Dual processing and diagnostic errors

Reliability, validity and acceptability of an online clinical reasoning simulator for medical students: An international pilot

INTRODUCTION

Clinical reasoning skills are essential for decision-making. Current assessment methods are limited when testing clinical reasoning and management of uncertainty. This study evaluates the reliability, validity and acceptability of Practicum Script, an online simulation-based programme, for developing medical students' clinical reasoning skills using real-life cases.

METHODS

In 2020, we conducted an international, multicentre pilot study using 20 clinical cases with 2457 final-year medical students from 21 schools worldwide. Psychometric analysis was performed (n = 1502 students completing at least 80% of cases). Classical estimates of reliability for three test domains (hypothesis generation, hypothesis argumentation and knowledge application) were calculated using Cronbach's alpha and McDonald's omega coefficients. Validity evidence was obtained by confirmatory factor analysis (CFA) and measurement alignment (MA). Items from the knowledge application domain were analysed using cognitive diagnostic modelling (CDM). Acceptability was evaluated by an anonymous student survey.

RESULTS

Reliability estimates were high with narrow confidence intervals. CFA revealed acceptable goodness-of-fit indices for the proposed three-factor model. CDM analysis demonstrated good absolute test fit and high classification accuracy estimates. Student survey responses showed high levels of acceptability.

CONCLUSION

Our findings suggest that Practicum Script is a useful resource for strengthening students' clinical reasoning skills and ability to manage uncertainty.

Prevalence and characteristics of the 'bad feeling' among healthcare professionals in the context of emergency situations: A Bi-Hospital Survey

INTRODUCTION

Clinical decision-making is based on objective and subjective criteria, including healthcare workers impressions and feelings. This research examines the perception and implications of a 'bad feeling' experienced by healthcare professionals, focusing on its prevalence and characteristics.

METHODS

A cross-sectional paper-based survey was conducted from January to July 2023 at the University Medicine Greifswald and the hospital Sömmerda involving physicians, nurses, medical students and trainees from various specialties. With ethics committee approval, participants were recruited and surveyed at regular clinical events. Data analysis was performed using SPSS® Statistics. The manuscript was written using the Strobe checklist.

RESULTS

Out of 250 questionnaires distributed, 217 were valid for analysis after a 94.9% return rate and subsequent exclusions. Sixty-five per cent of respondents experience the 'bad feeling' occasionally to frequently. There was a significant positive correlation between the frequency of 'bad feeling' and work experience. The predominant cause of this feeling was identified as intuition, reported by 79.8% of participants, with 80% finding it often helpful in their clinical judgement. Notably, in 16.1% of cases, the 'bad feeling' escalated in the further clinical course into an actual emergency. Furthermore, 60% of respondents indicated that this feeling occasionally or often serves as an early indicator of a potential, yet unrecognised, emergency in patient care.

CONCLUSIONS

This study demonstrates the relevance of clinical experience to decision-making. As an expression of this, there is a correlation between the frequency of a 'bad feeling' and the number of years of experience. It is recommended that the 'bad feeling' be deliberately acknowledged and reinforced as an early warning signal for emergency situations, given its significant implications for patient safety. Future initiatives could include advanced training and research, as well as tools such as pocket maps, to better equip healthcare professionals in responding to this intuition.

Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Exploring adaptive expertise in residency: the (missed) opportunity of uncertainty

Preparing novice physicians for an unknown clinical future in healthcare is challenging. This is especially true for emergency departments (EDs) where the framework of adaptive expertise has gained traction. When medical graduates start residency in the ED, they must be supported in becoming adaptive experts. However, little is known about how residents can be supported in developing this adaptive expertise. This was a cognitive ethnographic study conducted at two Danish EDs. The data comprised 80 h of observations of 27 residents treating 32 geriatric patients. The purpose of this cognitive ethnographic study was to describe contextual factors that mediate how residents engage in adaptive practices when treating geriatric patients in the ED. Results showed that all residents fluidly engaged in both adaptive and routine practices, but they were challenged when engaging in adaptive practices in the face of uncertainty. Uncertainty was often observed when residents' workflows were disrupted. Furthermore, results highlighted how residents construed professional identity and how this affected their ability to shift between routine and adaptive practices. Residents reported that they thought that they were expected to perform on par with their more experienced physician colleagues. This negatively impacted their ability to tolerate uncertainty and hindered the performance of adaptive practices. Thus, aligning clinical uncertainty with the premises of clinical work, is imperative for residents to develop adaptive expertise.

