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Krimmel-Morrison JD, Watsjold BK, Berger GN, Bowen JL, Ilgen JS. 'Walking together': How relationships shape physicians' clinical reasoning. MEDICAL EDUCATION 2024; 58:961-969. [PMID: 38525645 DOI: 10.1111/medu.15377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning. METHODS Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest. RESULTS The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts. CONCLUSION Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.
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Affiliation(s)
| | - Bjorn K Watsjold
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Gabrielle N Berger
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Judith L Bowen
- Department of Medical Education and Clinical Sciences, Washington State University Elson S. Floyd School of Medicine, Spokane, Washington, USA
| | - Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Minter DJ, Parsons AS, Abdoler E. Reasoning Report: Engineering Case Conferences to Maximize Clinical Reasoning Education for All Learners. J Gen Intern Med 2024:10.1007/s11606-024-08778-8. [PMID: 38980464 DOI: 10.1007/s11606-024-08778-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/18/2024] [Indexed: 07/10/2024]
Abstract
Case conferences, specifically those in which an unknown case is presented and discussed, are widely utilized in the delivery of medical education. However, the format of case conferences is not always optimized to engage and challenge audience members' clinical reasoning (CR). Based on the current conception of CR and our experience, we provide recommendations on how to better engineer case conferences to maximize CR education for learners at all levels through case selection, conference format, and intentional case construction.
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Affiliation(s)
- Daniel J Minter
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, CA, 94143, USA.
| | - Andrew S Parsons
- Division of General, Geriatric, Palliative, and Hospital Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Emily Abdoler
- Division of Infectious Diseases, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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Harvie DS, McEvoy M, Tomkinson GR. A comparison of visual and direct assessments of lumbar spine posture. J Bodyw Mov Ther 2024; 39:209-213. [PMID: 38876627 DOI: 10.1016/j.jbmt.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Posture is assessed clinically and used to guide treatment of low back pain. Collectively, the relevance of posture and clinical postural assessments have come under scrutiny. This study aimed to determine (a) the intra-rater and inter-rater reliability of visual assessments of lumbar lordosis, and (b) the agreement between visual and direct postural assessments. METHODS Ten physiotherapists visually assessed the lumbar lordosis from 3D scans of 50 asymptomatic participants, and 15 duplicates, using a grading scale of deviations (range: 0 = normal to 3 = severe). Lumbar lordosis angle was directly assessed using the Vitus Smart 3D whole body scanner. Cohen's Kappa was used to determine the intra-rater and inter-rater reliability of visual assessments, with polyserial correlation (ps) used to determine the agreement between visual and direct assessments. RESULTS Overall, 93% and 83% of all intra-rater and inter-rater differences in visual assessments were within a single grade point, respectively. The intra-rater and inter-rater reliability of visual assessments was moderate (κ (95%CI): 0.56 (0.45, 0.67)) and slight (κ (95%CI): 0.13 (0.08, 0.19)), respectively. The agreement between visual and direct assessments was moderate (ps = -0.41, p = 0.04). CONCLUSION Visual assessments of lumbar posture demonstrated moderate repeatability and agreement with quantitative assessments. While agreement between assessors was slight, 83% of the visual ratings were within a single grade point, suggesting greater coherence among clinicians than our statistics suggested. As with any clinical assessments involving uncertainty, postural assessment should not solely guide treatment.
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Affiliation(s)
- Daniel S Harvie
- Allied Health and Human Performance Unit, University of South Australia, Adelaide, Australia.
| | - Maureen McEvoy
- Allied Health and Human Performance Unit, University of South Australia, Adelaide, Australia
| | - Grant R Tomkinson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, SA, Australia
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Sikora A, Keats K, Murphy DJ, Devlin JW, Smith SE, Murray B, Buckley MS, Rowe S, Coppiano L, Kamaleswaran R. A common data model for the standardization of intensive care unit medication features. JAMIA Open 2024; 7:ooae033. [PMID: 38699649 PMCID: PMC11064096 DOI: 10.1093/jamiaopen/ooae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/12/2024] [Accepted: 04/09/2024] [Indexed: 05/05/2024] Open
Abstract
Objective Common data models provide a standard means of describing data for artificial intelligence (AI) applications, but this process has never been undertaken for medications used in the intensive care unit (ICU). We sought to develop a common data model (CDM) for ICU medications to standardize the medication features needed to support future ICU AI efforts. Materials and Methods A 9-member, multi-professional team of ICU clinicians and AI experts conducted a 5-round modified Delphi process employing conference calls, web-based communication, and electronic surveys to define the most important medication features for AI efforts. Candidate ICU medication features were generated through group discussion and then independently scored by each team member based on relevance to ICU clinical decision-making and feasibility for collection and coding. A key consideration was to ensure the final ontology both distinguished unique medications and met Findable, Accessible, Interoperable, and Reusable (FAIR) guiding principles. Results Using a list of 889 ICU medications, the team initially generated 106 different medication features, and 71 were ranked as being core features for the CDM. Through this process, 106 medication features were assigned to 2 key feature domains: drug product-related (n = 43) and clinical practice-related (n = 63). Each feature included a standardized definition and suggested response values housed in the electronic data library. This CDM for ICU medications is available online. Conclusion The CDM for ICU medications represents an important first step for the research community focused on exploring how AI can improve patient outcomes and will require ongoing engagement and refinement.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA 30912, United States
| | - Kelli Keats
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA 30912, United States
| | - David J Murphy
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA 30322, United States
| | - John W Devlin
- Northeastern University School of Pharmacy, Boston, MA 02115, United States
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA 30601, United States
| | - Brian Murray
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC 27514, United States
| | - Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, AZ 85032, United States
| | - Sandra Rowe
- Department of Pharmacy, Oregon Health and Science University, Portland, OR 97239, United States
| | - Lindsey Coppiano
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA 30322, United States
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30322, United States
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA 30322, United States
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30322, United States
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5
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Clinical sensemaking: Advancing a conceptual learning model of clinical reasoning. MEDICAL EDUCATION 2024. [PMID: 38899766 DOI: 10.1111/medu.15461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 05/06/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
CONTEXT Much remains unanswered regarding how clinical reasoning is learned in the clinical environment. This study attempts to unravel how novice medical students learn to reason, by examining how they make sense of the clinical patient encounter. METHOD The current study was part of a greater research project employing constructivist grounded theory (CGT) to develop a learning model of clinical reasoning. Introducing the sensemaking perspective, as a sensitising concept, we conducted a second level analytic phase with CGT, to further advance our previously developed model. This involved re-examining collected data from semi-structured interviews, participant observations and field interviews of novice students during their early clinical clerkships. RESULTS A learning model of how medical students make sense of the patient encounter emerged from the analysis. At its core lie three interdependent processes that co-constitute the students' clinical sensemaking activity. Framing the situation is the process whereby students discern salient situational elements, place them into a meaningful relationship and integrate them into a clinical problem. Inquiring into the situation is the process whereby students gain further insight into the situation by determining which questions need to be asked. Lastly, taking meaningful action is the process whereby students carve out a pathway of action, appropriate for the circumstances. Tensions experienced during these processes impair clinical sensemaking. CONCLUSIONS The study provides an empirically informed learning model of clinical reasoning, during the early curricular stages. The model attempts to capture the complexity of medical practice, as students learn to recognise and respond to what constitutes the essence of a clinical situation. In this way, it contributes to a conceptual shift in how we think and talk about clinical reasoning. It introduces the concept of clinical sensemaking, as the act of carving a tangible clinical problem out of an often undetermined clinical situation and pursuing justified action.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Department of Infectious Diseases, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Anakin MG, Desselle S, Wright DFB. Leverage points for establishing clinical decision-maker as a vital component of pharmacists' professional identity. Res Social Adm Pharm 2024:S1551-7411(24)00191-8. [PMID: 38866606 DOI: 10.1016/j.sapharm.2024.06.002] [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: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/14/2024]
Abstract
This commentary explores how a change in the professional identity of pharmacists from medicines supplier to clinical decision-maker might take place. Three leverage points are identified that support this change. The first leverage point involves workplace culture. Pharmacists require workplaces that support them to assume direct responsibility for drug therapy decisions that may not have traditionally been part of pharmacy practice. The second leverage point involves terminology. Pharmacists need to be able to name and describe the process they use when making decisions about drug therapy. The third leverage point encompasses pharmacy education. Future pharmacists require a foundation that enables them to mobilize their knowledge and skills about drug therapy to act as clinical decision-makers with patients that require complex care. By acting on multiple leverage points, advocates for change in the pharmacy profession can assist pharmacists to establish themselves as decision-makers about drug therapy, shift their professional identity, and reformulate their view of the profession.
