed a 2-back distraction task for 3 min before giving a diagnosis, and the CT group could take as long as necessary before giving a diagnosis. We found no differences in diagnostic accuracy between groups (P= 0.95). The CT group took a median of 7 s to diagnose, which suggests that physicians were able to diagnose "online," as information was being presented. The lack of a difference between the immediate and UT groups suggests that the distraction had no additional effect on performance. To assess the decisiveness of the evidence of this null result, we computed a Bayes factor (BF01) for the 2 comparisons of interest. We found a BF01of 5.76 for the UT versus immediate comparison and of 3.61 for the UT versus CT comparison. Both BFs provide substantial evidence in favor of the null hypothesis: physicians' diagnoses made after distraction are no better than diagnoses made either immediately or after self-paced deliberation.

The professional socialization of the graduate assistant athletic trainer

CONTEXT

The graduate assistant athletic trainer (AT) position often serves as one's first experience working independently as an AT and is also an important aspect of the professional socialization process. The socialization experiences of graduate assistant ATs have yet to be fully explored.

OBJECTIVE

To understand the socialization process for graduate assistant ATs during their graduate experience.

DESIGN

Qualitative study.

SETTING

We conducted phone interviews with all participants.

PATIENTS OR OTHER PARTICIPANTS

A total of 25 graduate assistant ATs (20 women, 5 men) studying in 1 of 3 academic tracks: (1) accredited postprofessional athletic training program (n = 8), (2) postprofessional athletic training program (n = 11), or (3) a nonathletic training degree program (n = 6). The average age was 25 ± 5 years, and the median age was 24 years. Participants were certified by the Board of Certification for an average of 2 ± 0.4 years.

DATA COLLECTION AND ANALYSIS

We analyzed the data using a general inductive approach. Peer review, field notes, and intercoder reliability established trustworthiness. Data saturation guided participant recruitment.

RESULTS

The ability to gain clinical independence as a practitioner was an important socialization process. Having the chance to develop a relationship with a mentor, who provided support, guidance, and more of a hierarchical relationship, was an important socializing agent for the graduate assistant AT. Participants used the orientation session as a means to understand the expectations and role of the graduate-assistant position. Academic coursework was a way to achieve better inductance into the role via the opportunity to apply classroom skills during their clinical practice.

CONCLUSIONS

Socializing the graduate assistant blends formal and informal processes. Transition to practice is a critical aspect of the profession; thus, supporting autonomous practice with directed mentoring can promote professional maturity.

Example-based learning: comparing the effects of additionally providing three different integrative learning activities on physiotherapy intervention knowledge

BACKGROUND

Example-based learning using worked examples can foster clinical reasoning. Worked examples are instructional tools that learners can use to study the steps needed to solve a problem. Studying worked examples paired with completion examples promotes acquisition of problem-solving skills more than studying worked examples alone. Completion examples are worked examples in which some of the solution steps remain unsolved for learners to complete. Providing learners engaged in example-based learning with self-explanation prompts has been shown to foster increased meaningful learning compared to providing no self-explanation prompts. Concept mapping and concept map study are other instructional activities known to promote meaningful learning. This study compares the effects of self-explaining, completing a concept map and studying a concept map on conceptual knowledge and problem-solving skills among novice learners engaged in example-based learning.

METHODS

Ninety-one physiotherapy students were randomized into three conditions. They performed a pre-test and a post-test to evaluate their gains in conceptual knowledge and problem-solving skills (transfer performance) in intervention selection. They studied three pairs of worked/completion examples in a digital learning environment. Worked examples consisted of a written reasoning process for selecting an optimal physiotherapy intervention for a patient. The completion examples were partially worked out, with the last few problem-solving steps left blank for students to complete. The students then had to engage in additional self-explanation, concept map completion or model concept map study in order to synthesize and deepen their knowledge of the key concepts and problem-solving steps.

RESULTS

Pre-test performance did not differ among conditions. Post-test conceptual knowledge was higher (P < .001) in the concept map study condition (68.8 ± 21.8%) compared to the concept map completion (52.8 ± 17.0%) and self-explanation (52.2 ± 21.7%) conditions. Post-test problem-solving performance was higher (P < .05) in the self-explanation (63.2 ± 16.0%) condition compared to the concept map study (53.3 ± 16.4%) and concept map completion (51.0 ± 13.6%) conditions. Students in the self-explanation condition also invested less mental effort in the post-test.

CONCLUSIONS

Studying model concept maps led to greater conceptual knowledge, whereas self-explanation led to higher transfer performance. Self-explanation and concept map study can be combined with worked example and completion example strategies to foster intervention selection.