Teaching Before, During, and After a Surgical Resuscitation

Teaching during a surgical resuscitation can be difficult due to the infrequency of these events. Furthermore, when these events do occur, the trainee can experience cognitive overload and an overwhelming amount of stress, thereby impairing the learning process. The emergent nature of these scenarios can make it difficult for the surgical educator to adequately teach. Repeated exposure through simulation, role play, and "war games" are great adjuncts to teaching and preparation before crisis. However, surgical educators can further enhance the knowledge of their trainees during these scenarios by using tactics such as talking out loud, targeted teaching, and debriefing.

Clinical reasoning in pharmacy: What do eye movements and verbal protocols tell us about the processing of a case task?

This study investigates pharmacy students' reasoning while solving a case task concerning an acute patient counselling situation in a pharmacy. Participants' (N = 34) reasoning processes were investigated with written tasks utilizing eye-tracking in combination with verbal protocols. The case was presented in three pages, each page being followed by written questions. Eye movements were recorded during case processing. Success in the task required differentiating the relevant information from the task redundant information, and initial activation of several scripts and verification of the most likely one, when additional information became available. 2nd (n = 16) and 3rd (n = 18)-year students' and better and worse succeeding students' processes were compared. The results showed that only a few 2nd-year students solved the case correctly, whereas almost all of the 3rd-year students were successful. Generally, the average total processing times of the case material did not differ between the groups. However, better-succeeding and 3rd-year students processed the very first task-relevant sentences longer, indicating that they were able to focus on relevant information. Differences in the written answers to the 2nd and 3rd question were significant, whereas differences regarding the first question were not. Thus, eye-tracking seems to be able to capture illness script activation during case processing, but other methods are needed to depict the script verification process. Based on the results, pedagogical suggestions for advancing pharmacy education are discussed.

Consultation-Liaison Case Conference: Overcoming Bias in the Differential Diagnosis of Psychosis

We present the case of a 34-year-old Black patient with no significant psychiatric history who presented with catatonia and psychotic symptoms following a recent severe acute respiratory syndrome coronavirus-2 infection, whose diagnosis of coronavirus disease 2019 encephalitis was delayed by premature attribution of his symptoms to a primary psychiatric etiology. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching topics include the diagnosis and management of coronavirus disease 2019 encephalitis, cognitive bias, and racial bias. Specifically, this case illustrates the role of the consultation-liaison psychiatrist in identifying medical conditions that may overlap with psychiatric presentations and in advocating for marginalized patients.

Long-term risk prediction after major lower limb amputation: 1-year results of the PERCEIVE study

BACKGROUND

Decision-making when considering major lower limb amputation is complex and requires individualized outcome estimation. It is unknown how accurate healthcare professionals or relevant outcome prediction tools are at predicting outcomes at 1-year after major lower limb amputation.

METHODS

An international, multicentre prospective observational study evaluating healthcare professional accuracy in predicting outcomes 1 year after major lower limb amputation and evaluation of relevant outcome prediction tools identified in a systematic search of the literature was undertaken. Observed outcomes at 1 year were compared with: healthcare professionals' preoperative predictions of death (surgeons and anaesthetists), major lower limb amputation revision (surgeons) and ambulation (surgeons, specialist physiotherapists and vascular nurse practitioners); and probabilities calculated from relevant outcome prediction tools.

RESULTS

A total of 537 patients and 2244 healthcare professional predictions of outcomes were included. Surgeons and anaesthetists had acceptable discrimination (C-statistic = 0.715), calibration and overall performance (Brier score = 0.200) when predicting 1-year death, but performed worse when predicting major lower limb amputation revision and ambulation (C-statistics = 0.627 and 0.662 respectively). Healthcare professionals overestimated the death and major lower limb amputation revision risks. Consultants outperformed trainees, especially when predicting ambulation. Allied healthcare professionals marginally outperformed surgeons in predicting ambulation. Two outcome prediction tools (C-statistics = 0.755 and 0.717, Brier scores = 0.158 and 0.178) outperformed healthcare professionals' discrimination, calibration and overall performance in predicting death. Two outcome prediction tools for ambulation (C-statistics = 0.688 and 0.667) marginally outperformed healthcare professionals.

CONCLUSION

There is uncertainty in predicting 1-year outcomes following major lower limb amputation. Different professional groups performed comparably in this study. Two outcome prediction tools for death and two for ambulation outperformed healthcare professionals and may support shared decision-making.