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Affiliation(s)
- Megan G Anakin
- Sydney Pharmacy School, University of Sydney, New South Wales, Australia.
| | - Shane Desselle
- Touro University California College of Pharmacy, Vallejo, CA, USA
| | - Daniel F B Wright
- Sydney Pharmacy School, University of Sydney, New South Wales, Australia; St Vincent's Clinical School, School of Medical Sciences, University of New South Wales, Sydney, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Darlinghurst, Australia
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Zhu AQ, Wang Q, Shi YL, Ren WW, Cao X, Ren TT, Wang J, Zhang YQ, Sun YK, Chen XW, Lai YX, Ni N, Chen YC, Hu JL, Mou LC, Zhao YJ, Liu YQ, Sun LP, Zhu XX, Xu HX, Guo LH. A deep learning fusion network trained with clinical and high-frequency ultrasound images in the multi-classification of skin diseases in comparison with dermatologists: a prospective and multicenter study. EClinicalMedicine 2024; 67:102391. [PMID: 38274117 PMCID: PMC10808933 DOI: 10.1016/j.eclinm.2023.102391] [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] [Received: 10/03/2023] [Revised: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024] Open
Abstract
Background Clinical appearance and high-frequency ultrasound (HFUS) are indispensable for diagnosing skin diseases by providing internal and external information. However, their complex combination brings challenges for primary care physicians and dermatologists. Thus, we developed a deep multimodal fusion network (DMFN) model combining analysis of clinical close-up and HFUS images for binary and multiclass classification in skin diseases. Methods Between Jan 10, 2017, and Dec 31, 2020, the DMFN model was trained and validated using 1269 close-ups and 11,852 HFUS images from 1351 skin lesions. The monomodal convolutional neural network (CNN) model was trained and validated with the same close-up images for comparison. Subsequently, we did a prospective and multicenter study in China. Both CNN models were tested prospectively on 422 cases from 4 hospitals and compared with the results from human raters (general practitioners, general dermatologists, and dermatologists specialized in HFUS). The performance of binary classification (benign vs. malignant) and multiclass classification (the specific diagnoses of 17 types of skin diseases) measured by the area under the receiver operating characteristic curve (AUC) were evaluated. This study is registered with www.chictr.org.cn (ChiCTR2300074765). Findings The performance of the DMFN model (AUC, 0.876) was superior to that of the monomodal CNN model (AUC, 0.697) in the binary classification (P = 0.0063), which was also better than that of the general practitioner (AUC, 0.651, P = 0.0025) and general dermatologists (AUC, 0.838; P = 0.0038). By integrating close-up and HFUS images, the DMFN model attained an almost identical performance in comparison to dermatologists (AUC, 0.876 vs. AUC, 0.891; P = 0.0080). For the multiclass classification, the DMFN model (AUC, 0.707) exhibited superior prediction performance compared with general dermatologists (AUC, 0.514; P = 0.0043) and dermatologists specialized in HFUS (AUC, 0.640; P = 0.0083), respectively. Compared to dermatologists specialized in HFUS, the DMFN model showed better or comparable performance in diagnosing 9 of the 17 skin diseases. Interpretation The DMFN model combining analysis of clinical close-up and HFUS images exhibited satisfactory performance in the binary and multiclass classification compared with the dermatologists. It may be a valuable tool for general dermatologists and primary care providers. Funding This work was supported in part by the National Natural Science Foundation of China and the Clinical research project of Shanghai Skin Disease Hospital.
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Affiliation(s)
- An-Qi Zhu
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, China
| | - Qiao Wang
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Yi-Lei Shi
- MedAI Technology (Wuxi) Co., Ltd., Wuxi, China
| | - Wei-Wei Ren
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Xu Cao
- MedAI Technology (Wuxi) Co., Ltd., Wuxi, China
| | - Tian-Tian Ren
- Department of Medical Ultrasound, Ma'anshan People's Hospital, Ma'anshan, China
| | - Jing Wang
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Ya-Qin Zhang
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, China
| | - Yi-Kang Sun
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, China
| | - Xue-Wen Chen
- Department of Dermatological Surgery, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yong-Xian Lai
- Department of Dermatological Surgery, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Na Ni
- Department of Dermatological Surgery, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yu-Chong Chen
- Department of Dermatological Surgery, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | | | - Li-Chao Mou
- MedAI Technology (Wuxi) Co., Ltd., Wuxi, China
| | - Yu-Jing Zhao
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ye-Qiang Liu
- Department of Pathology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Li-Ping Sun
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Xiao-Xiang Zhu
- Chair of Data Science in Earth Observation, Technical University of Munich, Munich, Germany
| | - Hui-Xiong Xu
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, China
| | - Le-Hang Guo
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - China Alliance of Multi-Center Clinical Study for Ultrasound (Ultra-Chance)
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
- MedAI Technology (Wuxi) Co., Ltd., Wuxi, China
- Department of Medical Ultrasound, Ma'anshan People's Hospital, Ma'anshan, China
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, China
- Department of Dermatological Surgery, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Pathology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Chair of Data Science in Earth Observation, Technical University of Munich, Munich, Germany
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Boyle JG, Walters MR, Jamieson S, Durning SJ. Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159. MEDICAL TEACHER 2023; 45:1323-1333. [PMID: 37043405 DOI: 10.1080/0142159x.2023.2190479] [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: 06/19/2023]
Abstract
Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, 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, MD, USA
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Ishizuka K, Shikino K, Kasai H, Hoshina Y, Miura S, Tsukamoto T, Yamauchi K, Ito S, Ikusaka M. The influence of Gamification on medical students' diagnostic decision making and awareness of medical cost: a mixed-method study. BMC MEDICAL EDUCATION 2023; 23:813. [PMID: 37898743 PMCID: PMC10613361 DOI: 10.1186/s12909-023-04808-x] [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: 04/10/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND The gamification of learning increases student enjoyment, and motivation and engagement in learning tasks. This study investigated the effects of gamification using decision-making cards (DMCs) on diagnostic decision-making and cost using case scenarios. METHOD Thirty medical students in clinical clerkship participated and were randomly assigned to 14 small groups of 2-3 medical students each. Decision-making was gamified using DMCs with a clinical information heading and medical cost on the front, and clinical information details on the back. First, each team was provided with brief clinical information on case scenarios. Subsequently, DMCs depending on the case were distributed to each team, and team members chose cards one at a time until they reached a diagnosis of the case. The total medical cost was then scored based on the number and contents of cards drawn. Four case scenarios were conducted. The quantitative outcomes including confidence in effective clinical decision-making, motivation to learn diagnostic decision-making, and awareness of medical costs were measured before and after our gamification by self-evaluation using a 7-point Likert scale. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using DMCs. RESULT Confidence in effective clinical decision-making, motivation to learn diagnostic decision-making, and awareness of medical cost were significantly higher after the gamification. Furthermore, comparing the clinical case scenario tackled last with the one tackled first, the average medical cost of all cards drawn by students decreased significantly from 11,921 to 8,895 Japanese yen. In the content analysis, seven advantage categories of DMCs corresponding to clinical reasoning components were extracted (information gathering, hypothesis generation, problem representation, differential diagnosis, leading or working diagnosis, diagnostic justification, and management and treatment). CONCLUSION Teaching medical students clinical reasoning using DMCs can improve clinical decision-making confidence and learning motivation, and reduces medical cost in clinical case scenarios. In addition, it can help students to acquire practical knowledge, deepens their understanding of clinical reasoning, and identifies several important clinical reasoning skills including diagnostic decision-making and awareness of medical costs. Gamification using DMCs can be an effective teaching method for improving medical students' diagnostic decision-making and reducing costs.
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Affiliation(s)
- Kosuke Ishizuka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan.
- Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan.
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
- Department of Community-oriented Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
| | - Hajme Kasai
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoji Hoshina
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
| | - Saito Miura
- Department of Psychiatry, Chiba University Hospital, Chiba, Japan
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
- Department of Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuyo Yamauchi
- Department of Community-oriented Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
| | - Shoichi Ito
- Health Professional Development Center, Chiba University Hospital, Chiba, Japan
- Department of Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba pref, Japan
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10
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Boyle SM, Martindale J, Parsons AS, Sozio SM, Hilburg R, Bahrainwala J, Chan L, Stern LD, Warburton KM. Development and Validation of a Formative Assessment Tool for Nephrology Fellows' Clinical Reasoning. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00267. [PMID: 37851423 PMCID: PMC10843222 DOI: 10.2215/cjn.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Diagnostic errors are commonly driven by failures in clinical reasoning. Deficits in clinical reasoning are common among graduate medical learners, including nephrology fellows. We created and validated an instrument to assess clinical reasoning in a national cohort of nephrology fellows and established performance thresholds for remedial coaching. METHODS Experts in nephrology education and clinical reasoning remediation designed an instrument to measure clinical reasoning through a written patient encounter note from a web-based, simulated AKI consult. The instrument measured clinical reasoning in three domains: problem representation, differential diagnosis with justification, and diagnostic plan with justification. Inter-rater reliability was established in a pilot cohort ( n =7 raters) of first-year nephrology fellows using a two-way random effects agreement intraclass correlation coefficient model. The instrument was then administered to a larger cohort of first-year fellows to establish performance standards for coaching using the Hofstee method ( n =6 raters). RESULTS In the pilot cohort, there were 15 fellows from four training program, and in the study cohort, there were 61 fellows from 20 training programs. The intraclass correlation coefficients for problem representation, differential diagnosis, and diagnostic plan were 0.90, 0.70, and 0.50, respectively. Passing thresholds (% total points) in problem representation, differential diagnosis, and diagnostic plan were 59%, 57%, and 62%, respectively. Fifty-nine percent ( n =36) met the threshold for remedial coaching in at least one domain. CONCLUSIONS We provide validity evidence for a simulated AKI consult for formative assessment of clinical reasoning in nephrology fellows. Most fellows met criteria for coaching in at least one of three reasoning domains, demonstrating a need for learner assessment and instruction in clinical reasoning.