Influence of predicting the diagnosis from history on the accuracy of physical examination

BACKGROUND

This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information.

METHODS

The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction.

RESULTS

For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P<0.001).

CONCLUSION

Obtaining a history alone does not improve the diagnostic accuracy of physical examination. However, accurately predicting the diagnosis from the history is associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination.

Integration of clinical and basic sciences in concept maps: a mixed-method study on teacher learning

BACKGROUND

The explication of relations between clinical and basic sciences can help vertical integration in medical curricula. Concept mapping might be a useful technique for this explication. Little is known about teachers' ability regarding the articulation of integration. We examined therefore which factors affect the learning of groups of clinicians and basic scientists on different expertise levels who learn to articulate the integration of clinical and basic sciences in concept maps.

METHODS

After a pilot for fine-tuning group size and instructions, seven groups of expert clinicians and basic scientists and seven groups of residents with a similar disciplinary composition constructed concept maps about a clinical problem that fit their specializations. Draft and final concepts maps were compared on elaborateness and articulated integration by means of t-tests. Participants completed a questionnaire on motivation and their evaluation of the instructions. ANOVA's were run to compare experts' and residents' views. Data from video tapes and notes were qualitatively analyzed. Finally, the three data sources were interpreted in coherence by using Pearson's correlations and qualitative interpretation.

RESULTS

Residents outshone experts as regards learning to articulate integration as comparison of the draft and final versions showed. Experts were more motivated and positive about the concept mapping procedure and instructions, but this did not correlate with the extent of integration fond in the concept maps. The groups differed as to communication: residents interacted from the start (asking each other for clarification), whereas overall experts only started interaction when they had to make joint decisions.

CONCLUSIONS

Our results suggest that articulation of integration can be learned, but this learning is not related to participants' motivation or their views on the instructions. Decision making and interaction, however, do relate to the articulation of integration and this suggests that teacher learning programs for designing integrated educational programmes should incorporate co-construction tasks. Expertise level turned out to be decisive for both the level of articulation of integration, the ability to improve the articulated integration and the cooperation pattern.

The IDEA Assessment Tool: Assessing the Reporting, Diagnostic Reasoning, and Decision-Making Skills Demonstrated in Medical Students' Hospital Admission Notes

Construct: Clinical skills are used in the care of patients, including reporting, diagnostic reasoning, and decision-making skills. Written comprehensive new patient admission notes (H&Ps) are a ubiquitous part of student education but are underutilized in the assessment of clinical skills. The interpretive summary, differential diagnosis, explanation of reasoning, and alternatives (IDEA) assessment tool was developed to assess students' clinical skills using written comprehensive new patient admission notes.

BACKGROUND

The validity evidence for assessment of clinical skills using clinical documentation following authentic patient encounters has not been well documented. Diagnostic justification tools and postencounter notes are described in the literature (1,2) but are based on standardized patient encounters. To our knowledge, the IDEA assessment tool is the first published tool that uses medical students' H&Ps to rate students' clinical skills.

APPROACH

The IDEA assessment tool is a 15-item instrument that asks evaluators to rate students' reporting, diagnostic reasoning, and decision-making skills based on medical students' new patient admission notes. This study presents validity evidence in support of the IDEA assessment tool using Messick's unified framework, including content (theoretical framework), response process (interrater reliability), internal structure (factor analysis and internal-consistency reliability), and relationship to other variables.

RESULTS

Validity evidence is based on results from four studies conducted between 2010 and 2013. First, the factor analysis (2010, n = 216) yielded a three-factor solution, measuring patient story, IDEA, and completeness, with reliabilities of .79, .88, and .79, respectively. Second, an initial interrater reliability study (2010) involving two raters demonstrated fair to moderate consensus (κ = .21-.56, ρ =.42-.79). Third, a second interrater reliability study (2011) with 22 trained raters also demonstrated fair to moderate agreement (intraclass correlations [ICCs] = .29-.67). There was moderate reliability for all three skill domains, including reporting skills (ICC = .53), diagnostic reasoning skills (ICC = .64), and decision-making skills (ICC = .63). Fourth, there was a significant correlation between IDEA rating scores (2010-2013) and final Internal Medicine clerkship grades (r = .24), 95% confidence interval (CI) [.15, .33].

CONCLUSIONS

The IDEA assessment tool is a novel tool with validity evidence to support its use in the assessment of students' reporting, diagnostic reasoning, and decision-making skills. The moderate reliability achieved supports formative or lower stakes summative uses rather than high-stakes summative judgments.

