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Flemming DJ, White C, Fox E, Fanburg-Smith J, Cochran E. Diagnostic errors in musculoskeletal oncology and possible mitigation strategies. Skeletal Radiol 2023; 52:493-503. [PMID: 36048252 DOI: 10.1007/s00256-022-04166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/04/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
The objective of this paper is to explore sources of diagnostic error in musculoskeletal oncology and potential strategies for mitigating them using case examples. As musculoskeletal tumors are often obvious, the diagnostic errors in musculoskeletal oncology are frequently cognitive. In our experience, the most encountered cognitive biases in musculoskeletal oncologic imaging are as follows: (1) anchoring bias, (2) premature closure, (3) hindsight bias, (4) availability bias, and (5) alliterative bias. Anchoring bias results from failing to adjust an early impression despite receiving additional contrary information. Premature closure is the cognitive equivalent of "satisfaction of search." Hindsight bias occurs when we retrospectively overestimate the likelihood of correctly interpreting the examination prospectively. In availability bias, the radiologist judges the probability of a diagnosis based on which diagnosis is most easily recalled. Finally, alliterative bias occurs when a prior radiologist's impression overly influences the diagnostic thinking of another radiologist on a subsequent exam. In addition to cognitive biases, it is also important for radiologists to acknowledge their feelings when making a diagnosis to recognize positive and negative impact of affect on decision making. While errors decrease with radiologist experience, the lack of application of medical knowledge is often the primary source of error rather than a deficiency of knowledge, emphasizing the need to foster clinical reasoning skills and assist cognition. Possible solutions for reducing error exist at both the individual and the system level and include (1) improvement in knowledge and experience, (2) improvement in clinical reasoning and decision-making skills, and (3) improvement in assisting cognition.
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Affiliation(s)
- Donald J Flemming
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, 500 University Drive H066, Hershey, PA, 17033, USA.
| | - Carissa White
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, 500 University Drive H066, Hershey, PA, 17033, USA
| | - Edward Fox
- Department of Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Julie Fanburg-Smith
- Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Eric Cochran
- Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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Olson APJ, Zwaan L, Rencic J. The Oral Case Presentation. J Gen Intern Med 2023; 38:1076. [PMID: 35469361 PMCID: PMC10039120 DOI: 10.1007/s11606-022-07611-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Andrew P J Olson
- Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Laura Zwaan
- Erasmus MC, Institute of Medical Education Research Rotterdam (iMERR), Rotterdam, The Netherlands
| | - Joseph Rencic
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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53
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Salava A. Metacognition in teaching dermatology-Role of the dual process model. J Eur Acad Dermatol Venereol 2023. [PMID: 36799725 DOI: 10.1111/jdv.18974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/15/2023] [Indexed: 02/18/2023]
Affiliation(s)
- A Salava
- Department of Dermatology, Venereology and Allergology, University Hospital Helsinki and University of Helsinki, Helsinki, Finland
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Harendza S, Bacher HJ, Berberat PO, Kadmon M, Gärtner J. Implicit expression of uncertainty in medical students during different sequences of clinical reasoning in simulated patient handovers. GMS JOURNAL FOR MEDICAL EDUCATION 2023; 40:Doc7. [PMID: 36923315 PMCID: PMC10010770 DOI: 10.3205/zma001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 08/19/2022] [Accepted: 11/23/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Dealing with medical uncertainty is an essential competence of physicians. During handovers, communication of uncertainty is important for patient safety, but is often not explicitly expressed and can hamper medical decisions. This study examines medical students' implicit expression of uncertainty in different sequences of clinical reasoning during simulated patient handovers. METHODS In 2018, eighty-seven final-year medical students participated in handovers of three simulated patient cases, which were videotaped and transcribed verbatim. Sequences of clinical reasoning and language references to implicit uncertainty that attenuate and strengthen information based on a framework were identified, categorized, and analyzed with chi-square goodness-of-fit tests. RESULTS A total of 6358 sequences of clinical reasoning were associated with the four main categories "statement", "assessment", "consideration", and "implication", with statements occurring significantly (p<0.001) most frequently. Attenuated sequences of clinical reasoning occurred significantly (p<0.003) more frequently than strengthened sequences. Implications were significantly more often attenuated than strengthened (p<0.003). Statements regarding results occurred significantly more often plain or strengthened than statements regarding actions (p<0.0025). CONCLUSION Implicit expressions of uncertainty in simulated medical students' handovers occur in different degrees during clinical reasoning. These findings could contribute to courses on clinical case presentations by including linguistic terms and implicit expressions of uncertainty and making them explicit.
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Affiliation(s)
- Sigrid Harendza
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Hans Jakob Bacher
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Pascal O. Berberat
- Technische Universität München, Fakultät für Medizin, TUM Medical Education Center, München, Germany
| | - Martina Kadmon
- Universität Augsburg, Medizinische Fakultät, Dekanat, Augsburg, Germany
| | - Julia Gärtner
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
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Lukama L, Aldous C, Michelo C, Kalinda C. Ear, Nose and Throat (ENT) disease diagnostic error in low-resource health care: Observations from a hospital-based cross-sectional study. PLoS One 2023; 18:e0281686. [PMID: 36758061 PMCID: PMC9910637 DOI: 10.1371/journal.pone.0281686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/28/2023] [Indexed: 02/10/2023] Open
Abstract
Although the global burden of ear, nose and throat (ENT) diseases is high, data relating to ENT disease epidemiology and diagnostic error in resource-limited settings remain scarce. We conducted a retrospective cross-sectional review of ENT patients' clinical records at a resource-limited tertiary hospital. We determined the diagnostic accuracy and appropriateness of patient referrals for ENT specialist care using descriptive statistics. Cohens kappa coefficient (κ) was calculated to determine the diagnostic agreement between non-ENT clinicians and the ENT specialist, and logistic regression applied to establish the likelihood of patient misdiagnosis by non-ENT clinicians. Of the 1543 patients studied [age 0-87 years, mean age 25(21) years (mean(SD)], non-ENT clinicians misdiagnosed 67.4% and inappropriately referred 50.4%. Compared to those aged 0-5 years, patients aged 51-87 years were 1.77 (95%CI: 1.03-3.04) fold more likely to have a referral misdiagnosis for specialist care. Patients with ear (aOR: 1.63; 95% CI: 1.14-2.33) and those with sinonasal diseases (aOR: 1.80; 95% CI: 1.14-2.45) had greater likelihood of referral misdiagnosis than those with head and neck diseases. Agreement in diagnosis between the ENT specialist and non-ENT clinicians was poor (κ = 0.0001). More effective, accelerated training of clinicians may improve diagnostic accuracy in low-resource settings.
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Affiliation(s)
- Lufunda Lukama
- Department of Otorhinolaryngology, Head and Neck Surgery, Ndola Teaching Hospital, Ndola, Zambia
- College of Health Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- * E-mail:
| | - Colleen Aldous
- College of Health Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Charles Michelo
- School of Public Health, Department of Epidemiology, Harvest University, Lusaka, Zambia
- Strategic Centre for Health Systems Metrics & Evaluations (SCHEME), School of Public Health, University of Zambia, Lusaka, Zambia
| | - Chester Kalinda
- Bill and Joyce Cummings Institute of Global Health, University of Global Health Equity, Kigali, Rwanda
- Howard College Campus, College of Health Sciences, School of Public Health and Nursing, University of KwaZulu-Natal, Durban, South Africa
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Diagnostic Delays in Sepsis: Lessons Learned From a Retrospective Study of Canadian Medico-Legal Claims. Crit Care Explor 2023; 5:e0841. [PMID: 36751515 PMCID: PMC9894347 DOI: 10.1097/cce.0000000000000841] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Although rapid treatment improves outcomes for patients presenting with sepsis, early detection can be difficult, especially in otherwise healthy adults. OBJECTIVES Using medico-legal data, we aimed to identify areas of focus to assist with early recognition of sepsis. DESIGN SETTING AND PARTICIPANTS Retrospective descriptive design. We analyzed closed medico-legal cases involving physicians from a national database repository at the Canadian Medical Protective Association. The study included cases closed between 2011 and 2020 that had documented peer expert criticism of a diagnostic issue related to sepsis or relevant infections. MAIN OUTCOMES AND MEASURES We used univariate statistics to describe patients and physicians and applied published frameworks to classify contributing factors (provider, team, system) and diagnostic pitfalls based on peer expert criticisms. RESULTS Of 162 involved patients, the median age was 53 years (interquartile range [IQR], 34-66 yr) and mortality was 49%. Of 218 implicated physicians, 169 (78%) were from family medicine, emergency medicine, or surgical specialties. Eighty patients (49%) made multiple visits to outpatient care leading up to sepsis recognition/hospitalization (median = two visits; IQR, 2-4). Almost 40% of patients were admitted to the ICU. Deficient assessments, such as failing to consider sepsis or not reassessing the patient prior to discharge, contributed to the majority of cases (81%). CONCLUSIONS AND RELEVANCE Sepsis continues to be a challenging diagnosis for clinicians. Multiple visits to outpatient care may be an early warning sign requiring vigilance in the patient assessment.