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Affiliation(s)
- Suzanne M. Boyle
- Section of Nephrology, Hypertension, and Kidney Transplantation, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - James Martindale
- Office of Medical Education, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Andrew S. Parsons
- Division of General, Geriatric, Palliative, and Hospital Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Stephen M. Sozio
- Division of Nephrology, Department of Medicine, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Hilburg
- Renal, Electrolyte, and Hypertension Division, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jehan Bahrainwala
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Lili Chan
- Barbara T. Murphy Division of Nephrology, Mt. Sinai School of Medicine, New York, New York
| | - Lauren D. Stern
- Renal Section, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Karen M. Warburton
- Division of Nephrology, University of Virginia School of Medicine, Charlottsville, Virginia
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11
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Duong QH, Pham TN, Reynolds L, Yeap Y, Walker S, Lyons K. A scoping review of therapeutic reasoning process research. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2023; 28:1289-1310. [PMID: 37043070 PMCID: PMC10624714 DOI: 10.1007/s10459-022-10187-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/09/2022] [Indexed: 06/19/2023]
Abstract
Therapeutic reasoning is when the purpose, task, or goal for engaging in reasoning is to determine the patient's management plan. As the field's understanding of the process of therapeutic reasoning is less well understood, we focused on studies that collected data on the process of therapeutic reasoning. To synthesize previous studies of therapeutic reasoning characteristics, methodological approaches, theoretical underpinnings, and results. We conducted a scoping review with systematic searching for English language articles with no date limits. Databases included MEDLINE, CINAHL Plus, Scopus, Embase, Proquest Dissertations and Theses Global, and ERIC. Search terms captured therapeutic reasoning in health professions education research. Initial search yielded 5450 articles. The title and abstract screening yielded 180 articles. After full-text review, 87 studies were included in this review. Articles were excluded if they were outside health professions education, did not collect data on the process of therapeutic reasoning, were not empirical studies, or not focused on therapeutic reasoning. We analyzed the included articles according to scoping questions using qualitative content analysis. 87 articles dated from 1987 to 2019 were included. Several study designs were employed including think-aloud protocol, interview and written documentation. More than half of the articles analyzed the data using qualitative coding. Authors often utilized several middle-range theories to explain therapeutic reasoning processes. The hypothetico-deductive model was most frequently mentioned. The included articles rarely built off the results from previous studies. Six key result categories were found: identifying themes, characterizing and testing previous local theory, exploring factors, developing new local theory, testing tools, and testing hypothesis. Despite the cast body of therapeutic reasoning research, individual study results remain isolated from previous studies. Our future recommendations include synthesizing pre-existing models, developing novel methodologies, and investigating other aspects of therapeutic reasoning.
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Affiliation(s)
- Quang Hung Duong
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - To Nhu Pham
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Lorenna Reynolds
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Yan Yeap
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Steven Walker
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Pde, Parkville, 3052, Australia
| | - Kayley Lyons
- Centre for Digital Transformation of Health, University of Melbourne, 700 Swanston St, Carlton, 3053, Australia.
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12
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Cook DA, Hargraves IG, Stephenson CR, Durning SJ. Management reasoning and patient-clinician interactions: Insights from shared decision-making and simulated outpatient encounters. MEDICAL TEACHER 2023; 45:1025-1037. [PMID: 36763491 DOI: 10.1080/0142159x.2023.2170776] [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: 06/18/2023]
Abstract
PURPOSE To expand understanding of patient-clinician interactions in management reasoning. METHODS We reviewed 10 videos of simulated patient-clinician encounters to identify instances of problematic and successful communication, then reviewed the videos again through the lens of two models of shared decision-making (SDM): an 'involvement-focused' model and a 'problem-focused' model. Using constant comparative qualitative analysis we explored the connections between these patient-clinician interactions and management reasoning. RESULTS Problems in patient-clinician interactions included failures to: encourage patient autonomy; invite the patient's involvement in decision-making; convey the health impact of the problem; explore and address concerns and questions; explore the context of decision-making (including patient preferences); meet the patient where they are; integrate situational preferences and priorities; offer >1 viable option; work with the patient to solve a problem of mutual concern; explicitly agree to a final care plan; and build the patient-clinician relationship. Clinicians' 'management scripts' varied along a continuum of prioritizing clinician vs patient needs. Patients also have their own cognitive scripts that guide their interactions with clinicians. The involvement-focused and problem-focused SDM models illuminated distinct, complementary issues. CONCLUSIONS Management reasoning is a deliberative interaction occurring in the space between individuals. Juxtaposing management reasoning alongside SDM generated numerous insights.
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Affiliation(s)
- David A Cook
- Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science; and Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ian G Hargraves
- Mayo Clinic National Shared Decision Making Resource Center, Mayo Clinic, Rochester, MN, USA
| | | | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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13
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Boyle JG, Walters MR, Jamieson S, Durning SJ. Reframing context specificity in team diagnosis using the theory of distributed cognition. Diagnosis (Berl) 2023; 10:235-241. [PMID: 37401783 DOI: 10.1515/dx-2022-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 05/17/2023] [Indexed: 07/05/2023]
Abstract
Context specificity refers to the vexing phenomenon whereby a physician can see two patients with the same presenting complaint, identical history and physical examination findings, but due to specific situational (contextual) factors arrives at two different diagnostic labels. Context specificity remains incompletely understood and undoubtedly leads to unwanted variance in diagnostic outcomes. Previous empirical work has demonstrated that a variety of contextual factors impacts clinical reasoning. These findings, however, have largely focused on the individual clinician; here we broaden this work to reframe context specificity in relation to clinical reasoning by an internal medicine rounding team through the lens of Distributed Cognition (DCog). In this model, we see how meaning is distributed amongst the different members of a rounding team in a dynamic fashion that evolves over time. We describe four different ways in which context specificity plays out differently in team-based clinical care than for a single clinician. While we use examples from internal medicine, we believe that the concepts we present apply equally to other specialties and fields in health care.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, 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, MD, USA
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14
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Hege I, Adler M, Donath D, Durning SJ, Edelbring S, Elvén M, Bogusz A, Georg C, Huwendiek S, Körner M, Kononowicz AA, Parodis I, Södergren U, Wagner FL, Wiegleb Edström D. Developing a European longitudinal and interprofessional curriculum for clinical reasoning. Diagnosis (Berl) 2023; 10:218-224. [PMID: 36800998 DOI: 10.1515/dx-2022-0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/24/2023] [Indexed: 02/19/2023]
Abstract
Clinical reasoning is a complex and crucial ability health professions students need to acquire during their education. Despite its importance, explicit clinical reasoning teaching is not yet implemented in most health professions educational programs. Therefore, we carried out an international and interprofessional project to plan and develop a clinical reasoning curriculum with a train-the-trainer course to support educators in teaching this curriculum to students. We developed a framework and curricular blueprint. Then we created 25 student and 7 train-the-trainer learning units and we piloted 11 of these learning units at our institutions. Learners and faculty reported high satisfaction and they also provided helpful suggestions for improvements. One of the main challenges we faced was the heterogeneous understanding of clinical reasoning within and across professions. However, we learned from each other while discussing these different views and perspectives on clinical reasoning and were able to come to a shared understanding as the basis for developing the curriculum. Our curriculum fills an important gap in the availability of explicit clinical reasoning educational materials both for students and faculty and is unique with having specialists from different countries, schools, and professions. Faculty time and time for teaching clinical reasoning in existing curricula remain important barriers for implementation of clinical reasoning teaching.