Incident commander decision making: Quantitative evaluation of instantaneous and considered decisions

The Incident Commander (IC) decision-making process has previously been modeled primarily by qualitative evaluation methods, which has made it difficult to generalize an objective model. In this study, we took a quantitative approach to elucidate a decision-making model based on the "dual-process" model that consists of instantaneous decisions ("System 1") and considered decisions ("System 2") to gain new insights regarding the IC decision-making process. High-fidelity simulation data from eight mass-casualty incidents (MCIs) were analyzed in two categories. The first category represents cues of new information and the IC's actions, divided into three main subcategories: actions following the MCI protocol, responses following cues, and actions without a cue. The second category divides the simulation into three MCI management phases: (1) evaluation and triage, (2) treatment and preparedness for evacuation, and (3) evacuation. Actions that followed the MCI protocol were significantly higher in the first phase compared to the other two phases (p<0.01 for both phases). Responses following cues were significantly higher in the second phase compared to the first (p<0.01). Actions without a cue were significantly higher in both the second and third phases compared to the first (p<0.01 for both phases). The results reveal that the IC followed MCI protocol guidance in the simulation initiation and immediately responded to cues, which fits "System 1". As the simulation evolved, the IC made more planned tasks and initiated actions without leading cues, which fits "System 2". The study found that ICs can change their decision-making mode, and this understanding can serve to improve their decision-making process and increase casualty survival rates.

Insights into diagnostic errors in endocrinology: a prospective, case-based, international study

BACKGROUND

Diagnostic errors in internal medicine are common. While cognitive errors have previously been identified to be the most common contributor to errors, very little is known about errors in specific fields of internal medicine such as endocrinology. This prospective, multicenter study focused on better understanding the causes of diagnostic errors made by general practitioners and internal specialists in the area of endocrinology.

METHODS

From August 2019 until January 2020, 24 physicians completed five endocrine cases on an online platform that simulated the diagnostic process. After each case, the participants had to state and explain why they chose their assumed diagnosis. The data gathering process as well as the participants' explanations were quantitatively and qualitatively analyzed to determine the causes of the errors. The diagnostic processes in correctly and incorrectly solved cases were compared.

RESULTS

Seven different causes of diagnostic error were identified, the most frequent being misidentification (mistaking one diagnosis with a related one or with more frequent and similar diseases) in 23% of the cases. Other causes were faulty context generation (21%) and premature closure (17%). The diagnostic confidence did not differ between correctly and incorrectly solved cases (median 8 out of 10, p = 0.24). However, in incorrectly solved cases, physicians spent less time on the technical findings (such as lab results, imaging) (median 250 s versus 199 s, p < 0.049).

CONCLUSIONS

The causes for errors in endocrine case scenarios are similar to the causes in other fields of internal medicine. Spending more time on technical findings might prevent misdiagnoses in everyday clinical practice.

Decision-making processes in image guided radiotherapy: A think aloud study

INTRODUCTION

3D Image Guided Radiotherapy (IGRT) using Cone Beam Computer Tomography (CBCT) has been implemented for a range of treatment sites across the UK in the last decade. A paucity of evidence exists to understand how radiation therapists (RTTs) make clinical decisions during image interpretation as part of the IGRT process. The aim of this study was to investigate the decision-making processes used by RTTs during image interpretation of IGRT.

METHOD

Case study methodology was adopted utilising a think aloud observational method with follow-up interviews. 12 RTTs were observed and interviewed across three UK radiotherapy centres. Participants were observed reviewing and making clinical decisions in a simulated environment using clinical scenarios developed in partnership with each centres' Clinical Imaging Lead. Protocol analysis was used to analyse the observational data and thematic analysis was used to analyse the interview data.

RESULTS

A range of approaches to decision-making was observed which varied in length from nine phrases to 57 (mean 24) per case. Six themes emerged from the data: Set Sequence, Site Specific Clinical Priorities, Initial Gross Review, Decision to treat, Compromise and experience. In addition, three cognitive decision-making processes were identified: Simple linear, Linear repeating and Intuitive decision-making process. The findings of the study align with general principles of expert performance, whereby experience in a specific scope of practice is more beneficial in developing expertise than overall experience.

CONCLUSION

This study has provided new and original insight in the decision-making processes of RTTs. The study has highlighted three process models to explain how RTTs make decisions during IGRT: Simple linear, Linear repeating and Intuitive decision-making process. Intuitive processes are widely accepted to be error prone and linked to bias. When using this process, some RTTs followed this with a confirmation phase. This second phase of the process should be encouraged when teaching IGRT. The results of the study support the concept of expert performance, where performance and expertise are only improved by exposing individuals to specific types of experiences. RTTs, managers and Higher Education Institutions are encouraged to review these models and implement them into IGRT training. It is clear from the evidence base that understanding how we make decisions, enables us to develop expertise and reduce errors during the decision-making process.