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Clayton DA, Eguchi MM, Kerr KF, Miyoshi K, Brunyé TT, Drew T, Weaver DL, Elmore JG. Are Pathologists Self-Aware of Their Diagnostic Accuracy? Metacognition and the Diagnostic Process in Pathology. Med Decis Making 2023; 43:164-174. [PMID: 36124966 PMCID: PMC9825636 DOI: 10.1177/0272989x221126528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Metacognition is a cognitive process that involves self-awareness of thinking, understanding, and performance. This study assesses pathologists' metacognition by examining the association between their diagnostic accuracy and self-reported confidence levels while interpreting skin and breast biopsies. DESIGN We studied 187 pathologists from the Melanoma Pathology Study (M-Path) and 115 pathologists from the Breast Pathology Study (B-Path). We measured pathologists' metacognitive ability by examining the area under the curve (AUC), the area under each pathologist's receiver operating characteristic (ROC) curve summarizing the association between confidence and diagnostic accuracy. We investigated possible relationships between this AUC measure, referred to as metacognitive sensitivity, and pathologist attributes. We also assessed whether higher metacognitive sensitivity affected the association between diagnostic accuracy and a secondary diagnostic action such as requesting a second opinion. RESULTS We found no significant associations between pathologist clinical attributes and metacognitive AUC. However, we found that pathologists with higher AUC showed a stronger trend to request secondary diagnostic action for inaccurate diagnoses and not for accurate diagnoses compared with pathologists with lower AUC. LIMITATIONS Pathologists reported confidence in specific diagnostic terms, rather than the broader classes into which the diagnostic terms were later grouped to determine accuracy. In addition, while there is no gold standard for the correct diagnosis to determine the accuracy of pathologists' interpretations, our studies achieved a high-quality reference diagnosis by using the consensus diagnosis of 3 experienced pathologists. CONCLUSIONS Metacognition can affect clinical decisions. If pathologists have self-awareness that their diagnosis may be inaccurate, they can request additional tests or second opinions, providing the opportunity to correct inaccurate diagnoses. HIGHLIGHTS Metacognitive sensitivity varied across pathologists, with most showing higher sensitivity than expected by chance.None of the demographic or clinical characteristics we examined was significantly associated with metacognitive sensitivity.Pathologists with higher metacognitive sensitivity were more likely to request additional tests or second opinions for their inaccurate diagnoses.
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Affiliation(s)
- Dayna A. Clayton
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Megan M. Eguchi
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Kathleen F. Kerr
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Kiyofumi Miyoshi
- Department of Psychology, University of California, Los Angeles, CA, United States of America
| | - Tad T. Brunyé
- Center for Applied Brain and Cognitive Sciences, Tufts University, Medford, MA, United States of America
| | - Trafton Drew
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America
| | - Donald L. Weaver
- Department of Pathology & Laboratory Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
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Gamborg ML, Mehlsen M, Paltved C, Vetter SS, Musaeus P. Clinical decision-making and adaptive expertise in residency: a think-aloud study. BMC MEDICAL EDUCATION 2023; 23:22. [PMID: 36635669 PMCID: PMC9835279 DOI: 10.1186/s12909-022-03990-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.
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Affiliation(s)
- Maria Louise Gamborg
- Centre for Educational Development, Aarhus University, Aarhus C, Denmark.
- Coporate HR MidtSim & Department of Clinical Medicine, Faculty of Health, Aarhus University, Central Denmark Region, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark.
| | - Mimi Mehlsen
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Bartholins Allé 11, 8000, Aarhus C, Denmark
| | - Charlotte Paltved
- Coporate HR MidtSim & Department of Clinical Medicine, Faculty of Health, Aarhus University, Central Denmark Region, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark
| | - Sigrid Strunge Vetter
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Bartholins Allé 11, 8000, Aarhus C, Denmark
| | - Peter Musaeus
- Centre for Educational Development, Aarhus University, Aarhus C, Denmark
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Del Campo Rivas MN, Silva-Ríos AP. Prueba de concordancia de guiones para entrenar el razonamiento clínico en estudiantes de fonoaudiología. REVISTA DE INVESTIGACIÓN EN LOGOPEDIA 2023. [DOI: 10.5209/rlog.80748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
La prueba de concordancia de guiones (PCG) ha sido utilizada en el entrenamiento y evaluación del razonamiento clínico (RC) como una estrategia innovadora en la formación de profesionales. Sin embargo, no se dispone de evidencia de su aplicación en el pregrado de fonoaudiología. El objetivo de esta investigación fue analizar el desempeño y la percepción de estudiantes de fonoaudiología con respecto al uso de scripts. Se diseñó un piloto pre-experimental y multicéntrico, complementado con tres grupos focales. Las variables cuantitativas continuas fueron resumidas a través de medias y desviación estándar. La comparación entre grupos se ejecutó con Anova one way y la prueba post hoc de Bonferroni, considerando un nivel de significancia p<.05. La fase cualitativa incorporó un análisis de contenido mediante la codificación abierta de textos y la identificación e interpretación de familias de significado emergentes. El rendimiento promedio de los estudiantes fue de 4.03 (DS= 0.35), observándose un incremento en el rendimiento de RC durante el semestre (p= 0.03). La percepción de los estudiantes resulto positiva y se identificó cuatro familias de significado relacionadas con: razonamiento clínico, oportunidades de mejora implementación de la estrategia y retroalimentación docente. A modo de conclusión, la incorporación de scripts en estudiantes de pregrado de fonoaudiología es factible, incrementa el rendimiento y apoya el desarrollo del RC.
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Mantri P, Subramonyam H, Michal AL, Xiong C. How Do Viewers Synthesize Conflicting Information from Data Visualizations? IEEE TRANSACTIONS ON VISUALIZATION AND COMPUTER GRAPHICS 2023; 29:1005-1015. [PMID: 36166526 DOI: 10.1109/tvcg.2022.3209467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Scientific knowledge develops through cumulative discoveries that build on, contradict, contextualize, or correct prior findings. Scientists and journalists often communicate these incremental findings to lay people through visualizations and text (e.g., the positive and negative effects of caffeine intake). Consequently, readers need to integrate diverse and contrasting evidence from multiple sources to form opinions or make decisions. However, the underlying mechanism for synthesizing information from multiple visualizations remains under-explored. To address this knowledge gap, we conducted a series of four experiments ( N=1166) in which participants synthesized empirical evidence from a pair of line charts presented sequentially. In Experiment 1, we administered a baseline condition with charts depicting no specific context where participants held no strong belief. To test for the generalizability, we introduced real-world scenarios to our visualizations in Experiment 2 and added accompanying text descriptions similar to online news articles or blog posts in Experiment 3. In all three experiments, we varied the relative direction and magnitude of line slopes within the chart pairs. We found that participants tended to weigh the positive slope more when the two charts depicted relationships in the opposite direction (e.g., one positive slope and one negative slope). Participants tended to weigh the less steep slope more when the two charts depicted relationships in the same direction (e.g., both positive). Through these experiments, we characterize participants' synthesis behaviors depending on the relationship between the information they viewed, contribute to theories describing underlying cognitive mechanisms in information synthesis, and describe design implications for data storytelling.
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Mamede S, Schmidt HG. Deliberate reflection and clinical reasoning: Founding ideas and empirical findings. MEDICAL EDUCATION 2023; 57:76-85. [PMID: 35771936 PMCID: PMC10083910 DOI: 10.1111/medu.14863] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/15/2022] [Accepted: 06/26/2022] [Indexed: 06/15/2023]
Abstract
CONTEXT The idea that reflection improves reasoning and learning, since long present in other fields, emerged in the 90s in the medical education literature. Since then, the number of publications on reflection as a means to improve diagnostic learning and clinical problem-solving has increased steeply. Recently, concerns with diagnostic errors have raised further interest in reflection. Several approaches based on reflection have been proposed to reduce clinicians' errors during diagnostic reasoning. What reflection entails varies substantially, and most approaches still require empirical examination. PURPOSE The present essay aims to help clarify the role of deliberate reflection in diagnostic reasoning. Deliberate reflection is an approach whose effects on diagnostic reasoning and learning have been empirically studied over the past 15 years. The philosophical roots of the approach will be briefly examined, and the theory and practice of deliberate reflection, particularly its effectiveness, will be reviewed. Lessons learned and unresolved issues will be discussed. DISCUSSION The deliberate reflection approach originated from a conceptualization of the nature of reflection practice in medicine informed by Dewey's and Schön's work. The approach guides physicians through systematically reviewing the grounds of their initial diagnosis and considering alternatives. Experimental evidence has supported the effectiveness of deliberate reflection in increasing physicians' diagnostic performance, particularly in nonstraightforward diagnostic tasks. Deliberate reflection has also proved helpful to improve students' diagnostic learning and to facilitate learning of new information. The mechanisms behind the effects of deliberate reflection remain unclear. Tentative explanations focus on the activation/reorganisation of prior knowledge induced by deliberate reflection. Its usefulness depends therefore on the difficulty of the problem relative to the clinician's knowledge. Further research should examine variations in instructions on how to reflect upon a case, the value of further guidance while learning from deliberate reflection, and its benefits in real practice.
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Affiliation(s)
- Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus MC; Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
| | - Henk G. Schmidt
- Institute of Medical Education Research Rotterdam, Erasmus MC; Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
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Pavlov CS, Kovalevskaya VI, Kireeva NV, Dudnik EN, Voronova EI, Litvinova TM, Volel BA. Educational priorities and programs for the development of research competencies in science-based medical education. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The active development of technology since the middle of the 20th century has changed the requirements for education in view of the demand for knowledge-intensive specialties. The current approach is focused on the intersubjectivity and complexity of problem solving, the project organization of training and the practical orientation of learning courses. The training of specialists capable of solving qualitatively new tasks is possible only in a special environment where personal and professional competencies are formed. The transformation of education in medicine has led to the active integration of research and clinical experience. A significant impetus for the transition to a new level is provided by the development of cognitive competencies, critical thinking, which is closely interrelated with evidence-based medicine. Novel training programs make it possible to receive research, management, entrepreneurial and communication competencies inaddition to classical clinical education. At present, the future belongs to interdisciplinary teams based on developed clusters.
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Affiliation(s)
| | - V. I. Kovalevskaya
- Non-profit organization "Society for the support of scientific and practical activities in the field of complex study of the liver by doctors of various specialties"
| | | | - E. N. Dudnik
- I.M. Sechenov First Moscow State Medical University
| | | | | | - B. A. Volel
- I.M. Sechenov First Moscow State Medical University
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Roberts TJ, Sellars MC, Sands JM, Jacobson JO. A Perfect Storm Averted: Flawed Systems, a Dropped Ball, and Cognitive Biases Delay a Critical Diagnosis. JCO Oncol Pract 2022; 18:833-839. [PMID: 36049142 DOI: 10.1200/op.22.00145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
This is the first case of Cancer Morbidity, Mortality, and Improvement Rounds, a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. This case highlights how multiple overlapping factors contributed to a delay in diagnosing disseminated tuberculosis in a patient with lung cancer. The discussion focuses on the ways that cognitive biases contributed to the delayed diagnosis in a patient who, with the benefit of hindsight, exhibited several signs and symptoms suggesting tuberculosis.Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal.1.