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Affiliation(s)
- Inga Hege
- Medical Education Sciences, University of Augsburg, Augsburg, Germany
| | | | - Daniel Donath
- Faculty of Medicine and Health, EDU Higher Education Institute, Kalkara, Malta
| | - Steven J Durning
- Uniformed Services University of the Health Sciences, Bethesda, USA
| | | | - Maria Elvén
- School of Health Sciences, Örebro University, Örebro, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Örebro, Sweden
| | - Ada Bogusz
- Jagiellonian University Medical College, Kraków, Poland
| | - Carina Georg
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Sören Huwendiek
- Department for Assessment and Evaluation, Institute for Medical Education, Bern, Switzerland
| | - Melina Körner
- Medical Education Sciences, University of Augsburg, Augsburg, Germany
| | | | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Felicitas L Wagner
- Department for Assessment and Evaluation, Institute for Medical Education, Bern, Switzerland
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15
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Fong JMN, Hoe RHM, Huang DH, Wong JC, Kee XLJ, Teng KLA, Hong R, Saffari SE, Tan K, Tan NCK. Script concordance test to assess diagnostic and management reasoning in acute medicine. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:383-385. [PMID: 38904506 DOI: 10.47102/annals-acadmedsg.202327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Clinical reasoning, an essential skill for patient care, can be difficult to assess. We created and validated a script concordance test (SCT) to assess clinical reasoning in acute medicine. This tool was used to provide feedback and targeted remediation for Postgraduate-Year-1 (PGY1) doctors, guide teaching and learning, and facilitate programme evaluation.
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Affiliation(s)
| | | | | | | | | | | | - Rilong Hong
- Department of Cardiology, National Heart Centre Singapore
| | - Seyed Ehsan Saffari
- Department of Neurology, National Neuroscience Institute, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute, Singapore
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16
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Quail NPA, Boyle JG. Twine virtual patient games as an online resource for undergraduate diabetes acute care education. BMC MEDICAL EDUCATION 2023; 23:417. [PMID: 37286971 PMCID: PMC10244842 DOI: 10.1186/s12909-023-04231-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 04/03/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Virtual patients provide a safe way to simulate authentic clinical practice. Twine is an open-source software that can be used to create intricate virtual patient games, including elements like non-linear free text history taking and time-related changes to the game's narrative. We evaluated the incorporation of Twine virtual patient games into a diabetes acute care online learning package for undergraduate medical students at the University of Glassgow, Scotland. METHODS Three games were developed using Twine, Wacom Intuous Pro, Autodesk SketchBook, Camtasia Studio, and simulated patients. Online material included three VP games, eight microlectures, and a single best answer multiple choice question quiz. The games were evaluated at Kirkpatrick Level 1 with an acceptability and usability questionnaire. The entire online package was evaluated at Kirkpatrick Level 2 with pre- and post-course multiple choice and confidence questions, with statistical analysis performed using paired t-tests. RESULTS 122 of approximately 270 eligible students provided information on resource utilisation, with 96% of these students using at least one online resource. 68% of students who returned surveys used at least one VP game. 73 students provided feedback on the VP games they had played, with the majority of median responses being "agree" on positive usability and acceptability statements. The online resources were associated with a mean multiple choice score increase from 4.37 out of 10 to 7.96 out of 10 (p < 0.0001, 95% CI + 2.99 to + 4.20, n = 52) and a mean total confidence score increase from 4.86 out of 10 to 6.70 out of 10 (p < 0.0001, 95% CI + 1.37 to + 2.30, n = 48). CONCLUSIONS Our VP games were well-received by students and promoted engagement with online material. The package of online material led to statistically significant increases in confidence and knowledge in diabetes acute care outcomes. A blueprint with supporting instructions has now been created to facilitate rapid creation of further games using Twine software.
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Affiliation(s)
| | - James Graham Boyle
- University of Glasgow, Glasgow, G12 8QQ, UK
- Glasgow Royal Infirmary, Glasgow, G4 0SF, UK
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17
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Vreugdenhil J, Somra S, Ket H, Custers EJFM, Reinders ME, Dobber J, Kusurkar RA. Reasoning like a doctor or like a nurse? A systematic integrative review. Front Med (Lausanne) 2023; 10:1017783. [PMID: 36936242 PMCID: PMC10020202 DOI: 10.3389/fmed.2023.1017783] [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: 08/12/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
When physicians and nurses are looking at the same patient, they may not see the same picture. If assuming that the clinical reasoning of both professions is alike and ignoring possible differences, aspects essential for care can be overlooked. Understanding the multifaceted concept of clinical reasoning of both professions may provide insight into the nature and purpose of their practices and benefit patient care, education and research. We aimed to identify, compare and contrast the documented features of clinical reasoning of physicians and nurses through the lens of layered analysis and to conduct a simultaneous concept analysis. The protocol of this systematic integrative review was published doi: 10.1136/bmjopen-2021-049862. A comprehensive search was performed in four databases (PubMed, CINAHL, Psychinfo, and Web of Science) from 30th March 2020 to 27th May 2020. A total of 69 Empirical and theoretical journal articles about clinical reasoning of practitioners were included: 27 nursing, 37 medical, and five combining both perspectives. Two reviewers screened the identified papers for eligibility and assessed the quality of the methodologically diverse articles. We used an onion model, based on three layers: Philosophy, Principles, and Techniques to extract and organize the data. Commonalities and differences were identified on professional paradigms, theories, intentions, content, antecedents, attributes, outcomes, and contextual factors. The detected philosophical differences were located on a care-cure and subjective-objective continuum. We observed four principle contrasts: a broad or narrow focus, consideration of the patient as such or of the patient and his relatives, hypotheses to explain or to understand, and argumentation based on causality or association. In the technical layer a difference in the professional concepts of diagnosis and the degree of patient involvement in the reasoning process were perceived. Clinical reasoning can be analysed by breaking it down into layers, and the onion model resulted in detailed features. Subsequently insight was obtained in the differences between nursing and medical reasoning. The origin of these differences is in the philosophical layer (professional paradigms, intentions). This review can be used as a first step toward gaining a better understanding and collaboration in patient care, education and research across the nursing and medical professions.
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Affiliation(s)
- Jettie Vreugdenhil
- Research in Education, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- VUmc Amstel Academie, Institute for Education and Training, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Faculty of Psychology and Education, LEARN! Research Institute for Learning and Education, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Hans Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Marcel E. Reinders
- Family Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jos Dobber
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam School of Nursing, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Rashmi A. Kusurkar
- Research in Education, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Faculty of Psychology and Education, LEARN! Research Institute for Learning and Education, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, Netherlands
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18
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Young M, Szulewski A, Anderson R, Gomez-Garibello C, Thoma B, Monteiro S. Clinical Reasoning in CanMEDS 2025. CANADIAN MEDICAL EDUCATION JOURNAL 2023; 14:58-62. [PMID: 36998494 PMCID: PMC10042778 DOI: 10.36834/cmej.75843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Meredith Young
- Institute of Health Sciences Education, McGill University, Quebec, Canada
| | | | | | | | - Brent Thoma
- University of Saskatchewan, Saskatchewan, Canada
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19
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20
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Sader J, Diana A, Coen M, Nendaz M, Audétat MC. A GP's clinical reasoning in the context of multimorbidity: beyond the perception of an intuitive approach. Fam Pract 2023; 40:113-118. [PMID: 35849124 DOI: 10.1093/fampra/cmac076] [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] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION GP's clinical reasoning processes in the context of patients suffering from multimorbidity are often a process which remains implicit. Therefore, the goal of this case study analysis is to gain a better understanding of the processes at play in the management of patients suffering from multimorbidity. METHODS A case study analysis, using a qualitative thematic analysis was conducted. This case follows a 54-year-old woman who has been under the care of her GP for almost 10 years and suffers from a number of chronic conditions. The clinical reasoning of an experienced GP who can explicitly unfold his processes was chosen for this case analysis. RESULTS Four main themes emerged from this case analysis: The different roles that GPs have to manage; the GP's cognitive flexibility and continual adaptation of their clinical reasoning processes, the patient's empowerment, and the challenges related to the collaboration with specialists and healthcare professionals. CONCLUSION This could help GPs gain a clearer understanding of their clinical reasoning processes and motivate them to communicate their findings with others during clinical supervision or teaching. Furthermore, this may emphasize the importance of valuing the role of the primary care physician in the management of multimorbid patients.
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Affiliation(s)
- Julia Sader
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,iEh2-Institute for Ethics, History, and the Humanities, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alessandro Diana
- IuMFE-Institute of Primary Care, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Matteo Coen
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HUG-Department of Medicine, University Hospitals Geneva, Geneva, Switzerland
| | - Mathieu Nendaz
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HUG-Department of Medicine, University Hospitals Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- UDREM-Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,IuMFE-Institute of Primary Care, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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21
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Abdoler EA, Parsons AS, Wijesekera TP. The future of teaching management reasoning: important questions and potential solutions. Diagnosis (Berl) 2023; 10:19-23. [PMID: 36420532 DOI: 10.1515/dx-2022-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022]
Abstract
Management reasoning is distinct from but inextricably linked to diagnostic reasoning in the iterative process that is clinical reasoning. Complex and situated, management reasoning skills are distinct from diagnostic reasoning skills and must be developed in order to promote cogent clinical decisions. While there is growing interest in teaching management reasoning, key educational questions remain regarding when it should be taught, how it can best be taught in the clinical setting, and how it can be taught in a way that helps mitigate implicit bias. Here, we describe several useful tools to structure teaching of management reasoning across learner levels and educational settings. The management script provides a scaffold for organizing knowledge around management and can serve as a springboard for discussion of uncertainty, thresholds, high-value care, and shared decision-making. The management pause reserves space for management discussions and exploration of a learner's reasoning. Finally, the equity reflection invites learners to examine management decisions from a health equity perspective, promoting the practice of metacognition around implicit bias. These tools are easily deployable, and - when used regularly - foster a learning environment primed for the successful teaching of management reasoning.