Considering "Nonlinearity" Across the Continuum in Medical Education Assessment: Supporting Theory, Practice, and Future Research Directions

The purpose of this article is to propose new approaches to assessment that are grounded in educational theory and the concept of "nonlinearity." The new approaches take into account related phenomena such as "uncertainty," "ambiguity," and "chaos." To illustrate these approaches, we will use the example of assessment of clinical reasoning, although the principles we outline may apply equally well to assessment of other constructs in medical education. Theoretical perspectives include a discussion of script theory, assimilation theory, self-regulated learning theory, and situated cognition. Assessment examples to include script concordance testing, concept maps, self-regulated learning microanalytic technique, and work-based assessment, which parallel the above-stated theories, respectively, are also highlighted. We conclude with some practical suggestions for approaching nonlinearity.

Students' perceptions of the Script Concordance Test and its impact on their learning behavior: a mixed methods study

The Script Concordance Test (SCT) is increasingly used in postgraduate and undergraduate education as a method of summative clinical assessment. It has been shown to have high validity and reliability but there is little evidence of its use in veterinary education as assessment for learning. This study investigates some students' perceptions of the SCT and its effects on their approaches to learning. Final-year undergraduates of the School of Veterinary Medicine and Science (SVMS) at the University of Nottingham participated in a mixed-methods study after completing three formative SCT assessments. A qualitative, thematic analysis was produced from transcripts of three focus group discussions. The quantitative study was a survey based on the analyses of the qualitative study. Out of 50 students who registered for the study, 18 participated in the focus groups and 28 completed the survey. Clinical experience was regarded as the most useful source of information for answering the SCT. The students also indicated that recall of facts was perceived as useful for multiple-choice questions but least useful for the SCT. Themes identified in the qualitative study related to reliability, acceptability, educational impact, and validity of the SCT. The evidence from this study shows that the SCT has high face validity among veterinary students. They reported that it encouraged them to reflect upon their clinical experience, to participate in discussions of case material, and to adopt a deeper approach to clinical learning. These findings strongly suggest that the SCT is potentially a valuable method for assessing clinical reasoning and enhancing student learning.

Evaluating the guideline enhancement tool (GET): an innovative clinical training tool to enhance the use of hypertension guidelines in general practice

BACKGROUND

This project aims to evaluate the effectiveness of an innovative educational intervention in enhancing clinical decision making related to the management of hypertension in general practice. The relatively low level of uptake of clinical practice guidelines by clinicians is widely recognised as a problem that impacts on clinical outcomes. This project addresses this problem with a focus on hypertension guidelines. Hypertension is the most frequently managed problem in general practice but evidence suggests that management of Hypertension in general practice is sub-optimal.

METHODS/DESIGN

This study will explore the effectiveness of an educational intervention named the 'Guideline Enhancement Tool (GET)'. The intervention is designed to guide clinicians through a systematic process of considering key decision points related to the management of hypertension and provides a mechanism for clinicians to engage with the hypertension clinical guidelines. The intervention will be administered within the Australian General Practice Training program, via one of the regional training providers. Two cohorts of trainees will participate as the intervention and delayed intervention groups. This process is expected to improve clinicians' engagement with the hypertension guidelines in particular, and enhance their clinical reasoning abilities in general. The effectiveness of the intervention in improving clinical reasoning will be evaluated using the 'Script Concordance Test'.

DISCUSSION

The study design presented in this protocol aims to achieve two major outcomes. Firstly, the trial and evaluation of the educational intervention can lead to the development of a validated clinical education strategy that can be used in GP training to enhance the decision-making processes related to the management of hypertension. This has the potential to be adapted to other clinical conditions and training programs and can benefit clinicians in their clinical decision-making. Secondly, the study explores features that influence the effective use of clinical practice guidelines. The study thus addresses a significant problem in clinical education.

Improving the learning of clinical reasoning through computer-based cognitive representation

OBJECTIVE

Clinical reasoning is usually taught using a problem-solving approach, which is widely adopted in medical education. However, learning through problem solving is difficult as a result of the contextualization and dynamic aspects of actual problems. Moreover, knowledge acquired from problem-solving practice tends to be inert and fragmented. This study proposed a computer-based cognitive representation approach that externalizes and facilitates the complex processes in learning clinical reasoning. The approach is operationalized in a computer-based cognitive representation tool that involves argument mapping to externalize the problem-solving process and concept mapping to reveal the knowledge constructed from the problems.

METHODS

Twenty-nine Year 3 or higher students from a medical school in east China participated in the study. Participants used the proposed approach implemented in an e-learning system to complete four learning cases in 4 weeks on an individual basis. For each case, students interacted with the problem to capture critical data, generate and justify hypotheses, make a diagnosis, recall relevant knowledge, and update their conceptual understanding of the problem domain. Meanwhile, students used the computer-based cognitive representation tool to articulate and represent the key elements and their interactions in the learning process.