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Affiliation(s)
- Thomas J Roberts
- Dana-Farber Cancer Institute, Boston, MA.,Massachusetts General Hospital, Boston, MA
| | - Maclean C Sellars
- Dana-Farber Cancer Institute, Boston, MA.,Massachusetts General Hospital, Boston, MA
| | - Jacob M Sands
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Joseph O Jacobson
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
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Lee CY, Lai HY, Lee CH, Chen MM. Medical Dispute Cases Caused by Errors in Clinical Reasoning: An Investigation and Analysis. Healthcare (Basel) 2022; 10:healthcare10112224. [PMID: 36360564 PMCID: PMC9690055 DOI: 10.3390/healthcare10112224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
Studies that examine medical dispute cases (MDC) due to clinical reasoning (CR) are scarce in Taiwan. A retrospective analysis was undertaken to review MDC filed at four hospitals in Taiwan between 2011 and 2015. Cases were examined for the healthcare professionals involved, their relevance to CR errors, clinical specialties, and seniority. Seventy-eight MDC were identified and 57.7% of which were determined to be related to CR errors (n = 45). Among the 45 cases associated with CR errors, 82.2% (37) and 22.2% (10) were knowledge- and skill-related errors, respectively. The healthcare professionals with the most MDC were obstetrician-gynecologists (10/90, 11.1%), surgeons (8/90, 8.9%), and emergency physicians (7/90, 7.8%). The seniority of less than 5 years or lower had the highest number of attending physicians to be associated with MDC. In contrast, the highest seniority (>25 years) in the physician group and year 6 in the resident group are both shown with zero MDC. In our study, the larger hospitals had a significantly higher incidence of MDC compared to the smaller hospitals (Pearson Correlation Coefficient = 0.984, p = 0.016). An examination of MDC reveals the frequency and nature of medical errors in Taiwanese hospitals. Having identified that CR errors contributed a substantial fraction to the overall MDC, strategies to promote reasoning skills and hence reduce medico-legal issues help safeguard both patients and healthcare professionals.
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Affiliation(s)
- Ching-Yi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 2119); Fax: +886-3-3285818
| | - Hung-Yi Lai
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Ching-Hsin Lee
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 333423, Taiwan
| | - Mi-Mi Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
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65
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Kim OT. Patient safety as a global health priority. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Patient safety is a discipline that has arisen in response to the increasing complexity of health care delivery and the associated increase in patient harm. Adverse health care events are a serious problem, causing significant harm to the patient and increasing health care costs. The World Health Organization has identified patient safety as one of the key priorities for world health. The current review presents the historical background that led to the formation of the discipline of patient safety, the determinants of adverse events in medical practice, and the main tools for dealing with them.
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Affiliation(s)
- O. T. Kim
- National Medical Research Center for Therapy and Preventive Medicine
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66
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Ben‐Assuli O, Arazy O, Kumar N, Shabtai I. Too much information? The use of extraneous information to support decision‐making in emergency settings. DECISION SCIENCES 2022. [DOI: 10.1111/deci.12585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ofir Ben‐Assuli
- Information System Department, Faculty of Business Administration, Ono Academic College Kiryat Ono Israel
| | - Ofer Arazy
- Department of Information Systems, University of Haifa Haifa Israel
| | - Nanda Kumar
- Computer Information Systems Department, Zicklin School of Business, Baruch College City University of New York New York City New York
| | - Itamar Shabtai
- School of Economics, College of Management Academic Studies Rishon Lezion Israel
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67
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Hage R, Fourré A, Ramonfosse L, Leteneur S, Jones M, Dierick F. Description and rules of a new card game to learn clinical reasoning in musculoskeletal physiotherapy. J Man Manip Ther 2022:1-10. [DOI: 10.1080/10669817.2022.2132346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Affiliation(s)
- Renaud Hage
- TFTM, Manual Therapy Center, Brussels, Belgium
- CeREF-Technique, Haute Ecole Louvain en Hainaut, Mons, Belgium
| | - Antoine Fourré
- TFTM, Manual Therapy Center, Brussels, Belgium
- Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium
- Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, Antwerp, Belgium
| | - Laura Ramonfosse
- FoRS, Haute Ecole de Namur-Liège-Luxembourg, Marche-en-Famenne, Belgium
| | - Sébastien Leteneur
- Université Polytechnique Hauts-de-France, LAMIH, CNRS, UMR 8201, Valenciennes, France
| | - Mark Jones
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, Australia
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia
| | - Frédéric Dierick
- CeREF-Technique, Haute Ecole Louvain en Hainaut, Mons, Belgium
- Laboratoire d’Analyse du Mouvement et de la Posture (LAMP), Centre National de Rééducation Fonctionnelle et de Réadaptation – Rehazenter, Luxembourg, Luxembourg
- Faculté des Sciences de la Motricité, UCLouvain, Ottignies-Louvain-la-Neuve, Belgium
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68
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Cheung JJH, Park YS, Aufderheide K, Holden J, Yudkowsky R. Optimizing Clinical Reasoning Assessments With Analytic and Holistic Ratings: Examining the Validity, Reliability, and Cost of a Simplified Patient Note Scoring Procedure. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:S15-S21. [PMID: 35947475 DOI: 10.1097/acm.0000000000004908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Post-standardized patient (SP) encounter patient notes used to assess students' clinical reasoning represent a significant time burden for faculty who traditionally score them. To reduce this burden, the authors previously reported a complex faculty-developed scoring method to assess patient notes rated by nonclinicians. The current study explored whether a simplified scoring procedure for nonclinician raters could further optimize patient note assessments by reducing time, cost, and creating additional opportunities for formative feedback. METHOD Ten nonclinician raters scored patient notes of 141 students across 5 SP cases by identifying case-specific patient note checklist items. The authors identified the bottom quintile of students using the proportion of correct items identified in the note (percent-scores) and case-specific faculty-generated scoring formulas (formula-scores). Five faculty raters scored a subset of notes from low, borderline, and high-performing students (n = 30 students) using a global rating scale. The authors performed analyses to gather validity evidence for percent-scores (i.e., relationship to other variables), investigate its reliability (i.e., generalizability study), and evaluate its costs (i.e., faculty time). RESULTS Nonclinician percent- and formula-scores were highly correlated ( r = .88) and identified similar lists of low-performing students. Both methods demonstrated good agreement for pass-fail determinations with each other (Kappa = .68) and with faculty global ratings (Kappa percent =.61; Kappa formula =.66). The G-coefficient of percent-scores was .52, with 38% of variability attributed to checklist items nested in cases. Using percent-scores saved an estimated $746 per SP case (including 6 hours of faculty time) in development costs over formula-scores. CONCLUSIONS Nonclinician percent-scores reliably identified low-performing students without the need for complex faculty-developed scoring formulas. Combining nonclinician analytic and faculty holistic ratings can reduce the time and cost of patient note scoring and afford faculty more time to coach at-risk students and provide targeted assessment input for high-stakes summative exams.
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Affiliation(s)
- Jeffrey J H Cheung
- J.J.H. Cheung is assistant professor, Department of Medical Education, University of Illinois College of Medicine at Chicago, Chicago, Illinois; ORCID: https://orcid.org/0000-0002-6037-5811
| | - Yoon Soo Park
- Y.S. Park is associate professor, Harvard Medical School, and director of health professions education research, Massachusetts General Hospital, Boston, Massachusetts; ORCID: https://orcid.org/0000-0001-8583-4335
| | - Kassidee Aufderheide
- K. Aufderheide is a doctor of pharmacy candidate, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Jaime Holden
- J. Holden is a clinical pharmacist, IngenioRx Specialty Pharmacy with CVS Caremark, Mount Prospect, Illinois
| | - Rachel Yudkowsky
- R. Yudkowsky is professor and director of graduate studies, Department of Medical Education, University of Illinois College of Medicine at Chicago, Chicago, Illinois; ORCID: https://orcid.org/0000-0002-2145-7582
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69
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Watsjold BK, Ilgen JS, Regehr G. An Ecological Account of Clinical Reasoning. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:S80-S86. [PMID: 35947479 DOI: 10.1097/acm.0000000000004899] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE The prevailing paradigms of clinical reasoning conceptualize context either as noise that masks, or as external factors that influence, the internal cognitive processes involved in reasoning. The authors reimagined clinical reasoning through the lens of ecological psychology to enable new ways of understanding context-specific manifestations of clinical performance and expertise, and the bidirectional ways in which individuals and their environments interact. METHOD The authors performed a critical review of foundational and current literature from the field of ecological psychology to explore the concepts of clinical reasoning and context as presented in the health professions education literature. RESULTS Ecological psychology offers several concepts to explore the relationship between an individual and their context, including affordance, effectivity, environment, and niche. Clinical reasoning may be framed as an emergent phenomenon of the interactions between a clinician's effectivities and the affordances in the clinical environment. Practice niches are the outcomes of historical efforts to optimize practice and are both specialty-specific and geographically diverse. CONCLUSIONS In this framework, context specificity may be understood as fundamental to clinical reasoning. This changes the authors' understanding of expertise, expert decision making, and definition of clinical error, as they depend on both the expert's actions and the context in which they acted. Training models incorporating effectivities and affordances might allow for antiableist formulations of competence that apply learners' abilities to solving problems in context. This could offer both new means of training and improve access to training for learners of varying abilities. Rural training programs and distance education can leverage technology to provide comparable experience to remote audiences but may benefit from additional efforts to integrate learners into local practice niches.