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Affiliation(s)
- Emily A Abdoler
- Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrew S Parsons
- Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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22
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Schaye V, Parsons AS, Graber ML, Olson APJ. The future of diagnosis - where are we going? Diagnosis (Berl) 2023; 10:1-3. [PMID: 36720463 DOI: 10.1515/dx-2023-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Verity Schaye
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Andrew S Parsons
- Department of Medicine, Section of Hospital Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Mark L Graber
- Founder and President Emeritus, Society to Improve Diagnosis in Medicine, Plymouth, MA, USA.,Professor Emeritus, Stony Brook University, NY, USA
| | - Andrew P J Olson
- Division of Hospital Medicine, Department of Medicine, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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23
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Elvén M, Welin E, Wiegleb Edström D, Petreski T, Szopa M, Durning SJ, Edelbring S. Clinical Reasoning Curricula in Health Professions Education: A Scoping Review. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231209093. [PMID: 37900617 PMCID: PMC10605682 DOI: 10.1177/23821205231209093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/09/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVES This scoping review aimed to explore and synthesize current literature to advance the understanding of how to design clinical reasoning (CR) curricula for students in health professions education. METHODS Arksey and O'Malley's 6-stage framework was applied. Peer-reviewed articles were searched in PubMed, Web of Science, CINAHL, and manual searches, resulting in the identification of 2932 studies. RESULTS Twenty-six articles were included on CR in medical, nursing, physical therapy, occupational therapy, midwifery, dentistry, and speech language therapy education. The results describe: features of CR curriculum design; CR theories, models, and frameworks that inform curricula; and teaching content, methods, and assessments that inform CR curricula. CONCLUSIONS Several CR theories, teaching, and assessment methods are integrated into CR curricula, reflecting the multidimensionality of CR among professions. Specific CR elements are addressed in several curricula; however, no all-encompassing CR curriculum design has been identified. These findings offer useful insights for educators into how CR can be taught and assessed, but they also suggest the need for further guidance on educational strategies and assessments while learners progress through an educational program.
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Affiliation(s)
- Maria Elvén
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Elisabet Welin
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Desiree Wiegleb Edström
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Tadej Petreski
- Institute for Biomedical Sciences, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Magdalena Szopa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Steven J. Durning
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Samuel Edelbring
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Brian R, Syed S. Therapeutic Reasoning: A Conceptual Challenge for Medical Students' Surgical Clerkship. TEACHING AND LEARNING IN MEDICINE 2023; 35:95-100. [PMID: 35034525 DOI: 10.1080/10401334.2021.2017943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 11/06/2021] [Accepted: 11/23/2021] [Indexed: 06/14/2023]
Abstract
Issue: Medical students' transition between pre-clinical and clinical environments can be jarring. Unclear expectations, disconnect between the pre-clinical and clinical environments, and feelings of exclusion from the team all negatively influence clerkship experiences. These difficulties are magnified on interventional-based clerkships due to the central role of therapeutic reasoning. Therapeutic reasoning is the process by which clinicians review and select treatments for their patients. Surgical therapeutic reasoning is challenging and infrequently addressed explicitly in the pre-clinical curriculum. This contributes to confusion among medical students as they transition from pre-clinical to clinical learning. Evidence: Multiple studies have identified challenges to medical students' transition to clinical clerkships. Prior authors have outlined numerous barriers to successful medical student integration to clinical teams, including surgical teams. Studies that have assessed students' perceptions of their transition to a clinical setting noted poor understanding of treatment decisions as a source of anxiety. Additionally, of particular importance to medical student team learning is their assimilation into the "communities of clinical practice," groups of healthcare professionals who form teams with which students rotate. Surgeons have distinct approaches to the clinical process compared with non-interventionalists, particularly related to post-diagnostic involvement in care and performing diagnostic workup and treatment concurrently. Knowledge of these approaches is important for integration into surgical teams. Implications: An understanding of interventional therapeutic reasoning is critical to allow for medical students' team integration on surgical and interventional clerkships. By incorporating education involving these concepts during the orientation period prior to students' transition to surgical clerkships, we can help students modify traditional mental frameworks to effectively evaluate, present, and select appropriate interventions for patients. Such education should include a didactic introduction to therapeutic reasoning, interactive discussion with surgeons, and exercises for students to practice skills. This will maximize learning opportunities and clerkship experience.
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Affiliation(s)
- Riley Brian
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Shareef Syed
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Cook DA, Stephenson CR, Gruppen LD, Durning SJ. Management Reasoning: Empirical Determination of Key Features and a Conceptual Model. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:80-87. [PMID: 35830267 DOI: 10.1097/acm.0000000000004810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Management reasoning is a critical yet understudied phenomenon in clinical practice and medical education. The authors sought to empirically identify key features of management reasoning and construct a model describing the management reasoning process. METHOD In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters and used a coding form to document key features and insights related to management reasoning. The team used a constant comparative approach to distill 120 pages of raw observations into an 18-page list of management tasks, processes, and insights. The team then had a series of discussions to iteratively refine these findings into a parsimonious model of management reasoning. RESULTS The investigators empirically identified 12 distinct features of management reasoning: contrasting and selection among multiple solutions; prioritization of patient, clinician, and system preferences and constraints; communication and shared decision making; ongoing monitoring and adjustment of the management plan; dynamic interplay among people, systems, and competing priorities; illness-specific knowledge; process knowledge; management scripts; clinician roles as patient teacher and salesperson; clinician-patient relationship; prognostication; and organization of the clinical encounter (sequencing and time management). Management scripts seemed to play a prominent and critical role. The model of management reasoning comprised 4 steps: instantiation of a management script, identifying (multiple) options and beginning to teach the patient, shared decision making, and ongoing monitoring and adjustment. This model also conceives 2 overarching features: that management reasoning is personalized to the patient and that it occurs between individuals rather than exclusively within the clinician's mind. CONCLUSIONS Management scripts constitute a key feature of management reasoning, along with teaching patients about viable options, shared decision making, ongoing monitoring and adjustment, and personalization. Management reasoning seems to be constructed and negotiated between individuals rather than exclusively within the clinician.
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Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and professor of medical education, director of education science, Office of Applied Scholarship and Education Science, and consultant, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633
| | - Christopher R Stephenson
- C.R. Stephenson is assistant professor of medicine and consultant, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; ORCID: https://orcid.org/0000-0001-8537-392X
| | - Larry D Gruppen
- L.D. Gruppen is professor, Department of Learning Health Sciences, and director, Master in Health Professions Education Program, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0002-2107-0126
| | - Steven J Durning
- S.J. Durning is professor and vice chair, Department of Medicine, and director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0001-5223-1597
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Cheung JJH, Kulasegaram KM. Beyond the tensions within transfer theories: implications for adaptive expertise in the health professions. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:1293-1315. [PMID: 36369374 DOI: 10.1007/s10459-022-10174-y] [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: 05/25/2022] [Accepted: 10/08/2022] [Indexed: 06/16/2023]
Abstract
Ensuring trainees develop the flexibility with their knowledge to address novel problems, and to efficiently build upon prior knowledge to learn new knowledge is a common goal in health profession education. How trainees come to develop this capacity to transfer and transform knowledge across contexts can be described by adaptive expertise, which focuses on the ability of some experts to innovate upon their existing knowledge to develop novel solutions to novel problems. While adaptive expertise is often presented as an alternative framework to more traditional cognitivist and constructivist expertise models, it is unclear whether the non-routine and routine forms of transfer it describes are distinct from those described by other accounts of transfer. Furthermore, whether what (e.g., knowledge) is transferred and how (e.g., cognitive processes) differs between these views is still debated. In this review, we describe various theories of transfer and present a synthesis clarifying the relationship between transfer and adaptive expertise. Informed by our analysis, we argue that the mechanisms of transfer in adaptive expertise share important commonalities with traditional accounts of transfer, which when understood, can complement efforts by educators and researchers to foster and study adaptive expertise. We present three instructional principles that may better support transfer and adaptive expertise in trainees: i) identifying and incorporating meaningful variability in practice, ii) integrating conceptual knowledge during practice iii) using assessments of trainees' transfer. Taken together, we offer an integrative perspective to how educational systems and experiences can be designed to develop and encourage adaptive expertise and transfer.