RESULTS

A significant improvement was found in students' learning products from the beginning to the end of the study, consistent with students' report of close-to-moderate progress in developing problem-solving and knowledge-construction abilities. No significant differences were found between the pretest and posttest scores with the 4-week period. The cognitive representation approach was found to provide more formative assessment.

CONCLUSIONS

The computer-based cognitive representation approach improved the learning of clinical reasoning in both problem solving and knowledge construction.

Methods and outcomes for the remediation of clinical reasoning

INTRODUCTION

There is no widely accepted structured, evidence based strategy for the remediation of clinical reasoning skills.

AIM

To assess the effectiveness of a standardized clinical reasoning remediation plan for medical learners at various stages of training.

SETTING

Learners enrolled in the University of Colorado School of Medicine Remediation Program.

PROGRAM DESCRIPTION

From 2006 to 2012, the learner remediation program received 151 referrals. Referrals were made by medical student clerkship directors, residency and fellowship program directors, and through self-referrals. Each learner's deficiencies were identified using a standardized assessment process; 53 were noted to have clinical reasoning deficits. The authors developed and implemented a ten-step clinical reasoning remediation plan for each of these individuals, whose subsequent performance was independently assessed by unbiased faculty and senior trainees. Participant demographics, faculty time invested, and learner outcomes were tracked.

PROGRAM EVALUATION

Prevalence of clinical reasoning deficits did not differ by level of training of the remediating individual (p = 0.49). Overall, the mean amount of faculty time required for remediation was 29.6 h (SD = 29.3), with a median of 18 h (IQR 5-39) and a range of 2-100 h. Fifty-one of the 53 (96%) passed the post remediation reassessment. Thirty-eight (72%) learners either graduated from their original program or continue to practice in good standing. Four (8%) additional residents who were placed on probation and five (9%) who transferred to another program have since graduated.

DISCUSSION

The ten-step remediation plan proved to be successful for the majority of learners struggling with clinical reasoning based on reassessment and limited subsequent educational outcomes. Next steps include implementing the program at other institutions to assess generalizability and tracking long-term outcomes on clinical care.

Midshaft humeral fracture following a proximal humeral fracture: a case report

BACKGROUND AND PURPOSE

Proximal humeral fractures are relatively uncommon injuries. While previous research has led to effective clinical and diagnostic evaluation and treatment of proximal fractures, less is currently known regarding the typical evaluation and treatment of midshaft humeral fractures. The purpose of this case is to describe the clinical reasoning and utilization of diagnostic imaging in the physical therapy management of a midshaft humeral fracture, sustained during the course of rehabilitation of a proximal humerus fracture.

CASE DESCRIPTION

A 63-year-old female recreational tennis player presented to physical therapy, progressing well following a proximal humeral fracture, sustained 18 weeks prior. During the course of care, the patient had a significant regression in range of motion and function, with increased pain, following a seemingly trivial injury. Based on a cluster of subjective and objective flags, the therapist was concerned about a new fracture. The therapist communicated findings with a physician and recommended plain film radiographs before continuing therapy.

OUTCOMES

Radiographs showed an oblique displaced fracture extending through the midshaft of the humerus. The patient ultimately underwent surgical plating. At one-year post injury e-mail follow up, she had functional mobility of her left arm, and was playing tennis recreationally three times a week.

DISCUSSION

In this case, a patient who was progressing well following a proximal humeral fracture sustained a separate displaced fracture of the midshaft of the humerus, not associated with therapy. Her reported mechanism was not consistent with a typical injury. This highlights the need for clinicians, specifically physical therapists, to cluster subjective information, objective data, and the patient's medical history when interpreting patient appropriateness for therapy, and to optimize outcomes.

LEVEL OF EVIDENCE

5 (single case report).

Pattern recognition as a concept for multiple-choice questions in a national licensing exam

BACKGROUND

Multiple-choice questions (MCQ) are still widely used in high stakes medical exams. We wanted to examine whether and to what extent a national licensing exam uses the concept of pattern recognition to test applied clinical knowledge.

METHODS

We categorized all 4,134 German National medical licensing exam questions between October 2006 and October 2012 by discipline, year, and type. We analyzed questions from the four largest disciplines: internal medicine (n = 931), neurology (n = 305), pediatrics (n = 281), and surgery (n = 233), with respect to the following question types: knowledge questions (KQ), pattern recognition questions (PRQ), inverse PRQ (IPRQ), and pseudo PRQ (PPRQ).