The impact of patient skin colour on diagnostic ability and confidence of medical students

Previous literature has explored unconscious racial biases in clinical education and medicine, finding that people with darker skin tones can be underrepresented in learning resources and managed differently in a clinical setting. This study aimed to examine whether patient skin colour can affect the diagnostic ability and confidence of medical students, and their cognitive reasoning processes. We presented students with 12 different clinical presentations on both white skin (WS) and non-white skin (NWS). A think aloud (TA) study was conducted to explore students' cognitive reasoning processes (n = 8). An online quiz was also conducted where students submitted a diagnosis and confidence level for each clinical presentation (n = 185). In the TA interviews, students used similar levels of information gathering and analytical reasoning for each skin type but appeared to display increased uncertainty and reduced non-analytical reasoning methods for the NWS images compared to the WS images. In the online quiz, students were significantly more likely to accurately diagnose five of the 12 clinical presentations (shingles, cellulitis, Lyme disease, eczema and meningococcal disease) on WS compared to NWS (p < 0.01). With regards to students' confidence, they were significantly more confident diagnosing eight of the 12 clinical presentations (shingles, cellulitis, Lyme disease, eczema, meningococcal disease, urticaria, chickenpox and Kawasaki disease) on WS when compared to NWS (p < 0.01). These findings highlight the need to improve teaching resources to include a greater diversity of skin colours exhibiting clinical signs, to improve students' knowledge and confidence, and ultimately, to avoid patients being misdiagnosed due to the colour of their skin.

Automated Item Generation: impact of item variants on performance and standard setting

BACKGROUND

Automated Item Generation (AIG) uses computer software to create multiple items from a single question model. There is currently a lack of data looking at whether item variants to a single question result in differences in student performance or human-derived standard setting. The purpose of this study was to use 50 Multiple Choice Questions (MCQs) as models to create four distinct tests which would be standard set and given to final year UK medical students, and then to compare the performance and standard setting data for each.

METHODS

Pre-existing questions from the UK Medical Schools Council (MSC) Assessment Alliance item bank, created using traditional item writing techniques, were used to generate four 'isomorphic' 50-item MCQ tests using AIG software. Isomorphic questions use the same question template with minor alterations to test the same learning outcome. All UK medical schools were invited to deliver one of the four papers as an online formative assessment for their final year students. Each test was standard set using a modified Angoff method. Thematic analysis was conducted for item variants with high and low levels of variance in facility (for student performance) and average scores (for standard setting).

RESULTS

Two thousand two hundred eighteen students from 12 UK medical schools participated, with each school using one of the four papers. The average facility of the four papers ranged from 0.55-0.61, and the cut score ranged from 0.58-0.61. Twenty item models had a facility difference > 0.15 and 10 item models had a difference in standard setting of > 0.1. Variation in parameters that could alter clinical reasoning strategies had the greatest impact on item facility.

CONCLUSIONS

Item facility varied to a greater extent than the standard set. This difference may relate to variants causing greater disruption of clinical reasoning strategies in novice learners compared to experts, but is confounded by the possibility that the performance differences may be explained at school level and therefore warrants further study.

Semantic competence and prototypical verbalizations are associated with higher OSCE and global medical degree scores: a multi-theory pilot study on year 6 medical student verbalizations

OBJECTIVES

The organization of medical knowledge is reflected in language and can be studied from the viewpoints of semantics and prototype theory. The purpose of this study is to analyze student verbalizations during an Objective Structured Clinical Examination (OSCE) and correlate them with test scores and final medical degree (MD) scores. We hypothesize that students whose verbalizations are semantically richer and closer to the disease prototype will show better academic performance.

METHODS

We conducted a single-center study during a year 6 (Y6) high-stakes OSCE where one probing intervention was included at the end of the exam to capture students' reasoning about one of the clinical cases. Verbalizations were transcribed and coded. An assessment panel categorized verbalizations regarding their semantic value (Weak, Good, Strong). Semantic categories and prototypical elements were compared with OSCE, case-based exam and global MD scores.

RESULTS

Students with Semantic 'Strong' verbalizations displayed higher OSCE, case-based exam and MD scores, while the use of prototypical elements was associated with higher OSCE and MD scores.

CONCLUSIONS

Semantic competence and verbalizations matching the disease prototype may identify students with better organization of medical knowledge. This work provides empirical groundwork for future research on language analysis to support assessment decisions.