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Affiliation(s)
- Jeffrey J H Cheung
- Department of Medical Education, University of Illinois College of Medicine at Chicago, 808 South Wood Street, 966 CMET MC 591, Chicago, IL, 60612, USA.
| | - Kulamakan M Kulasegaram
- Department of Community and Family Medicine, University of Toronto, Toronto, ON, Canada
- The Wilson Centre, The Toronto General Hospital, Toronto, ON, Canada
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Singaraju RC, Durning SJ, Battista A, Konopasky A. Exploring procedure-based management reasoning: a case of tension pneumothorax. Diagnosis (Berl) 2022; 9:437-445. [PMID: 35924305 DOI: 10.1515/dx-2022-0028] [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: 03/06/2022] [Accepted: 07/10/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Management reasoning has not been widely explored but likely requires broader abilities than diagnostic reasoning. An enhanced understanding of management reasoning could improve medical education and patient care. We conducted a novel exploratory study to gain further insights into procedure-based management reasoning. METHODS Participant physicians managed a simulated patient who acutely decompensates in a team-based, time-pressured, live scenario. Immediately following the scenario, physicians perform a think-aloud protocol by watching video recordings of their performance and narrating their reflections in real-time. Verbatim transcripts of the think-aloud protocol were inductively coded using a constant comparative method and evaluated for themes. RESULTS We recruited 19 physicians (15 internal medicine, one family medicine, and three general surgery) for this study. Recognizing that diagnostic and management reasoning intertwine, this paper focuses on management reasoning's characteristics. We developed three categories of management reasoning factors with eight subthemes. These are Patient factors: Acuity and Preferences; Physician factors: Recognized Errors, Anxiety, Metacognition, Monitoring, and Threshold to Treat; and one Environment factor: Resources. CONCLUSIONS Our findings on procedure-based management reasoning are consistent with Situation Awareness and Situated Cognition models and the extant work on management reasoning, demonstrating that management is inherently complex and contextually bound. Unique to this study, all physicians focused on prognosis, indicating that attaining competency in procedural management may require planning and prediction abilities. Physicians also expressed concerns about making mistakes, potentially resulting from the scenario's emphasis on a procedure and our physicians' having less expertise in the treatment of tension pneumothorax.
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Affiliation(s)
- Raj C Singaraju
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Steven J Durning
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alexis Battista
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Abigail Konopasky
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Managing uncertainty in decision-making of common congenital cardiac defects. Cardiol Young 2022; 32:1705-1717. [PMID: 36300500 DOI: 10.1017/s1047951122003316] [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] [Indexed: 11/07/2022]
Abstract
Decision-making in congenital cardiac care, although sometimes appearing simple, may prove challenging due to lack of data, uncertainty about outcomes, underlying heuristics, and potential biases in how we reach decisions. We report on the decision-making complexities and uncertainty in management of five commonly encountered congenital cardiac problems: indications for and timing of treatment of subaortic stenosis, closure or observation of small ventricular septal defects, management of new-onset aortic regurgitation in ventricular septal defect, management of anomalous aortic origin of a coronary artery in an asymptomatic patient, and indications for operating on a single anomalously draining pulmonary vein. The strategy underpinning each lesion and the indications for and against intervention are outlined. Areas of uncertainty are clearly delineated. Even in the presence of "simple" congenital cardiac lesions, uncertainty exists in decision-making. Awareness and acceptance of uncertainty is first required to facilitate efforts at mitigation. Strategies to circumvent uncertainty in these scenarios include greater availability of evidence-based medicine, larger datasets, standardised clinical assessment and management protocols, and potentially the incorporation of artificial intelligence into the decision-making process.
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Chartash D, Rosenman M, Wang K, Chen E. Informatics in Undergraduate Medical Education: Analysis of Competency Frameworks and Practices Across North America. JMIR MEDICAL EDUCATION 2022; 8:e39794. [PMID: 36099007 PMCID: PMC9516378 DOI: 10.2196/39794] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/02/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND With the advent of competency-based medical education, as well as Canadian efforts to include clinical informatics within undergraduate medical education, competency frameworks in the United States have not emphasized the skills associated with clinical informatics pertinent to the broader practice of medicine. OBJECTIVE By examining the competency frameworks with which undergraduate medical education in clinical informatics has been developed in Canada and the United States, we hypothesized that there is a gap: the lack of a unified competency set and frame for clinical informatics education across North America. METHODS We performed directional competency mapping between Canadian and American graduate clinical informatics competencies and general graduate medical education competencies. Directional competency mapping was performed between Canadian roles and American common program requirements using keyword matching at the subcompetency and enabling competency levels. In addition, for general graduate medical education competencies, the Physician Competency Reference Set developed for the Liaison Committee on Medical Education was used as a direct means of computing the ontological overlap between competency frameworks. RESULTS Upon mapping Canadian roles to American competencies via both undergraduate and graduate medical education competency frameworks, the difference in focus between the 2 countries can be thematically described as a difference between the concepts of clinical and management reasoning. CONCLUSIONS We suggest that the development or deployment of informatics competencies in undergraduate medical education should focus on 3 items: the teaching of diagnostic reasoning, such that the information tasks that comprise both clinical and management reasoning can be discussed; precision medical education, where informatics can provide for more fine-grained evaluation; and assessment methods to support traditional pedagogical efforts (both at the bedside and beyond). Assessment using cases or structured assessments (eg, Objective Structured Clinical Examinations) would help students draw parallels between clinical informatics and fundamental clinical subjects and would better emphasize the cognitive techniques taught through informatics.
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Affiliation(s)
- David Chartash
- School of Medicine, University College Dublin - National University of Ireland, Dublin, Ireland
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, United States
| | - Marc Rosenman
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Karen Wang
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, United States
| | - Elizabeth Chen
- Center for Biomedical Informatics, The Warren Alpert Medical School of Brown University, Providence, RI, United States
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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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Peterson BD, Magee CD, Martindale JR, Dreicer JJ, Mutter MK, Young G, Sacco MJ, Parsons LC, Collins SR, Warburton KM, Parsons AS. REACT: Rapid Evaluation Assessment of Clinical Reasoning Tool. J Gen Intern Med 2022; 37:2224-2229. [PMID: 35710662 PMCID: PMC9202973 DOI: 10.1007/s11606-022-07513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/25/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Clinical reasoning encompasses the process of data collection, synthesis, and interpretation to generate a working diagnosis and make management decisions. Situated cognition theory suggests that knowledge is relative to contextual factors, and clinical reasoning in urgent situations is framed by pressure of consequential, time-sensitive decision-making for diagnosis and management. These unique aspects of urgent clinical care may limit the effectiveness of traditional tools to assess, teach, and remediate clinical reasoning. METHODS Using two validated frameworks, a multidisciplinary group of clinicians trained to remediate clinical reasoning and with experience in urgent clinical care encounters designed the novel Rapid Evaluation Assessment of Clinical Reasoning Tool (REACT). REACT is a behaviorally anchored assessment tool scoring five domains used to provide formative feedback to learners evaluating patients during urgent clinical situations. A pilot study was performed to assess fourth-year medical students during simulated urgent clinical scenarios. Learners were scored using REACT by a separate, multidisciplinary group of clinician educators with no additional training in the clinical reasoning process. REACT scores were analyzed for internal consistency across raters and observations. RESULTS Overall internal consistency for the 41 patient simulations as measured by Cronbach's alpha was 0.86. A weighted kappa statistic was used to assess the overall score inter-rater reliability. Moderate reliability was observed at 0.56. DISCUSSION To our knowledge, REACT is the first tool designed specifically for formative assessment of a learner's clinical reasoning performance during simulated urgent clinical situations. With evidence of reliability and content validity, this tool guides feedback to learners during high-risk urgent clinical scenarios, with the goal of reducing diagnostic and management errors to limit patient harm.
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Affiliation(s)
| | - Charles D Magee
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | | | - M Kathryn Mutter
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Gregory Young
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Laura C Parsons
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | | | - Andrew S Parsons
- University of Virginia School of Medicine, Charlottesville, VA, USA.
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Krimmel-Morrison JD, Dhaliwal G. How to Keep Training-After Residency Training. J Gen Intern Med 2022; 37:1524-1528. [PMID: 35226236 PMCID: PMC9086009 DOI: 10.1007/s11606-021-07240-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022]
Abstract
Lifelong learning in medicine is an important skill and ethical obligation, but many residents do not feel prepared to be effective self-directed learners when training ends. The learning sciences offer evidence to guide self-directed learning, but these insights have not been integrated into a practical and actionable plan for residents to improve their clinical knowledge and reasoning. We encourage residents to establish a self-directed learning plan, just as an athlete employs a training plan in the pursuit of excellence. We highlight four evidence-based learning principles (spaced practice, mixed practice, retrieval practice, and feedback) and four training strategies comprising a weekly training plan: case tracking, simulated cases, quizzing, and new evidence integration. We provide tips for residents to implement and refine their approach and discuss how residency programs can foster these routines and habits. By optimizing their scarce self-directed learning time with a training plan, residents may enhance patient care and their career satisfaction through their pursuit of clinical mastery.