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Affiliation(s)
- Bjorn K Watsjold
- B.K. Watsjold is assistant professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4888-8857
| | - Jonathan S Ilgen
- J.S. Ilgen is professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4590-6570
| | - Glenn Regehr
- G. Regehr is professor, Department of Surgery, and senior scientist, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada; ORCID: https://orcid.org/0000-0002-3144-331X
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Kaplan HM, Birnbaum JF, Kulkarni PA. Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure. Diagnosis (Berl) 2022; 9:421-429. [PMID: 35942949 DOI: 10.1515/dx-2022-0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/17/2022] [Indexed: 12/29/2022]
Abstract
Premature closure is often described as a significant contributor to diagnostic error. Therefore, developing strategies to mitigate premature closure could reduce diagnostic errors and improve patient care. Here we propose the novel concept of pursuit of an "endpoint diagnosis" as a cognitive forcing strategy (CFS) for avoiding premature diagnostic closure. We define an "endpoint diagnosis" as an underlying causative explanation for a patient's signs, symptoms, and laboratory and radiographic data that exhausts additional relevant diagnostic evaluation. We have observed four contexts in which the error of not pursuing an endpoint diagnosis most often occurs: (1) diagnoses that appear to result in the same treatment regardless of etiology, (2) cases that are particularly complex, (3) clinical scenarios that are vulnerable to systems errors, and (4) situations in which patients' problems are attributed to uncontrolled underlying risk factors or an exacerbation of a known condition. Additionally, we address why we believe endpoint diagnoses are not universally pursued, delineate when this approach might be particularly useful, attempt to reconcile the potential conflict between accepting diagnostic ambiguity in certain instances and pursuing endpoint diagnoses, and outline possible concerns that might arise with using this CFS, including the possibility of lengthy evaluations resulting in overdiagnosis and overtreatment. Our overarching goal is for this CFS to help clinicians in their daily clinical practice as they seek to optimize their diagnostic skill and patient care.
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Affiliation(s)
- Holland M Kaplan
- Department of Medicine, Section of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Jacqueline F Birnbaum
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Prathit A Kulkarni
- Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Section of Infectious Disease, Baylor College of Medicine, Houston, TX, USA
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71
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Tournier A, Fok Y, van Haselen R, To A. Searching for the Genus Epidemicus in Chinese Patients: Findings from the Clificol COVID-19 Clinical Case Registry. HOMEOPATHY 2022; 112:30-39. [PMID: 36183700 PMCID: PMC9868965 DOI: 10.1055/s-0042-1750380] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Clificol COVID-19 Support Project is an innovative international data collection project aimed at tackling some of the core questions in homeopathy. This paper reports on the further investigation of the genus epidemicus concept during the first wave of the pandemic in the Chinese population. METHODS The design is an observational clinical case registry study of Chinese patients with confirmed or suspected coronavirus disease 2019 (COVID-19). The symptoms were prospectively collected via a 150-item questionnaire. The concept of genus epidemicus, including the role of treatment individualization, was investigated by analyzing whether presenting symptoms clustered into distinct groups. Two standard statistical analysis techniques were utilized: principal component analysis for extracting the most meaningful symptoms of the dataset; the k-means clustering algorithm for automatically assigning groups based on similarity between presenting symptoms. RESULTS 20 Chinese practitioners collected 359 cases in the first half of 2020 (766 consultations, 363 prescriptions). The cluster analysis found two to be the optimum number of clusters. These two symptomatic clusters had a high overlap with the two most commonly prescribed remedies in these sub-populations: in cluster 1 there were 297 prescriptions, 95.6% of which were Gelsemium sempervirens; in cluster 2 there were 61 prescriptions, 95.1% of which were Bryonia alba. CONCLUSION This is the first study to investigate the notion of genus epidemicus by using modern statistical techniques. These analyses identified at least two distinct symptom pictures. The notion of a single COVID-19 genus epidemicus did not apply in the studied population.
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Affiliation(s)
- Alexander Tournier
- Institute of Complementary and Integrative Medicine, Faculty of Medicine, University of Bern, Bern, Switzerland,Homeopathy Research Institute, London, England
| | - Yvonne Fok
- Hong Kong Association of Homeopathy, People's Republic of China
| | - Robbert van Haselen
- International Institute for Integrated Medicine, Kingston, United Kingdom,Address for correspondence Robbert van Haselen, MSc International Institute for Integrated MedicineSuite 467, 29 Castle Street, Kingston KT1 1DNUnited Kingdom
| | - Aaron To
- Hong Kong Association of Homeopathy, People's Republic of China
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Valentine J, Tackett S, Bord S, Zink K, Botta J, Jung J. Problem representation and diagnostic accuracy during an OSCE. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:1021-1031. [PMID: 35859246 DOI: 10.1007/s10459-022-10126-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 05/08/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The National Academy of Medicine has called for "identifying opportunities to improve the diagnostic process". We studied the association between problem representation and diagnostic accuracy during an objective structured clinical exam (OSCE). MATERIALS AND METHODS We conducted a non-randomized controlled trial during a ten-case OSCE. We measured whether a summary statement prompt increased the likelihood that the student listed the correct diagnosis and whether better summary statements were correlated with diagnostic accuracy. RESULTS 114 students provided 1135 responses. The non-prompted control group yielded 631 responses, listing the correct diagnosis first 73% of the time and within the top three slots 85% of the time. The intervention group exposed to the prompt yielded 453 responses listing the correct diagnosis first 72% of the time (P = 0.617) and within the top three slots 84% of the time (P = 0.760). Summary statements were scored on a 0, 0.5, or 1 rubric. When grouped according to summary statement score, students listed the correct diagnosis first 74%, 70%, and 72% of the time respectively (P = 0.666). The correct diagnosis was included within the top three slots 88%, 82%, and 83% of the time (P = 0.238). CONCLUSIONS Prompting students to form a summary statement did not improve diagnostic accuracy. Better summary statements were not correlated with diagnostic accuracy.
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Affiliation(s)
- Jake Valentine
- Department of Emergency Medicine, Johns Hopkins, 1800 Orleans St, 21287, Baltimore, MD, USA.
| | - Sean Tackett
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Sharon Bord
- Department of Emergency Medicine, Johns Hopkins, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Korie Zink
- Department of Emergency Medicine, Johns Hopkins, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Julian Botta
- Department of Emergency Medicine, Johns Hopkins, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Julianna Jung
- Department of Emergency Medicine, Johns Hopkins, 1800 Orleans St, 21287, Baltimore, MD, USA
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McCollum N, Agrawal D. Don't go barking up the wrong tree: Thinking beyond infection in a toddler with stridor. Am J Emerg Med 2022; 62:149.e1-149.e4. [PMID: 36182581 DOI: 10.1016/j.ajem.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022] Open
Abstract
A toddler presented to the emergency department with persistent stridor and barky cough for 4 weeks and progressive dysphagia for 1 week. During this time, he had sought medical attention 6 additional times and had been treated for pneumonia, wheezing and croup, receiving antibiotics and several courses of steroids without improvement. On the final presentation, airway imaging did not reveal a foreign body. However, bedside laryngoscopy demonstrated bilateral vocal cord paralysis. Further imaging revealed an intracranial posterior fossa mass which provided the unifying diagnosis for his persistent symptoms.
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Affiliation(s)
- Nichole McCollum
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, United States of America; The George Washington School of Medicine and Health Sciences, 2300 I Street NW, Washington, DC 20052, United States of America.
| | - Dewesh Agrawal
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, United States of America; The George Washington School of Medicine and Health Sciences, 2300 I Street NW, Washington, DC 20052, United States of America
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Corrao S, Argano C. Rethinking clinical decision-making to improve clinical reasoning. Front Med (Lausanne) 2022; 9:900543. [PMID: 36160131 PMCID: PMC9492972 DOI: 10.3389/fmed.2022.900543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/16/2022] [Indexed: 11/22/2022] Open
Abstract
Improving clinical reasoning techniques is the right way to facilitate decision-making from prognostic, diagnostic, and therapeutic points of view. However, the process to do that is to fill knowledge gaps by studying and growing experience and knowing some cognitive aspects to raise the awareness of thinking mechanisms to avoid cognitive errors through correct educational training. This article examines clinical approaches and educational gaps in training medical students and young doctors. The authors explore the core elements of clinical reasoning, including metacognition, reasoning errors and cognitive biases, reasoning strategies, and ways to improve decision-making. The article addresses the dual-process theory of thought and the new Default Mode Network (DMN) theory. The reader may consider the article a first-level guide to deepen how to think and not what to think, knowing that this synthesis results from years of study and reasoning in clinical practice and educational settings.
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Affiliation(s)
- Salvatore Corrao
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Palermo, Italy
- Dipartimento di Promozione della Salute Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Palermo, Italy
- *Correspondence: Salvatore Corrao, ;
| | - Christiano Argano
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Palermo, Italy
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Gale MS. Diagnosis: Fundamental Principles and Methods. Cureus 2022; 14:e28730. [PMID: 36204022 PMCID: PMC9528852 DOI: 10.7759/cureus.28730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 11/05/2022] Open
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Cook DA, Stephenson CR, Gruppen LD, Durning SJ. Management reasoning scripts: Qualitative exploration using simulated physician-patient encounters. PERSPECTIVES ON MEDICAL EDUCATION 2022; 11:196-206. [PMID: 35653028 PMCID: PMC9391545 DOI: 10.1007/s40037-022-00714-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Management reasoning is distinct from diagnostic reasoning and remains incompletely understood. The authors sought to empirically investigate the concept of management scripts. METHODS In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters, and used a coding form to document observations about management reasoning. The team used constant comparative analysis to integrate empirically-grounded insights with theories related to cognitive scripts and Type 1/Type 2 thinking. RESULTS Management scripts are precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence. Management scripts appear to differ substantially from illness scripts. Management scripts varied in quality (in content, sequence, flexibility, and fluency) and generality. The authors empirically identified six key features (components) of management scripts: the problem (diagnosis); management options; preferences, values, and constraints; education needs; interactions; and encounter flow. The authors propose a heuristic framework describing script activation, selection, instantiation with case-specific details, and application to guide development of the management plan. They further propose that management reasoning reflects iterative, back-and-forth involvement of both Type 1 (non-analytic, effortless) and Type 2 (analytic, effortful) thinking. Type 1 thinking likely influences initial script activation, selection, and initial instantiation. Type 2 increasingly influences subsequent script revisions, as activation, selection, and instantiation become more deliberate (effortful) and more hypothetical (involving mental simulation). DISCUSSION Management scripts constitute a key feature of management reasoning, and could represent a new target for training in clinical reasoning (distinct from illness scripts).