Histology as a paradigm for a science-based learning experience: Visits by histology education spirits of past, present, and future

The term "histology" was coined a little over 200 years ago and the subject has always relied on microscopy as its defining technology. Microscopy was and still is an essential approach for the description of cellular components and their arrangements in living organisms. For more than a century and a half, histology or microanatomy has also been part of the basic science education for biomedical students. Traditionally, it has been taught in two major components, a didactic transfer of information, either in a lecture or self-learning format, and in active-learning laboratory sessions. These two modes of histology instruction conform with the dual-processing theory of learning, one being more automatic and depending mainly on rote memorization, whereas the other is analytical, requiring more advanced reasoning skills. However, these two components of histology education are not separate and independent, but rather complementary and part of a multi-step learning process that encourages a scientific analysis of visual information and involves higher-level learning skills. Conventional, as well as modern electronic instruction methods (e-learning) have been used in complementary ways to support the integrated succession of individual learning steps as outlined in this manuscript. However, as recent curricular reforms have curtailed instructional time, this traditional format of teaching histology is no longer sustainable and a reflective reassessment of the role of histology in modern biomedical education is a timely necessity.

Twelve tips for physicians’ mastering expertise in diagnostic excellence

Diagnostic errors, which account for a large proportion of medical errors, are a global medical challenge. The slogan of reducing diagnostic errors has recently shifted to a new strategy of diagnostic excellence, the core of which is the importance of improving the multidisciplinary diagnostic process. Many of the elements and strategies necessary for diagnostic excellence have been presented. In the context of this diagnostic improvement, some reports have been structured to improve the quality of performance of individual physicians as players. Still, surprisingly, only a few reports have focused on specific day-to-day training strategies for the diagnostic thinking process as expertise. This paper focuses on this point and proposes strategies for refining the diagnostic thinking expertise of frontline physicians in the new era, based on the following four elements: knowledge and experience, diagnostic thinking strategies, information management skills, and calibration and reflection.

Clinical decision-making and adaptive expertise in residency: a think-aloud study

Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.

A case study of a unique advanced clinical skills elective at the David Geffen School of Medicine at UCLA

Proficiency in clinical examination skills upon graduation from medical school is a core competency. Over the last few decades, the ability and confidence in this fundamental and crucial skill set has declined. The motivation and interest in meticulous physical examination by recently graduated residents has also eroded. In this case study, we describe a comprehensive, innovative, and immersive advanced clinical skills elective taken during the second half of the final year of medical school for students at the David Geffen School of Medicine. The course utilizes novel approaches to inspire, refresh and consolidate essential bedside observation skills and examination techniques. This approach gives senior students the confidence and fundamental understanding of how dedication to the patient exam can improve the doctor-patient relationship, core clinical reasoning and the practice of cost-effective and evidence-based care through their careers. We describe how the integration of fine art appreciation and introductory biding techniques are used to help students hone their visual diagnostic skills. We show how this is solidified through a longitudinal series of clinical image review sessions with diagnostic reasoning principles to formulate a clear differential. Point of care ultrasound, EKG analysis, advanced cardiac auscultation and diagnostic imaging skills are integrated in a comprehensive and memorable fashion. We present this case study to inspire clinical skills teachers everywhere to replicate our methods in resurrecting the importance of physical exams for their learners. Opening their trainees' eyes to new methods of honing their visual intelligence and developing healthy habits for stress and burnout reduction will aid the rest of their professional careers.

Development and Pilot Testing of a Data-Rich Clinical Reasoning Training and Assessment Tool

PROBLEM

Clinical reasoning is a core competency for physicians and also a common source of errors, driving high rates of misdiagnoses and patient harm. Efforts to provide training in and assessment of clinical reasoning skills have proven challenging because they are either labor- and resource-prohibitive or lack important data relevant to clinical reasoning. The authors report on the creation and use of online simulation cases to train and assess clinical reasoning skills among medical students.

APPROACH

Using an online library of simulation cases, they collected data relevant to the creation of the differential diagnosis, analysis of the history and physical exam, diagnostic justification, ordering tests; interpreting tests, and ranking of the most probable diagnosis. These data were compared with an expert-created scorecard, and detailed quantitative and qualitative feedback were generated and provided to the learners and instructors.

OUTCOMES

Following an initial pilot study to troubleshoot the software, the authors conducted a second pilot study in which 2 instructors developed and provided 6 cases to 75 second-year medical students. The students completed 376 cases (average 5.0 cases per student), generating more than 40,200 data points that the software analyzed to inform individual learner formative feedback relevant to clinical reasoning skills. The instructors reported that the workload was acceptable and sustainable.