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Affiliation(s)
- Jeffrey D Krimmel-Morrison
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, 98195-6420, USA.
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California, San Francisco and Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
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Atallah F, Hamm RF, Davidson CM, Combs CA. Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities. Am J Obstet Gynecol 2022; 227:B2-B10. [PMID: 35487325 DOI: 10.1016/j.ajog.2022.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The processes of diagnosis and management involve clinical decision-making. However, decision-making is often affected by cognitive biases that can lead to medical errors. This statement presents a framework of clinical thinking and decision-making and shows how these processes can be bias-prone. We review examples of cognitive bias in obstetrics and introduce debiasing tools and strategies. When an adverse event or near miss is reviewed, the concept of a cognitive autopsy-a root cause analysis of medical decision-making and the potential influence of cognitive biases-is promoted as part of the review process. Finally, areas for future research on cognitive bias in obstetrics are suggested.
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Affiliation(s)
- Fouad Atallah
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Rebecca F Hamm
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | | | - C Andrew Combs
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Tausendfreund O, Braun LT, Schmidmaier R. Types of therapeutic errors in the management of osteoporosis made by physicians and medical students. BMC MEDICAL EDUCATION 2022; 22:323. [PMID: 35473636 PMCID: PMC9044589 DOI: 10.1186/s12909-022-03384-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 04/11/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Clinical reasoning is of high importance in clinical practice and thus in medical education research. Regarding the clinical reasoning process, the focus has primarily been on diagnostic reasoning and diagnostic errors, but little research has been done on the subsequent management reasoning process, although the therapeutic decision-making process is at least equally important. The aim of this study was to investigate the frequency of therapeutic decision errors and the cognitive factors leading to these errors in the context of osteoporosis, as it is known to be frequently associated with inadequate treatment decisions in clinical practice worldwide. METHODS In 2019, 19 medical students and-for comparison-23 physicians worked on ten patient cases with the medical encounter of osteoporosis. A total of 254 cases were processed. The therapeutic decision errors were quantitatively measured, and the participants' cognitive contributions to therapeutic errors and their clinical consequences were qualitatively analysed. RESULTS In 26% of the cases, all treatment decisions were correct. In the remaining 74% cases, multiple errors occurred; on average, 3 errors occurred per case. These 644 errors were further classified regarding the cognitive contributions to the error. The most common cognitive contributions that led to errors were faulty context generation and interpretation (57% of students, 57% of physicians) and faulty knowledge (38% of students, 35% of physicians). Errors made due to faulty metacognition (5% of students, 8% of physicians) were less common. Consequences of these errors were false therapy (37% of cases), undertreatment (30% of cases) or overtreatment (2.5% of cases). CONCLUSION The study is the first to show that errors in therapy decisions can be distinguished and classified, similar to the already known classification for errors in diagnostic reasoning. Not only the correct diagnosis, but particularly the correct therapy, is critical for the outcome of a patient.
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Affiliation(s)
- Olivia Tausendfreund
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336 Munich, Germany
| | - Leah T. Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336 Munich, Germany
| | - Ralf Schmidmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336 Munich, Germany
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Over the Threshold: an Exercise in Clinical Reasoning. J Gen Intern Med 2022; 37:1290-1294. [PMID: 35075534 PMCID: PMC8971242 DOI: 10.1007/s11606-021-07206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 10/08/2021] [Indexed: 10/19/2022]
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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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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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Stojan JN, Daniel M, Hartley S, Gruppen L. Dealing with uncertainty in clinical reasoning: A threshold model and the roles of experience and task framing. MEDICAL EDUCATION 2022; 56:195-201. [PMID: 34609018 DOI: 10.1111/medu.14673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/21/2021] [Accepted: 09/29/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Uncertainty is integral to clinical practice and clinical reasoning but has proven difficult to study and model. Little is known about how clinicians manage uncertainty. According to evidence-based medicine theory, clinicians should utilise new information to reduce uncertainty until reaching action thresholds for further information gathering or treatment. We examined the impact of experience and task framing on uncertainty thresholds and the extent to which these thresholds guided clinical decisions. Finally, we sought to determine the impact of framing by having participants provide threshold responses as a range or as specific numbers. METHODS One hundred sixty-eight fourth-year medical students, 93 residents and 72 faculty were presented a case of viral pneumonia with a suspected superimposed bacterial infection. Participants identified their testing and treatment thresholds with either a specific number or an inter-threshold range of probabilities that would compel them to test further. Afterwards, they were told the patient had a 20% pre-test probability of a superimposed infection and asked whether they would treat the patient with antibiotics, order additional testing or neither. Responses were compared with their previously stated threshold values to assess decision-making consistency. RESULTS Testing thresholds were 15.8%, 20.6% and 25.8%, treatment thresholds were 78.5%, 71.6% and 73.4% and threshold spans (difference between testing and treatment thresholds) were 62.7, 51 and 47.6 for students, residents and faculty, respectively. Sixty-four percent of respondents made judgements consistent with their thresholds, 28% escalated their decision (doing more than their thresholds predicted) and 7.6% de-escalated their decision (doing less than their thresholds predicted). Framing had an impact on both faculty and resident decisions and a larger impact on students. DISCUSSION These findings help us understand how clinical reasoning and threshold determinations vary with clinical experience. As uncertainty can lead to unnecessary testing and cognitive discomfort, examining decision thresholds helps us ascertain how diagnostic and treatment decisions are made.
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Affiliation(s)
- Jennifer N Stojan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Michelle Daniel
- Department of Medical Education, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Emergency Medicine, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Sarah Hartley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Larry Gruppen
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
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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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Lea M, Hofmann BM. Dediagnosing - a novel framework for making people less ill. Eur J Intern Med 2022; 95:17-23. [PMID: 34417089 DOI: 10.1016/j.ejim.2021.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/23/2021] [Accepted: 07/30/2021] [Indexed: 01/06/2023]
Abstract
Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions including the prescription of medicines. Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to the reduction of persons' suffering and should be introduced to make people less ill. Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation, deprescribing, decommissioning, and disinvestment. Because diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient.
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Affiliation(s)
- Marianne Lea
- Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway; Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South Eastern Norway, Norway.
| | - Bjørn Morten Hofmann
- Department for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway; Centre of Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway
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Gruenberg K, Abdoler E, O'Brien BC, Schwartz BS, MacDougall C. How do pharmacists select antimicrobials? A model of pharmacists' therapeutic reasoning processes. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Katherine Gruenberg
- Department of Clinical Pharmacy University of California San Francisco San Francisco California USA
| | - Emily Abdoler
- Department of Medicine University of Michigan Ann Arbor Michigan USA
| | - Bridget C. O'Brien
- Department of Medicine University of California San Francisco San Francisco California USA
| | - Brian S. Schwartz
- Department of Medicine University of California San Francisco San Francisco California USA
| | - Conan MacDougall
- Department of Clinical Pharmacy University of California San Francisco San Francisco California USA
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Mira Solves JJ. [The time for high value practices]. Med Clin (Barc) 2021; 157:480-482. [PMID: 34598793 DOI: 10.1016/j.medcli.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/29/2021] [Accepted: 09/02/2021] [Indexed: 11/16/2022]
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Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing. BMC FAMILY PRACTICE 2021; 22:225. [PMID: 34781877 PMCID: PMC8591810 DOI: 10.1186/s12875-021-01574-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 11/02/2021] [Indexed: 11/21/2022]
Abstract
Background How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. Method The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. Results Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. Conclusion Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01574-x.
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Arisoy H. Striking the balance in peer-to-peer teaching. CLINICAL TEACHER 2021; 18:685-686. [PMID: 34669253 DOI: 10.1111/tct.13434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Huseyin Arisoy
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Atallah F, Moreno-Jackson R, McLaren R, Fisher N, Weedon J, Jones S, Minkoff H. Confirmation Bias Affects Estimation of Blood Loss and Amniotic Fluid Volume: A Randomized Simulation-Based Trial. Am J Perinatol 2021; 38:1277-1280. [PMID: 32485753 DOI: 10.1055/s-0040-1712167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study was aimed to determine if confirmation bias affects diagnoses in obstetrics, specifically estimation of blood loss and amniotic fluid volume. STUDY DESIGN We performed a randomized simulation-based trial. Participants went through the following three consecutive scenarios: (1) the first involved estimating the volume of blood (actually a blood-like substance) in a container at the simulation model's perineum. The actual volume was either 500 or 1,500 mL. Participants were told it was blood seen after a vaginal delivery. One group was told that the "patient" was normotensive, the other was told that the "patient" was hypotensive. (2) The second scenario involved estimation of amniotic fluid from an ultrasound picture of four quadrants, with one group told that the patient was normotensive and the other group told that the patient had chronic hypertension. (3) The third scenario was a "negative image" of the first (i.e., if they had been randomized to the 500 mL/normotensive in scenario one, then they would be presented with the 1,500 mL/hypotensive). They also filled a survey including demographics and tolerance of ambiguity and confirmation bias scales. RESULTS From April 2018 through May 2018, a convenience sample of 85 providers was recruited. Participants were more likely to overestimate blood loss when they were told that the patient was hypotensive (p = 0.024), in comparison to when they were told the patient had normal blood pressure. They were also less likely to estimate the amniotic fluid as normal when they were told that the patient was hypertensive (p = 0.032). CONCLUSION Confirmation bias affects estimates of blood loss and amniotic fluid.