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Affiliation(s)
- David A Cook
- Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | | | - Larry D Gruppen
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Congdon M, Clancy CB, Balmer DF, Anderson H, Muthu N, Bonafide CP, Rasooly IR. Diagnostic Reasoning of Resident Physicians in the Age of Clinical Pathways. J Grad Med Educ 2022; 14:466-474. [PMID: 35991115 PMCID: PMC9380621 DOI: 10.4300/jgme-d-21-01032.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/07/2022] [Accepted: 05/05/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described. OBJECTIVE To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning. METHODS We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework. RESULTS Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process. CONCLUSIONS This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.
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Affiliation(s)
- Morgan Congdon
- Morgan Congdon, MD, MPH, MSEd, is Assistant Professor of Clinical Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Caitlin B. Clancy
- Caitlin B. Clancy, MD, is Assistant Professor of Clinical Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Dorene F. Balmer
- Dorene F. Balmer, PhD, is Professor of Pediatrics and Director of Research on Pediatric Education, Division of General Pediatrics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Hannah Anderson
- Hannah Anderson, MBA, is Clinical Research Associate in Medical Education, Division of General Pediatrics, Children's Hospital of Philadelphia
| | - Naveen Muthu
- Naveen Muthu, MD, MSCE, is Instructor of Clinical Informatics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Christopher P. Bonafide
- Christopher P. Bonafide, MD, MSCE, is Associate Professor of Pediatrics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Irit R. Rasooly
- Irit R. Rasooly, MD, MSCE, is Clinical Instructor of Pediatrics and Clinical Informatics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
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Ivic R, Vicente V, Kurland L, Svensson J, Sahdev Klintemård R, Castrén M, Bohm K. Pre-hospital emergency nurse specialist's experiences in caring for patients with non-specific chief complaints in the ambulance - A qualitative interview study. Int Emerg Nurs 2022; 63:101178. [PMID: 35738055 DOI: 10.1016/j.ienj.2022.101178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 04/05/2022] [Accepted: 05/04/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pre-hospital emergency nurse (PEN) specialists are faced with patients presenting with non-specific chief complaints (NSC) to the emergency medical service (EMS) on a daily basis. These patients are often elderly and one in three has a serious condition and their acuity is not recognized. OBJECTIVE The aim of the current study was to explore PEN specialists' experiences in caring for patients presenting with non-specific chief complaints. DESIGN A qualitative study design with eleven individual interviews of PENs, between 2018 and 2020. Qualitative content analysis was used. RESULTS The analyses generated three categories including subcategories. The categories were "Unexplained suffering". "Systematic approach and experience enhances medical safety". "Organizational processes can be optimized". The relation between the categories compiled as ́In-depth systematic assessment is perceived to reduce suffering and increases patient safetý. CONCLUSION The PENs experiences in caring for patients presenting with non-specific chief complaints show that an in-depth systematic assessment may lead to a meaningful caring encounter which enables the identification of the cause of the chief complaint. Experience and a systematic approach were considered as essential to enhance medical safety. This could be strengthened through feedback on the nurse's care provided by care managers and employers. To optimize organizational processes, the development of the opportunity to convey the patient to different levels of care can be an important component.
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Affiliation(s)
- R Ivic
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Academic Emergency Medical Service, Region Stockholm, Stockholm, Sweden.
| | - V Vicente
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
| | - L Kurland
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Örebro University, Department for Medical Sciences, Örebro, Sweden.
| | | | | | - M Castrén
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
| | - K Bohm
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
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Nasr ZG, Moustafa DAH, Dahmani S, Wilby KJ. Investigating pharmacy students' therapeutic decision-making with respect to antimicrobial stewardship cases. BMC MEDICAL EDUCATION 2022; 22:467. [PMID: 35710400 PMCID: PMC9203133 DOI: 10.1186/s12909-022-03542-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 06/07/2022] [Indexed: 05/13/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) play a big role in minimizing antimicrobial resistance. Pharmacists are essential members of the health care team and in order for them to fulfill roles on ASP teams and become antimicrobial stewards, they must be prepared adequately by pharmacy schools prior to entry into actual practice. Although programming has been implemented into entry-to-practice programs worldwide, little is known about how students interpret antimicrobial stewardship (AMS) data and arrive at clinical decisions. We aimed to explore students' cognitive processes and determine how they formulate therapeutic decisions when presented with AMS cases. METHODS This was a qualitative study conducted using a case study approach, in which a sample (n=20) of pharmacy students was recruited to interpret AMS cases. Semi-structured 1-on-1 interviews were arranged with each participant. A think-aloud procedure with verbal protocol analysis was adopted to determine students' decision-making processes. Thematic analysis was used to interpret themes from the interview data. RESULTS Two themes were interpreted from the data: students' focus and students' approach to case interpretation. Students' focus relates to external factors students consider when interpreting AMS case data and use to make and justify therapeutic decisions including patient-centered factors, drug-related factors, AMS interventions, and pharmacist's role. Students' clinical reasoning describes the approach that students use to interpret the data and the decision-making processes they employ to arrive at a clinical decision including a systematic approach versus non-systematic approach. CONCLUSIONS Students vary in their focus and the cognitive strategies used to interpret AMS cases. Findings support the notion that clinical reasoning and decision-making should be explicitly taught in pharmacy curricula, in order to help students become aware of their own cognitive processes and decision-making abilities.
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Affiliation(s)
- Ziad G. Nasr
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
| | | | - Sara Dahmani
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
| | - Kyle J. Wilby
- College of Pharmacy, Dalhousie University, Halifax, Canada
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80
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Rajeswaran V, Devine L, Lorens E, Robertson S, Huszti E, Panisko DM. Types of clinical reasoning in a summative clerkship oral examination. MEDICAL TEACHER 2022; 44:657-663. [PMID: 35000527 DOI: 10.1080/0142159x.2021.2020230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Dual-process theory characterizes clinical reasoning (CR) as Type 1 (intuitive) and Type 2 (analytical) thinking. This study examined CR on a summative clinical clerkship structured clinical oral examination (SCOE). METHODS AND SUBJECTS 511 clinical clerks at the University of Toronto underwent SCOEs. Type 1, Type 2, and Global CR performance were compared to other internal medicine clerkship assessments using descriptive statistics and Spearman correlations. RESULTS Clinical clerks achieved mean marks >75% on the three clinical reasoning stations, on Type 1 and 2 CR tasks, and the overall SCOE. Performance on the SCOE CR stations correlated with each of the other clerkship assessments: written examination, inpatient, and ambulatory clinic assessments. The correlation of performance between Type 1 and Type 2 clinical reasoning tasks was statistically significant but weak (rs = 0.28). This suggests that defined measures of Type 1 and Type 2 reasoning were indeed assessing distinct constructs. CONCLUSION Clinical clerks used both Type 1 and Type 2 reasoning with success. This study's characterization of Type 1 and Type 2 CR as separate domains, distinct from existing measures on the SCOE as well as the other clerkship assessments, can suggest a further addition to multimodal clerkship assessment.
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Affiliation(s)
- Vamana Rajeswaran
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Endocrinology, William Osler Health System, Brampton, Canada
| | - Luke Devine
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- The HoPingKong Centre, University Health Network, Toronto, Canada
| | - Edmund Lorens
- Statistics & Evaluation, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sumitra Robertson
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Daniel M Panisko
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- The HoPingKong Centre, University Health Network, Toronto, Canada
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81
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Coen M, Sader J, Junod-Perron N, Audétat MC, Nendaz M. Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic. Intern Emerg Med 2022; 17:979-988. [PMID: 34997906 PMCID: PMC8742156 DOI: 10.1007/s11739-021-02884-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022]
Abstract
Cognitive biases are systematic cognitive distortions, which can affect clinical reasoning. The aim of this study was to unravel the most common cognitive biases encountered in in the peculiar context of the COVID-19 pandemic. Case study research design. Primary care. Single centre (Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland). A short survey was sent to all primary care providers (N = 169) taking care of hospitalised adult patients with COVID-19. Participants were asked to describe cases in which they felt that their clinical reasoning was "disrupted" because of the pandemic context. Seven case were sufficiently complete to be analysed. A qualitative analysis of the clinical cases was performed and a bias grid encompassing 17 well-known biases created. The clinical cases were analyzed to assess for the likelihood (highly likely, plausible, not likely) of the different biases for each case. The most common biases were: "anchoring bias", "confirmation bias", "availability bias", and "cognitive dissonance". The pandemic context is a breeding ground for the emergence of cognitive biases, which can influence clinical reasoning and lead to errors. Awareness of these cognitive mechanisms could potentially reduce biases and improve clinical reasoning. Moreover, the analysis of cognitive biases can offer an insight on the functioning of the clinical reasoning process in the midst of the pandemic crisis.
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Affiliation(s)
- Matteo Coen
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.150338.c0000 0001 0721 9812Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Julia Sader
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988iEh2-Institute for Ethics, History, and the Humanities-Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Noëlle Junod-Perron
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988Institute of Primary Care (IuMFE), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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82
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Gilkes L, Kealley N, Frayne J. Teaching and assessment of clinical diagnostic reasoning in medical students. MEDICAL TEACHER 2022; 44:650-656. [PMID: 35041564 DOI: 10.1080/0142159x.2021.2017869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Teaching diagnostic reasoning and giving feedback has an important role in medical education. Clinicians who teach may recognise errors, but be unfamiliar with the terminology used to describe them, leading to a lack of consistent and useful student feedback. OBJECTIVE This prospective project evaluation study aimed to develop an examiner training package regarding errors in diagnostic reasoning, utilising consistent language and feedback tool, and report on diagnostic reasoning errors in second year medical students over the transition from preclinical to early clinical training at objective structured clinical exams (OSCEs). RESULTS Likert questionnaire regarding examining, assessment and feedback pre- and post-training showed improvement in all measures, including examiner feedback confidence post training (p < .001). Students (n = 235) within the cohort were examined at the first preclinical OSCE 12 weeks into the teaching year and 236 students at the end of year OSCE. A range of 0-6 diagnostic reasoning errors were reported for individual students. When comparing mean history station scores at the preclinical OSCE for students who were observed to have diagnostic reasoning errors, students with 'poor pattern recognition' had a 4.2% lower score than those without this error type (p = .04, 95% CI of difference .14, 8.32), while those with 'unfocused data collection' error had a station score 7.7% lower than those without this error (p < .001, 95% CI of difference 3.50, 11.99). At the end of teaching year clinical OSCE, all common error types were associated with poorer performance. Error pattern shifted through the two longitudinal assessments, resulting in 'poor pattern recognition' having reduced and 'too narrow' and 'premature closure' increased rates. CONCLUSIONS Incorporating the identification and feedback of common diagnostic reasoning errors into existing clinical assessments was feasible and easy to implement. Understanding, identifying and providing consistent feedback on common errors assists educators and could guide curriculum design.