NEXT STEPS

The authors are actively expanding the library of clinical cases and providing more students and schools with formative feedback in clinical reasoning using our tool. Further, they have upgraded the software to identify and provide feedback on behaviors consistent with premature closure, anchoring, and confirmation biases. They are currently collecting and analyzing additional data using the same software to inform validation and psychometric outcomes for future publications.

Peripheral T-cell Lymphoma With Acute Exacerbating Fatigue and Chest Pain: A Case Report

Effectively treating vague symptoms in older adults can be challenging for clinicians. Many vague symptoms will resolve spontaneously with alleviating treatment. Two of the most alarming qualities of symptoms are duration and exacerbation. For primary care and family medicine physicians dealing with vague symptoms in older patients, identifying alarming symptoms and further investigating them can guide their decisions on advanced care directives. We experienced a case of a drastic clinical course of peripheral T-cell lymphoma in a 91-year-old man without specific symptoms or palpable lymphadenopathy on the surface of the body. Clinical observation and prompt pathological investigation were sufficient for diagnosis. However, the patient’s hope for home-based palliative care could not be achieved. For vague progressive symptoms in older patients, clinicians should consider the diagnostic process, including perspectives of palliative care, based on the needs of older patients.

Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic

Cognitive biases are systematic cognitive distortions, which can affect clinical reasoning. The aim of this study was to unravel the most common cognitive biases encountered in in the peculiar context of the COVID-19 pandemic. Case study research design. Primary care. Single centre (Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland). A short survey was sent to all primary care providers (N = 169) taking care of hospitalised adult patients with COVID-19. Participants were asked to describe cases in which they felt that their clinical reasoning was "disrupted" because of the pandemic context. Seven case were sufficiently complete to be analysed. A qualitative analysis of the clinical cases was performed and a bias grid encompassing 17 well-known biases created. The clinical cases were analyzed to assess for the likelihood (highly likely, plausible, not likely) of the different biases for each case. The most common biases were: "anchoring bias", "confirmation bias", "availability bias", and "cognitive dissonance". The pandemic context is a breeding ground for the emergence of cognitive biases, which can influence clinical reasoning and lead to errors. Awareness of these cognitive mechanisms could potentially reduce biases and improve clinical reasoning. Moreover, the analysis of cognitive biases can offer an insight on the functioning of the clinical reasoning process in the midst of the pandemic crisis.

Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self-Reflection Survey

This cross-sectional study aimed to clarify how cognitive biases and situational factors related to diagnostic errors among physicians. A self-reflection questionnaire survey on physicians’ most memorable diagnostic error cases was conducted at seven conferences: one each in Okayama, Hiroshima, Matsue, Izumo City, and Osaka, and two in Tokyo. Among the 147 recruited participants, 130 completed and returned the questionnaires. We recruited primary care physicians working in various specialty areas and settings (e.g., clinics and hospitals). Results indicated that the emergency department was the most common setting (47.7%), and the highest frequency of errors occurred during night-time work. An average of 3.08 cognitive biases was attributed to each error. The participants reported anchoring bias (60.0%), premature closure (58.5%), availability bias (46.2%), and hassle bias (33.1%), with the first three being most frequent. Further, multivariate logistic regression analysis for cognitive bias showed that emergency room care can easily induce cognitive bias (adjusted odds ratio 3.96, 95% CI 1.16−13.6, p-value = 0.028). Although limited to a certain extent by its sample collection, due to the sensitive nature of information regarding physicians’ diagnostic errors, this study nonetheless shows correlations with environmental factors (emergency room care situations) that induce cognitive biases which, in turn, cause diagnostic errors.

Representation, interaction and interpretation. Making sense of the context in clinical reasoning

BACKGROUND

All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised.

AIMS

Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning.

DISCUSSION

We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning.

CONCLUSION

The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.

Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study

OBJECTIVES

We sought to understand the knowledge, attitudes, and beliefs of emergency medicine (EM) physicians towards non-specific neurological conditions and the use of clinical decision support (CDS) to improve diagnostic accuracy.

METHODS

We conducted semi-structured interviews of EM physicians at four emergency departments (EDs) affiliated with a single US healthcare system. Interviews were conducted until thematic saturation was achieved. Conventional content analysis was used to identify themes related to EM physicians' perspectives on acute diagnostic neurology; directed content analysis was used to explore views regarding CDS. Each interview transcript was independently coded by two researchers using an iteratively refined codebook with consensus-based resolution of coding differences.