RESULTS

A total 51.1% of all questions were of a higher taxonomical order (PRQ and IPRQ) with a significant decrease in the percentage of these questions (p <0.001) from 2006 (61.5%) to 2012 (41.6%). The proportion of PRQs and IPRQs was significantly lower (p <0.001) in internal medicine and surgery, compared to neurology and pediatrics. PRQs were mostly used in questions about diagnoses (71.7%). A significantly higher (p <0.05) percentage of PR/therapy questions was found for internal medicine compared with neurology and pediatrics.

CONCLUSION

The concept of pattern recognition is used with different priorities and to various extents by the different disciplines in a high stakes exam to test applied clinical knowledge. Being aware of this concept may aid in the design and balance of MCQs in an exam with respect to testing clinical reasoning as a desired skill at the threshold of postgraduate medical education.

The effect of work-based mentoring on patient outcome in musculoskeletal physiotherapy: study protocol for a randomised controlled trial

BACKGROUND

Despite persistent calls to measure the effectiveness of educational interventions on patient outcomes, few studies have been conducted. Within musculoskeletal physiotherapy, the effects of postgraduate clinical mentoring on physiotherapist performance have been assessed, but the impact of this mentoring on patient outcomes remains unknown. The objective of this trial is to assess the effectiveness of a work-based mentoring programme to facilitate physiotherapist clinical reasoning on patient outcomes in musculoskeletal physiotherapy.

METHODS/DESIGN

A stepped wedge cluster randomised controlled trial (CRCT) has been designed to recruit a minimum of 12 senior physiotherapists who work in musculoskeletal outpatient departments of a large National Health Service (NHS) organization. Participating physiotherapists will be randomised by cluster to receive the intervention at three time periods. Patients will be blinded to whether their physiotherapist has received the intervention. The primary outcome measure will be the Patient-Specific Functional Scale; secondary outcome measures will include the EQ-5D, patient activation, patient satisfaction and physiotherapist performance. Sample size considerations used published methods describing stepped wedge designs, conventional values of 0.80 for statistical power and 0.05 for statistical significance, and pragmatic groupings of 12 participating physiotherapists in three clusters. Based on an intergroup difference of 1.0 on the PSFS with a standard deviation of 2.0, 10 patients are required to complete outcome measures per physiotherapist, at time period 1 (prior to intervention roll-out) and at each of time periods 2, 3 and 4, giving a sample size of 480 patients. To account for the potential loss to follow-up of 33%, 720 sets of patient outcomes will be collected.All physiotherapist participants will receive 150 hours of mentored clinical practice as the intervention and usual in-service training as control. Consecutive, consenting patients attending treatment by the participating physiotherapists during data collection periods will complete outcome measures at baseline, discharge and 12 months post-baseline. The lead researcher will be blinded to the allocation of the physiotherapist when analyzing outcome data; statistical analysis will involve classical linear models incorporating both an intervention effect and a random intercept term to reflect systematic differences among clusters.

TRIAL REGISTRATION

Assigned 31 July 2012: ISRCTN79599220.

Dental and dental hygiene students' diagnostic accuracy in oral radiology: effect of diagnostic strategy and instructional method

There has been much debate surrounding diagnostic strategies and the most appropriate training models for novices in oral radiology. It has been argued that an analytic approach, using a step-by-step analysis of the radiographic features of an abnormality, is ideal. Alternative research suggests that novices can successfully employ non-analytic reasoning. Many of these studies do not take instructional methodology into account. This study evaluated the effectiveness of non-analytic and analytic strategies in radiographic interpretation and explored the relationship between instructional methodology and diagnostic strategy. Second-year dental and dental hygiene students were taught four radiographic abnormalities using basic science instructions or a step-by-step algorithm. The students were tested on diagnostic accuracy and memory immediately after learning and one week later. A total of seventy-three students completed both immediate and delayed sessions and were included in the analysis. Students were randomly divided into two instructional conditions: one group provided a diagnostic hypothesis for the image and then identified specific features to support it, while the other group first identified features and then provided a diagnosis. Participants in the diagnosis-first condition (non-analytic reasoning) had higher diagnostic accuracy then those in the features-first condition (analytic reasoning), regardless of their learning condition. No main effect of learning condition or interaction with diagnostic strategy was observed. Educators should be mindful of the potential influence of analytic and non-analytic approaches on the effectiveness of the instructional method.

Heuristics in Managing Complex Clinical Decision Tasks in Experts' Decision Making

BACKGROUND

Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts.

OBJECTIVE

The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks.

METHOD

After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed.

RESULTS

We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb.

CONCLUSION

Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information.

APPLICATION

Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design.