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Affiliation(s)
- Lucy Gilkes
- General Practice, Notre Dame University Fremantle, Fremantle, Western Australia
- Medical School, Division of General Practice, University of Western, Perth, Australia
| | - Narelle Kealley
- Medical School, Division of General Practice, University of Western, Perth, Australia
| | - Jacqueline Frayne
- Medical School, Division of General Practice, University of Western, Perth, Australia
- Department of Obstetrics, Women and Newborn Health Service, Subiaco, Western Australia
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83
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Staal J, Speelman M, Brand R, Alsma J, Zwaan L. Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. BMC MEDICAL EDUCATION 2022; 22:256. [PMID: 35395938 PMCID: PMC8991944 DOI: 10.1186/s12909-022-03325-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/29/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Diagnostic errors are a major cause of preventable patient harm. Studies suggest that presenting inaccurate diagnostic suggestions can cause errors in physicians' diagnostic reasoning processes. It is common practice for general practitioners (GPs) to suggest a diagnosis when referring a patient to secondary care. However, it remains unclear via which underlying processes this practice can impact diagnostic performance. This study therefore examined the effect of a diagnostic suggestion in a GP's referral letter to the emergency department on the diagnostic performance of medical interns. METHODS Medical interns diagnosed six clinical cases formatted as GP referral letters in a randomized within-subjects experiment. They diagnosed two referral letters stating a main complaint without a diagnostic suggestion (control), two stating a correct suggestion, and two stating an incorrect suggestion. The referral question and case order were randomized. We analysed the effect of the referral question on interns' diagnostic accuracy, number of differential diagnoses, confidence, and time taken to diagnose. RESULTS Forty-four medical interns participated. Interns considered more diagnoses in their differential without a suggested diagnosis (M = 1.85, SD = 1.09) than with a suggested diagnosis, independent of whether this suggestion was correct (M = 1.52, SD = 0.96, d = 0.32) or incorrect ((M = 1.42, SD = 0.97, d = 0.41), χ2(2) =7.6, p = 0.022). The diagnostic suggestion did not influence diagnostic accuracy (χ2(2) = 1.446, p = 0.486), confidence, (χ2(2) = 0.058, p = 0.971) or time to diagnose (χ2(2) = 3.128, p = 0.209). CONCLUSIONS A diagnostic suggestion in a GPs referral letter did not influence subsequent diagnostic accuracy, confidence, or time to diagnose for medical interns. However, a correct or incorrect suggestion reduced the number of diagnoses considered. It is important for healthcare providers and teachers to be aware of this phenomenon, as fostering a broad differential could support learning. Future research is necessary to examine whether these findings generalize to other healthcare workers, such as more experienced specialists or triage nurses, whose decisions might affect the diagnostic process later on. TRIAL REGISTRATION The study protocol was preregistered and is available online at Open Science Framework ( https://osf.io/7de5g ).
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Affiliation(s)
- J Staal
- Erasmus University Medical Center Rotterdam, Institute of Medical Education Research, Rotterdam, the Netherlands.
| | - M Speelman
- Erasmus University Medical Center Rotterdam, Institute of Medical Education Research, Rotterdam, the Netherlands
- Faculty of Medical Sciences, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - R Brand
- Intensive Care Unit, Haaglanden Medical Center Den Haag, The Hague, the Netherlands
| | - J Alsma
- Department of Internal Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - L Zwaan
- Erasmus University Medical Center Rotterdam, Institute of Medical Education Research, Rotterdam, the Netherlands
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84
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Furlan L, Francesco PD, Costantino G, Montano N. Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care. J Intern Med 2022; 291:397-407. [PMID: 35307902 PMCID: PMC9314697 DOI: 10.1111/joim.13472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In recent years, the Choosing Wisely and Less is More campaigns have gained growing attention in the medical scientific community. Several projects have been launched to facilitate confrontation among patients and physicians, to achieve better and harmless patient-centered care. Such initiatives have paved the way to a new "way of thinking." Embracing such a philosophy goes through a cognitive process that takes into account several issues. Medicine is a highly inaccurate science and physicians should deal with uncertainty. Evidence from the literature should not be accepted as it is but rather be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics. A wise choice requires active effort into minimizing the chance that potential biases may affect our clinical decisions. Potential harms and all consequences (both direct and indirect) of prescribing tests, procedures, or medications should be carefully evaluated, as well as patients' needs and preferences. Through such a cognitive process, a patient management shift is needed, moving from being centered on establishing a diagnosis towards finding the best management strategy for the right patient at the right time. Finally, while "thinking wisely," physicians should also "act wisely," being among the leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.
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Affiliation(s)
- Ludovico Furlan
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Di Francesco
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Costantino
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Anaesthesia-Intensive Care Unit, Emergency Department and Emergency Medicine Unit, IRCCS Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
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85
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Boyle JG, Walters MR, Jamieson S, Durning SJ. Sharing the Bandwidth in Cognitively Overloaded Teams and Systems: Mechanistic Insights from a Walk on the Wild Side of Clinical Reasoning. TEACHING AND LEARNING IN MEDICINE 2022; 34:215-222. [PMID: 34167387 DOI: 10.1080/10401334.2021.1924723] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 06/13/2023]
Abstract
IssuePrevious work from the diagnostic error literature has provided indirect evidence that faulty clinical reasoning may be the most frequent cause of error when attaching a diagnostic label. The precise mechanisms underlying diagnostic error are unclear and continue to be subject to considerable theory informed debate in the clinical reasoning literature. Evidence: We take a theoretical approach to merging these two worlds of literature by first zooming out using distributed cognition as a social cognitive lens (macro theory) to develop a view of the process and outcome of clinical reasoning occurring in the wild - defined as the integrated clinical workplace - the natural habitat of clinicians working within teams. We then zoom in using the novel combination of cognitive load theory and distributed cognition to provide additional theoretical insights into the potential mechanisms of error. Implications: Through the lenses of distributed cognition and cognitive load theory, we can begin to prospectively investigate how cognitive overload is represented and shared within interprofessional teams over time and space and how this influences clinical reasoning performance and leads to error. We believe that this work will help teams manage cognitive load and prevent error.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, School of Medicine, Dentistry and Nursing, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthew R Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Susan Jamieson
- Health Professions Education Programme, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Steven J Durning
- Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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86
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Shaaban R, Richburg CM. Examining Audiology Students' Clinical Collaboration Skills When Using Virtual Audiology Cases Aided With No Collaboration, Live Collaboration, and Virtual Collaboration. Am J Audiol 2022; 31:101-111. [PMID: 35044841 DOI: 10.1044/2021_aja-21-00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The purpose of this study was to examine students' ability to use effective clinical collaboration online in a designed scaffolded environment. Three groups were formed to achieve this goal: two control groups (one using no collaboration and one using live, face-to-face collaboration) and one treatment group using virtual collaboration. METHOD A quasi-experimental design was conducted at two U.S. universities to examine whether there is a significant difference in clinical reasoning skills between three treatment groups using IUP Audiosim software. Two computer-based audiology case simulations were developed, and participants were randomly placed into the three groups. The clinical reasoning data were analyzed using one-way analysis of variance and Tukey's post hoc analyses. RESULTS The results indicated that there was a significant difference in clinical reasoning skills between the three treatment groups. The score obtained by the no-collaboration group was significantly less than the scores obtained by the virtual and live collaboration groups. CONCLUSIONS The results imply that lower scores were associated with students receiving more instructor-designed content and higher scores with students receiving less instructor-designed content. Students who received more scaffolds with the collaborations may have demonstrated better decision-making outside the training exercise than those who did not receive scaffolds. However, lower scores on the exercise did not necessarily imply lower skill. Lower scores simply implied a different path toward mastery.
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Affiliation(s)
- Ramy Shaaban
- Department of Instructional Technology and Learning Sciences, Utah State University, Logan
| | - Cynthia M. Richburg
- Department of Communication Sciences and Disorders, Wichita State University, KS
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87
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Anderson M, Hills-Meyer PR, Stamm JM, Brown K. Integrating Clinical Reasoning Skills in a Pre-professional Undergraduate Human Anatomy Course. ANATOMICAL SCIENCES EDUCATION 2022; 15:304-316. [PMID: 33387378 DOI: 10.1002/ase.2050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
Clinically integrated curricula in health science education has been shown to promote the development of problem-solving schema and positively impact knowledge acquisition. Despite its' purported benefits, this type of curricula can impose a high cognitive load, which may negatively impact novice learners' knowledge acquisition and problem-solving schema development. Introducing explicit clinical reasoning instruction within pre-professional undergraduate basic science courses may limit factors that increase cognitive load, enhance knowledge acquisition, and foster developing clinical problem-solving skills. This study, conducted over the Fall and Spring semesters of the 2018-2019 school year, sought to evaluate whether the implementation of a clinical reasoning instructional intervention within a clinically integrated pre-professional undergraduate general human anatomy course influenced students' acquisition of anatomical knowledge and development of clinical problem-solving skills. Results of the study were mixed regarding the acquisition of anatomical knowledge. Both the intervention and comparison groups performed similarly on multiple choice examinations of anatomical knowledge. However, the clinical reasoning intervention positively impacted students' ability to apply clinical reasoning skills to anatomically based clinical case studies. Results from M\mixed between-within subjects analysis of variance comparing scores on Written Clinical Reasoning Assessments revealed a significant interaction between time and group affiliation, with the groups receiving the interventions outperforming the comparison groups: Fall, P < 0.001; Spring, P < 0.001. The results of this study may imply that explicit clinical reasoning instruction within a clinically integrated undergraduate Human Anatomy course could hold potential for fostering students' early clinical reasoning skills.