RESULTS

We identified two domains regarding diagnostic safety: (1) challenges unique to neurological complaints and (2) challenges in EM more broadly. Themes relevant to neurology included: (1) knowledge gaps and uncertainty, (2) skepticism about neurology, (3) comfort with basic as opposed to detailed neurological examination, and (4) comfort with non-neurological diseases. Themes relevant to diagnostic decision making in the ED included: (1) cognitive biases, (2) ED system/environmental issues, (3) patient barriers, (4) comfort with diagnostic uncertainty, and (5) concerns regarding diagnostic error identification and measurement. Most participating EM physicians were enthusiastic about the potential for well-designed CDS to improve diagnostic accuracy for non-specific neurological complaints.

CONCLUSIONS

Physicians identified diagnostic challenges unique to neurological diseases as well as issues related more generally to diagnostic accuracy in EM. These physician-reported issues should be accounted for when designing interventions to improve ED diagnostic accuracy.

Dual Process Theory and Cognitive Load: How Intensivists Make Diagnoses

Improving clinical reasoning in order to reduce frequency of diagnostic errors is an important area of study. The authors discuss dual process theory as a model of clinical reasoning and explore the role that cognitive load plays in clinical reasoning in the intensive care unit environment.

Qualitative development and content validation of the "SPART" model; a focused ethnography study of observable diagnostic and therapeutic activities in the emergency medical services care process

BACKGROUND

Clinical reasoning is a crucial task within the Emergency Medical Services (EMS) care process. Both contextual and cognitive factors make the task susceptible to errors. Understanding the EMS care process' structure could help identify and address issues that interfere with clinical reasoning. The EMS care process is complex and only basically described. In this research, we aimed to define the different phases of the process and develop an overarching model that can help detect and correct potential error sources, improve clinical reasoning and optimize patient care.

METHODS

We conducted a focused ethnography study utilizing non-participant video observations of real-life EMS deployments combined with thematic analysis of peer interviews. After an initial qualitative analysis of 7 video observations, we formulated a tentative conceptual model of the EMS care process. To test and refine this model, we carried out a qualitative, thematic analysis of 28 video-recorded cases. We validated the resulting model by evaluating its recognizability with a peer content analysis utilizing semi-structured interviews.

RESULTS

Based on real-life observations, we were able to define and validate a model covering the distinct phases of an EMS deployment. We have introduced the acronym "SPART" to describe ten different phases: Start, Situation, Prologue, Presentation, Anamnesis, Assessment, Reasoning, Resolution, Treatment, and Transfer.

CONCLUSIONS

The "SPART" model describes the EMS care process and helps to understand it. We expect it to facilitate identifying and addressing factors that influence both the care process and the clinical reasoning task embedded in this process.

Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research

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.

Virtual Interactive Case-Based Education (VICE): A Conference for Deliberate Practice of Diagnostic Reasoning

INTRODUCTION

Current approaches to teaching diagnostic reasoning minimally address the need for deliberate practice. We developed an educational conference for internal medicine residents to practice diagnostic reasoning and examine how biases affect their differential diagnoses through cognitive autopsies.

METHODS

We formatted the Virtual Interactive Case-Based Education (VICE) conference as a clinical problem-solving exercise, in which a facilitator presents a case to a single discussant selected from the audience. We delivered VICE on an internet-based conferencing platform with screen-sharing capability over approximately 30 minutes. To maximize learners' psychological safety, we employed an active facilitation model that normalized uncertainty and prioritized the diagnostic process over arriving at the correct diagnosis.

RESULTS

Resident attitudes toward VICE were assessed by utilizing a postconference survey and gathering descriptive data for 11 sessions. Ninety-seven percent of respondents (n = 35) felt that VICE was a novel and valuable addition to their curriculum. Qualitative data suggested that positive features of the conference included the opportunity to practice diagnostic reasoning, the single-discussant format, and the supportive learning environment. Discussants reported that holding the conference in person would have negatively impacted their experience.

DISCUSSION

Internal medicine residents universally valued the opportunity to engage in deliberate practice of case-based reasoning in a psychologically safe environment during the VICE conference. The virtual nature of the conference contributed significantly to discussants' positive experience. This resource includes all materials necessary to implement VICE, as well as an instructional video on facilitation.

Unravelling the polyphony in clinical reasoning research in medical education

RATIONALE

Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion.

AIMS AND OBJECTIVES

We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses.

METHODS

A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review.

RESULTS

A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described.

CONCLUSIONS

Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.