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Affiliation(s)
- Fouad Atallah
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Rafine Moreno-Jackson
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Rodney McLaren
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Nelli Fisher
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Jeremy Weedon
- Department of Epidemiology & Biostatistics, State University of New York (SUNY) Downstate, School of Public Health, Brooklyn, New York
| | - Sharifa Jones
- Department of Psychology, Hunter College, City University of New York, Brooklyn, New York
| | - Howard Minkoff
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York.,Department of Obstetrics and Gynecology, State University of New York (SUNY) Downstate, Brooklyn, New York
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Ritz C, Sader J, Cairo Notari S, Lanier C, Caire Fon N, Nendaz M, Audétat MC. Multimorbidity and clinical reasoning through the eyes of GPs: a qualitative study. Fam Med Community Health 2021; 9:fmch-2020-000798. [PMID: 34556495 PMCID: PMC8461689 DOI: 10.1136/fmch-2020-000798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives Despite the high prevalence of patients suffering from multimorbidity, the clinical reasoning processes involved during the longitudinal management are still sparse. This study aimed to investigate what are the different characteristics of the clinical reasoning process clinicians use with patients suffering from multimorbidity, and to what extent this clinical reasoning differs from diagnostic reasoning. Design Given the exploratory nature of this study and the difficulty general practitioners (GPs) have in expressing their reasoning, a qualitative methodology was therefore, chosen. The Clinical reasoning Model described by Charlin et al was used as a framework to describe the multifaceted processes of the clinical reasoning. Setting Semistructured interviews were conducted with nine GPs working in an ambulatory setting in June to September 2018, in Geneva, Switzerland. Participants Participants were GPs who came from public hospital or private practice. The interviews were transcribed verbatim and a thematic analysis was conducted. Results The results highlighted how some cognitive processes seem to be more specific to the management reasoning. Thus, the main goal is not to reach a diagnosis, but rather to consider several possibilities in order to maintain a balance between the evidence-based care options, patient’s priorities and maintaining quality of life. The initial representation of the current problem seems to be more related to the importance of establishing links between the different pre-existing diseases, identifying opportunities for actions and trying to integrate the new elements from the patient’s context, rather than identifying the signs and symptoms that can lead to generating new clinical hypotheses. The multiplicity of options to resolve problems is often perceived as difficult by GPs. Furthermore, longitudinal management does not allow them to achieve a final resolution of problems and that requires continuous review and an ongoing prioritisation process. Conclusion This study contributes to a better understanding of the clinical reasoning processes of GPs in the longitudinal management of patients suffering from multimorbidity. Through a practical and accessible model, this qualitative study offers new perspectives for identifying the components of management reasoning. These results open the path to new research projects.
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Affiliation(s)
- Claire Ritz
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland
| | - Julia Sader
- Faculty of Medicine, (UDREM), University of Geneva, Geneva, Switzerland
| | | | - Cedric Lanier
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland
| | | | - Mathieu Nendaz
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland .,Faculty of Medicine, (UDREM), University of Geneva, Geneva, Switzerland.,Faculty of Medicine, Université de Montreal, Montreal, Quebec, Canada
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Willis JS, Tyler C, Schiff GD, Schreiner K. Ensuring Primary Care Diagnostic Quality in the Era of Telemedicine. Am J Med 2021; 134:1101-1103. [PMID: 34051151 PMCID: PMC9746257 DOI: 10.1016/j.amjmed.2021.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Joel Steven Willis
- Assistant Professor, Division of Family Medicine, Associate Medical Director, GW Immediate Primary Care, George Washington University, Washington, DC.
| | - Carl Tyler
- Professor of Family Medicine and Community Health, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Gordon D Schiff
- Associate Professor of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Mass
| | - Katherine Schreiner
- Medical Student, George Washington School of Medicine and Health Sciences, Washington, DC
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Cairo Notari S, Sader J, Caire Fon N, Sommer JM, Pereira Miozzari AC, Janjic D, Nendaz M, Audétat MC. Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research. Int J Clin Pract 2021; 75:e14187. [PMID: 33783098 PMCID: PMC8459259 DOI: 10.1111/ijcp.14187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term. METHODS A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. RESULTS A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient. CONCLUSIONS Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.
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Affiliation(s)
- Sarah Cairo Notari
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
| | - Julia Sader
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nathalie Caire Fon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Johanna Maria Sommer
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Danilo Janjic
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
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Garcia-Vidal C, Lewis RE, Kontoyiannis DP. Combination antifungal therapy for breakthrough invasive mould disease in patients with haematological malignancies: when management reasoning eclipses evidence-based medicine. J Antimicrob Chemother 2021; 75:3096-3098. [PMID: 32719877 DOI: 10.1093/jac/dkaa281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Timely diagnosis and treatment of invasive mould disease is challenging in severely immunocompromised patients, particularly for patients who develop breakthrough infections while on antifungal prophylaxis. Currently, there are no high-quality data on how to best diagnose and treat these infections. Many essential decisions affecting the management of breakthrough mould disease are made before a definitive diagnosis is established. In this scenario, sound management reasoning often favours the use of combination antifungal therapy, especially when antifungal resistance, suspicion of undetected sites of infection or pharmacokinetic/pharmacodynamic limitations at the site of infection are likely. In these scenarios, pre-emptive use of antifungal combination therapy with frequent re-evaluation with an aim of de-escalation could be justified for many high-risk patients.
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Affiliation(s)
- C Garcia-Vidal
- Infectious Diseases Department, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - R E Lewis
- Unit of Infectious Diseases, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - D P Kontoyiannis
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Waghorn J, Bates I, Davies JG, Jubraj B, Rakow T, Stevenson JM. Clinical Judgement Analysis: An innovative approach to explore the individual decision-making processes of pharmacists. Res Social Adm Pharm 2021; 17:2097-2107. [PMID: 34059473 DOI: 10.1016/j.sapharm.2021.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pharmacy stands increasingly on the frontline of patient care, yet current studies of clinical decision-making by pharmacists only capture deliberative processes that can be stated explicitly. Decision-making incorporates both deliberative and intuitive processes. Clinical Judgement Analysis (CJA) is a method novel to pharmacy that uncovers intuitive decision-making and may provide a more comprehensive understanding of the decision-making processes of pharmacists. OBJECTIVES This paper describes how CJA potentially uncovers the intuitive clinical decision-making processes of pharmacists. Using an illustrative decision-making example, the application of CJA will be described, including: METHOD: An illustrative study was used, applying an established method for CJA. The decision to initiate anticoagulation, alongside appropriate risk judgements, was chosen as the context. Expert anticoagulation pharmacists were interviewed to define and then refine variables (cues) involved in this decision. Decision tasks with sixty scenarios were developed to explore the effect of these cues on pharmacists' decision-making processes and distributed to participants for completion. Descriptive statistical and regression analyses were conducted for each participant. RESULTS The method produced individual judgement models for each participant, for example, demonstrating that when judging stroke risk each participant's judgements could be accurately predicted using only 3 or 4 out of the possible 11 cues given. The method also demonstrated that participants appeared to consider multiple cues when making risk judgements but used an algorithmic approach based on one or two cues when making the clinical decision. CONCLUSION CJA generates insights into the clinical decision-making processes of pharmacists not uncovered by the current literature. This provides a springboard for more in-depth explorations; explorations that are vital to the understanding and ongoing development of the role of pharmacists.
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Affiliation(s)
- Janique Waghorn
- Department of Pharmacy, Institute of Pharmaceutical Science, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, United Kingdom.
| | - Ian Bates
- University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - John Graham Davies
- Department of Pharmacy, Institute of Pharmaceutical Science, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, United Kingdom
| | - Barry Jubraj
- Department of Pharmacy, Institute of Pharmaceutical Science, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, United Kingdom
| | - Tim Rakow
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Great Maze Pond, London, SE1 9RT, United Kingdom
| | - Jennifer M Stevenson
- Department of Pharmacy, Institute of Pharmaceutical Science, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, United Kingdom; Pharmacy Department, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH, United Kingdom
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