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Affiliation(s)
- Margene Anderson
- Department of Academic Technology, University of Wisconsin, Madison, Wisconsin
| | | | - Julie M Stamm
- Department of Kinesiology, University of Wisconsin, Madison, Wisconsin
| | - Kirsten Brown
- Doctoral Program in Educational Leadership Policy Studies, School of Education, Edgewood College, Madison, Wisconsin
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88
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The Role of Intuitive Cognition in Radiologic Decision Making. J Am Coll Radiol 2022; 19:669-676. [DOI: 10.1016/j.jacr.2022.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/19/2022] [Indexed: 11/19/2022]
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89
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Patel SJ, Ipsaro A, Brady PW. Conversations on Diagnostic Uncertainty and Its Management Among Pediatric Acute Care Physicians. Hosp Pediatr 2022:e2021006076. [PMID: 35224634 DOI: 10.1542/hpeds.2021-006076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Diagnosis is a complex, iterative, and nonlinear process, often occurring over time. When presenting signs, symptoms, and diagnostic testing cannot be integrated into a diagnosis, clinicians are confronted with diagnostic uncertainty. Our aim was to study the self-reported cognitive, communication, and management behaviors of pediatric emergency medicine (PEM) and pediatric hospital medicine (PHM) physicians regarding diagnostic uncertainty. METHODS A qualitative study was conducted through focus groups with PEM and PHM physicians in a large academic pediatric medical center. Four focus groups were conducted. Interviews were recorded, deidentified, and transcribed by a team member. Thematic analysis was used to review the transcripts, highlight ideas, and organize ideas into themes. RESULTS Themes were categorized using the model of the diagnostic process from the National Academy of Sciences. "Red flags" and "gut feelings" were prominent during the information, integration, and interpretation phases. To combat diagnostic uncertainty, physicians employed strategies such as "the diagnostic pause" and having a set of "fresh eyes" to review the data. It was important to all clinicians to rule out any "cannot miss" diagnoses. Interphysician communication was direct; communication with patient and families about uncertainty was less direct because of physician concern of being thought of as untrustworthy. Contingency planning, "disposition over diagnosis" by ensuring patient safety, the "test of time," and availability of resources were techniques used by physicians to manage diagnostic uncertainty. CONCLUSIONS Physicians shared common mitigation strategies, which included consulting colleagues and targeting cannot miss diagnoses, but gaps remain regarding communicating diagnostic uncertainty to families.
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Affiliation(s)
- Shivani J Patel
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anna Ipsaro
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Patrick W Brady
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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90
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Zagury-Orly I, Kamin DS, Krupat E, Charlin B, Fernandez N, Fischer K. The Student-Generated Reasoning Tool (SGRT): Linking medical knowledge and clinical reasoning in preclinical education. MEDICAL TEACHER 2022; 44:158-166. [PMID: 34459337 DOI: 10.1080/0142159x.2021.1967904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The simultaneous integration of knowledge acquisition and development of clinical reasoning in preclinical medical education remains a challenge. To help address this challenge, the authors developed and implemented the Student-Generated Reasoning Tool (SGRT)-a tool asking students to propose and justify pathophysiological hypotheses, generate findings, and critically appraise information. METHODS In 2019, students in a first-year preclinical course (n = 171; SGRT group) were assigned to one of 20 teams. Students used the SGRT individually, then in teams, and faculty provided feedback. The control group (n = 168) consisted of students from 2018 who did not use SGRT. Outcomes included academic performance, effectiveness of collaborative environments using the SGRT, and student feedback. RESULTS Students were five times more likely to get questions correct if they were in the SGRT group versus control group. Accuracy of pathophysiological hypotheses was significantly lower for individuals than teams. Qualitative analysis indicated students benefited from generating their own data, justifying their reasoning, and working individually as well as in teams. CONCLUSIONS This study introduces the SGRT as a potentially engaging, case-based, and collaborative learning method that may help preclinical medical students become aware of their knowledge gaps and integrate their knowledge in basic and clinical sciences in the context of clinical reasoning.
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Affiliation(s)
- Ivry Zagury-Orly
- Faculty of Medicine, Université de Montréal, Montreal, Canada
- Harvard Medical School, Boston, MA, USA
| | - Daniel S Kamin
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Edward Krupat
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Bernard Charlin
- Centre for Pedagogy Applied to the Health Sciences, Department of Surgery, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Nicolas Fernandez
- Centre for Pedagogy Applied to the Health Sciences, Department of Surgery, Faculty of Medicine, Université de Montréal, Montreal, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Krisztina Fischer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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91
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Klasen JM, Teunissen PW, Driessen EW, Lingard LA. 'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors. MEDICAL TEACHER 2022; 44:196-205. [PMID: 34634990 DOI: 10.1080/0142159x.2021.1984408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Clinical supervisors acknowledge that they sometimes allow trainees to fail for educational purposes. What remains unknown is how supervisors decide whether to allow failure in a specific instance. Given the high stakes nature of these decisions, such knowledge is necessary to inform conversations about this educationally powerful and clinically delicate phenomenon. MATERIALS AND METHODS 19 supervisors participated in semi-structured interviews to explore how they view their decision to allow failure in clinical training. Following constructivist grounded theory methodology, the iteratively collected data and analysis were informed by theoretical sampling. RESULTS Recalling instances when they considered allowing residents to fail for educational purposes, supervisors characterized these as intuitive, in-the-moment decisions. In their post hoc reflections, they could articulate four factors that they believed influenced these decisions: patient, supervisor, trainee, and environmental factors. While patient factors were reported as primary, the factors appear to interact in dynamic and nonlinear ways, such that supervisory decisions about allowing failure may not be predictable from one situation to the next. CONCLUSIONS Clinical supervisors make many decisions in the moment, and allowing resident failure appears to be one of them. Upon reflection, supervisors understand their decisions to be shaped by recurring factors in the clinical training environment. The complex interplay among these factors renders predicting such decisions difficult, if not impossible. However, having a language for these dynamic factors can support clinical educators to have meaningful discussions about this high-stakes educational strategy.
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Affiliation(s)
- Jennifer M Klasen
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, University Hospital Basel, Basel, Switzerland
| | - Pim W Teunissen
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Erik W Driessen
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Lorelei A Lingard
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
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Shimizu T. System 2 Diagnostic Process for the Next Generation of Physicians: "Inside" and "Outside" Brain-The Interplay between Human and Machine. Diagnostics (Basel) 2022; 12:diagnostics12020356. [PMID: 35204447 PMCID: PMC8870869 DOI: 10.3390/diagnostics12020356] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/08/2022] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
Improving diagnosis has been one of the most critical issues in medicine for the last two decades. In the context of the rise of digital health and its augmentation and human diagnostic thinking, it has become necessary to integrate the concept of digital diagnosis into dual-process theory (DPT), which is the fundamental axis of the diagnostic thinking process physicians. Particularly, since the clinical decision support system (CDSS) corresponds to analytical thinking (system 2) in DPT, it is necessary to redefine system 2 to include the CDSS. However, to the best of my knowledge there has been no concrete conceptual model based on this need. The innovation and novelty of this paper are that it redefines system 2 to include new concepts and shows the relationship among the breakdown of system 2. In this definition, system 2 is divided into “inside” and “outside” brains, where “inside” includes symptomatologic, anatomical, biomechanical–physiological, and etiological thinking approaches, and “outside” includes CDSS. Moreover, this paper discusses the actual and possible future interplay between “inside” and “outside.” The author envisions that this paper will serve as a cornerstone for the future development of system 2 diagnostic thinking strategy.
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Affiliation(s)
- Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi 321-0293, Japan
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93
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Augustin RC, Simonson MG, Rothenberger SD, Lalama C, Bonifacino E, DiNardo DJ, Tilstra SA. The use of podcasts as a tool to teach clinical reasoning: a pseudorandomized and controlled study. Diagnosis (Berl) 2022; 9:323-331. [PMID: 35086184 DOI: 10.1515/dx-2021-0136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/06/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Podcasts have emerged as an efficient method for widespread delivery of educational clinical reasoning (CR) content. However, the impact of such podcasts on CR skills has not been established. We set out to determine whether exposure to expert reasoning in a podcast format leads to enhanced CR skills. METHODS This is a pseudo-randomized study of third-year medical students (MS3) to either a control group (n=22) of pre-established online CR modules, or intervention group (n=26) with both the online modules and novel CR podcasts. The podcasts were developed from four "clinical unknown" cases presented to expert clinician educators. After completing these assignments in weeks 1-2, weekly history and physical (H&P) notes were collected and graded according to the validated IDEA rubric between weeks 3-7. A longitudinal regression model was used to compare the H&P IDEA scores over time. Usage and perception of the podcasts was also assessed via survey data. RESULTS Ninety control and 128 intervention H&Ps were scored. There was no statistical difference in the change of average IDEA scores between intervention (0.92, p=0.35) and control groups (-0.33, p=0.83). Intervention participants positively received the podcasts and noted increased discussion of CR principles from both their ward (3.1 vs. 2.4, p=0.08) and teaching (3.2 vs. 2.5, p=0.05) attendings. CONCLUSIONS This is the first objective, pseudo-randomized assessment of CR podcasts in undergraduate medical education. While we did not demonstrate significant improvement in IDEA scores, our data show that podcasts are a well-received tool that can prime learners to recognize CR principles.
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Affiliation(s)
- Ryan C Augustin
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael G Simonson
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott D Rothenberger
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Research on Health Care (CRHC) Data Center, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christina Lalama
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Research on Health Care (CRHC) Data Center, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eliana Bonifacino
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah J DiNardo
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Sarah A Tilstra
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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94
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Abstract
Research in cognitive psychology shows that expert clinicians make a medical diagnosis through a two step process of hypothesis generation and hypothesis testing. Experts generate a list of possible diagnoses quickly and intuitively, drawing on previous experience. Experts remember specific examples of various disease categories as exemplars, which enables rapid access to diagnostic possibilities and gives them an intuitive sense of the base rates of various diagnoses. After generating diagnostic hypotheses, clinicians then test the hypotheses and subjectively estimate the probability of each diagnostic possibility by using a heuristic called anchoring and adjusting. Although both novices and experts use this two step diagnostic process, experts distinguish themselves as better diagnosticians through their ability to mobilize experiential knowledge in a manner that is content specific. Experience is clearly the best teacher, but some educational strategies have been shown to modestly improve diagnostic accuracy. Increased knowledge about the cognitive psychology of the diagnostic process and the pitfalls inherent in the process may inform clinical teachers and help learners and clinicians to improve the accuracy of diagnostic reasoning. This article reviews the literature on the cognitive psychology of diagnostic reasoning in the context of cardiovascular disease.
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Affiliation(s)
- John E Brush
- Sentara Health Research Center, Norfolk, VA, USA
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jonathan Sherbino
- McMaster Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Geoffrey R Norman
- McMaster Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
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95
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Davidson B, Ferrer Portillo KM, Wac M, McWilliams C, Bourdeaux C, Craddock I. Requirements for bespoke ICU Dashboard in response to the COVID-19 Pandemic. JMIR Hum Factors 2022; 9:e30523. [PMID: 35038301 PMCID: PMC9009380 DOI: 10.2196/30523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/27/2021] [Accepted: 01/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Intensive care units (ICUs) around the world are in high demand due to patients with COVID-19 requiring hospitalization. As researchers at the University of Bristol, we were approached to develop a bespoke data visualization dashboard to assist two local ICUs during the pandemic that will centralize disparate data sources in the ICU to help reduce the cognitive load on busy ICU staff in the ever-evolving pandemic. Objective The aim of this study was to conduct interviews with ICU staff in University Hospitals Bristol and Weston National Health Service Foundation Trust to elicit requirements for a bespoke dashboard to monitor the high volume of patients, particularly during the COVID-19 pandemic. Methods We conducted six semistructured interviews with clinical staff to obtain an overview of their requirements for the dashboard and to ensure its ultimate suitability for end users. Interview questions aimed to understand the job roles undertaken in the ICU, potential uses of the dashboard, specific issues associated with managing COVID-19 patients, key data of interest, and any concerns about the introduction of a dashboard into the ICU. Results From our interviews, we found the following design requirements: (1) a flexible dashboard, where the functionality can be updated quickly and effectively to respond to emerging information about the management of this new disease; (2) a mobile dashboard, which allows staff to move around on wards with a dashboard, thus potentially replacing paper forms to enable detailed and consistent data entry; (3) a customizable and intuitive dashboard, where individual users would be able to customize the appearance of the dashboard to suit their role; (4) real-time data and trend analysis via informative data visualizations that help busy ICU staff to understand a patient’s clinical trajectory; and (5) the ability to manage tasks and staff, tracking both staff and patient movements, handovers, and task monitoring to ensure the highest quality of care. Conclusions The findings of this study confirm that digital solutions for ICU use would potentially reduce the cognitive load of ICU staff and reduce clinical errors at a time of notably high demand of intensive health care.
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Affiliation(s)
| | | | | | | | - Chris Bourdeaux
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, GB
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96
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Bushunow V, Klein A, Follansbee W, Bonifacino E. Confusion and Representative Restraint: An Exercise in Clinical Reasoning. J Gen Intern Med 2022; 37:236-240. [PMID: 34755267 PMCID: PMC8738816 DOI: 10.1007/s11606-021-07219-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 10/15/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Vasilii Bushunow
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Andrew Klein
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William Follansbee
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Eliana Bonifacino
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Virtual Wards: A Rapid Adaptation to Clinical Attachments in MBChB During the COVID-19 Pandemic. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1356:95-116. [PMID: 35146619 DOI: 10.1007/978-3-030-87779-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
When the COVID-19 pandemic suddenly prevented medical students from attending their clinical attachments, the faculty involved in the third year of medical school (MBChB3) at the University of Glasgow created Virtual Wards. The focus of the Virtual Wards was to continue teaching of clinical reasoning remotely whilst COVID-19 restrictions were in place. Virtual Wards were mapped to the common and important presentations and conditions and provided opportunity for history-taking, clinical examination skills, requesting investigations, interpreting results, diagnosis and management. The Virtual Wards were successful, and further wards were developed the following academic year for MBChB4 students. This chapter describes the theoretical underpinnings of the Virtual Wards and the technological considerations, followed by a description of the Wards themselves. We then analyse an evaluation of the Virtual Wards and provide both a faculty and student perspective. Throughout the chapter, we provide tips for educators developing Virtual Ward environments.
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98
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Minúe Lorenzo S, Astier-Peña MP, Coll Benejam T. [Diagnostic error and overdiagnosis in Primary Care. Proposals for the improvement of clinical practice family medicine]. Aten Primaria 2021; 53 Suppl 1:102227. [PMID: 34961577 PMCID: PMC8721341 DOI: 10.1016/j.aprim.2021.102227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 10/24/2022] Open
Abstract
Family doctors see a wide range of patients, with a wide range of complexity, in a short time and with few diagnostic resources. This situation makes primary care professionals more vulnerable to diagnostic errors. For this reason, an adequate clinical reasoning process is the most powerful tool family doctors have to safely guide the patient care process. Considering these errors as missed opportunities for a correct diagnosis, which may cause harm to the patient, leads us as professionals to review how to improve this process. The review includes, among other aspects, identifying cognitive biases, analysing the ways in which work is organised in primary care teams, and situations in the care context that may contribute to such errors. In this article we describe the most frequent diagnostic errors and their causal factors in primary care, the impact of cognitive process failures, situations of overdiagnosis and the diagnostic and therapeutic cascades associated with them. Finally, we propose a set of tools to improve decision-making in the diagnostic process in primary care.
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Affiliation(s)
- Sergio Minúe Lorenzo
- Escuela Andaluza de Salud Pública, Jefe del Servicio Integrado de Salud basado en la Atención Primaria de Salud. Centro Colaborador de la OMS, Granada, España
| | - Maria Pilar Astier-Peña
- Servicio Aragonés de Salud, Universidad de Zaragoza, GIBA-IIS Aragón, Zaragoza, España; Grupo de Seguridad del Paciente de la Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Barcelona, España.
| | - Txema Coll Benejam
- Grupo de Seguridad del Paciente de la Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Barcelona, España; Atención Primaria, Área de Salut de Menorca, IB-SALUT, Mahón, Menorca, España
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99
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Savaria MC, Min S, Aghagoli G, Tunkel AR, Hirsh DA, Michelow IC. Enhancing the one-minute preceptor method for clinical teaching with a DEFT approach. Int J Infect Dis 2021; 115:149-153. [PMID: 34883233 PMCID: PMC8805221 DOI: 10.1016/j.ijid.2021.12.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/04/2022] Open
Abstract
Few validated methods that are grounded in educational theory exist to effectively teach medical knowledge, clinical skills, and diagnostic reasoning to learners at different stages of medical training. The goal of this Perspective was to address potential gaps in clinical education pedagogy by modeling new concepts for teaching in the field of infectious diseases. Our approach involved synthesizing the relevant literature, identifying proven approaches, and enhancing an existing educational microskills model — the one-minute preceptor. Our strategy was to emphasize the essential core elements of the one-minute preceptor using a descriptive acronym — DEFT (Diagnosis, Evidence, Feedback, Teaching), meaning skillful — as a potentially helpful reminder to improve the quality of interactions between learners and preceptors. The need for learners to discuss risk factors, mechanisms of disease, and potential complications, and for preceptors to model analytical and diagnostic skills, was further illustrated using a practical example of a teacher-learner interaction about a child with a respiratory infection. The one-minute preceptor/DEFT approach is experiential, adaptable, case-driven, and skills-focused, and also applicable to clinical training in other specialties.
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Affiliation(s)
- Michael C Savaria
- Office of Medical Education, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Sugi Min
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ghazal Aghagoli
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Allan R Tunkel
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - David A Hirsh
- Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, USA
| | - Ian C Michelow
- Department of Pediatrics, Division of Infectious Diseases, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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100
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Cleland J, Gates LJ, Waiter GD, Ho VB, Schuwirth L, Durning S. Even a little sleepiness influences neural activation and clinical reasoning in novices. Health Sci Rep 2021; 4:e406. [PMID: 34761123 PMCID: PMC8566838 DOI: 10.1002/hsr2.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND AIMS Sleepiness influences alertness and cognitive functioning and impacts many aspects of medical care, including clinical reasoning. However, dual processing theory suggests that sleepiness will impact clinical reasoning differently in different individual, depending on their level of experience with the given condition. Our aim, therefore, was to examine the association between clinical reasoning, neuroanatomical activation, and sleepiness in senior medical students. METHODS Our methodology replicated an earlier study but with novices rather than board-certified physicians. Eighteen final-year medical students answered validated multiple-choice questions (MCQs) during an fMRI scan. Each MCQ was projected in three phases: reading, answering, and reflection (modified think aloud). Echo-planar imaging (EPI) scans gave a time series that reflected blood oxygenation level dependent (BOLD) signal in each location (voxel) within the brain. Sleep data were collected via self-report (Epworth Sleepiness Scale) and actigraphy. These data were correlated with answer accuracy using Pearson correlation. RESULTS Analysis revealed an increased BOLD signal in the right dorsomedial prefrontal cortex (P < .05) during reflection (Phase 3) associated with increased self-reported sleepiness (ESS) immediately before scanning. Covariate analysis also revealed that increased BOLD signal in the right supramarginal gyrus (P < .05) when reflecting (Phase 3) was associated with increased correct answer response time. Both patterns indicate effortful analytic (System 2) reasoning. CONCLUSION Our findings that novices use System 2 thinking for clinical reasoning and even a little (perceived) sleepiness influences their clinical reasoning ability to suggest that the parameters for safe working may be different for novices (eg, junior doctors) and experienced physicians.
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Affiliation(s)
- Jennifer Cleland
- Lee Kong Chian School of Medicine, Nanyang Technological UniversitySingaporeSingapore
| | - Laura J. Gates
- Institute of Education for Medical and Dental Sciences, University of AberdeenAberdeenUK
| | - Gordon D. Waiter
- Aberdeen Biomedical Imaging Centre, University of AberdeenAberdeenUK
| | - Vincent B. Ho
- Department of Radiology and Radiological SciencesUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Lambert Schuwirth
- College of Medicine and Public Health, Flinders UniversityAdelaideAustralia
| | - Steven Durning
- Department of MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
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