Bedside teaching without bedside - an introduction to clinical reasoning in COVID-19 times

Introduction: The Corona virus pandemic rendered most live education this spring term impossible. Many classes were converted into e-learning formats. Teaching at the bedside (BST) seemed unfeasible under the circumstances. BST and clinical reasoning as its major outcome is introduced at the beginning of semester 5, henceforth all BST refers to this first presentation. Project outline: To ensure proficiency of current 5^th semester students in future BST sessions, the introduction could not be cancelled albeit teaching with patients was. Knowing that the practical learning objectives of bedside teaching cannot be mirrored in online formats, a compensating module to teach the concept of BST and clinical reasoning had to be designed. Summary of work: To facilitate an understanding of the concept of bedside teaching with a focus on clinical reasoning we developed paper cases and a survey in Microsoft Forms following the history and examination path used in live BST with the addendum of clinical reasoning tables. For the first paper case, a personal feedback was provided for the clinical reasoning tables. A sample solution was provided later for self-feedback on the whole case. The first case was completed by 87, the second by 40 of 336 students. Response to individual feedback was positive. Students still missed hands-on training in history taking and examination with patients. Discussion: Paper cases cannot fully substitute BST. However, given the prime directive during the pandemic to protect our patients, this module engaged around one third of the cohort. The review of uploaded clinical reasoning tables gave proof to the sufficient students' grasp of clinical reasoning. Conclusion: Albeit not an exhaustive substitute for BST, this online module seems a feasible way to convey clinical reasoning strategies to students.

A history of assessment in medical education

The way quality of assessment has been perceived and assured has changed considerably in the recent 5 decades. Originally, assessment was mainly seen as a measurement problem with the aim to tell people apart, the competent from the not competent. Logically, reproducibility or reliability and construct validity were seen as necessary and sufficient for assessment quality and the role of human judgement was minimised. Later, assessment moved back into the authentic workplace with various workplace-based assessment (WBA) methods. Although originally approached from the same measurement framework, WBA and other assessments gradually became assessment processes that included or embraced human judgement but based on good support and assessment expertise. Currently, assessment is treated as a whole system problem in which competence is evaluated from an integrated rather than a reductionist perspective. Current research therefore focuses on how to support and improve human judgement, how to triangulate assessment information meaningfully and how to construct fairness, credibility and defensibility from a systems perspective. But, given the rapid changes in society, education and healthcare, yet another evolution in our thinking about good assessment is likely to lurk around the corner.

Computer-aided heuristics in orthodontics

INTRODUCTION

During the decision-making process, physicians rely on heuristics that consist of simple, useful procedures for solving problems, intuitive shortcuts that produce reliable decisions based on limited information. In clinical situations characterized by a high degree of uncertainty such as those encountered in orthodontics, cognitive biases and judgment errors related to heuristics are not uncommon. This study aimed at promoting trust in the effective interface between the intuitive reasoning of the orthodontic practitioner and the computational heuristics emerging from simple statistical models.

METHODS

We propose an integrative model based on the interaction between clinical reasoning and 2 computational tools, cluster analysis and fast-and-frugal trees, to extract a structured craniofacial representation of untreated subjects with Class III malocclusion and to forecast the worsening of the malocclusion over time.

RESULTS

Cluster analysis of cephalometric values from 144 growing subjects with Class III malocclusion followed longitudinally (T1: mean age, 10.2 ± 1.9 years; T2: mean age, 13.8 ± 2.7 years) produced 3 morphologic subgroups with predominant sagittal, vertical, and slight maxillomandibular imbalances. Fast-and-frugal trees applied to different subgroups extracted heuristics that improved the prediction of key features associated with adverse craniofacial growth.

CONCLUSIONS

Provided that cephalometric values are placed in the appropriate framework, the matching between simple and fast computational approaches and clinical reasoning could help the intuitive logic, perception, and cognitive inferences of orthodontic practitioners on the outcome of patients affected by Class III disharmony, decreasing errors associated with flawed judgments and improving the accuracy of decision making.

A think-aloud study to inform the design of radiograph interpretation practice

Models for diagnostic reasoning in radiology have been based on the observed behaviors of experienced radiologists but have not directly focused on the thought processes of novices as they improve their accuracy of image interpretation. By collecting think-aloud verbal reports, the current study was designed to investigate differences in specific thought processes between medical students (novices) as they learn and radiologists (experts), so that we can better design future instructional environments. Seven medical students and four physicians with radiology training were asked to interpret and diagnose pediatric elbow radiographs where fracture is suspected. After reporting their diagnosis of a case, they were given immediate feedback. Participants were asked to verbalize their thoughts while completing the diagnosis and while they reflected on the provided feedback. The protocol analysis of their verbalizations showed that participants used some combination of four processes to interpret the case: gestalt interpretation, purposeful search, rule application, and reasoning from a prior case. All types of processes except reasoning from a prior case were applied significantly more frequently by experts. Further, gestalt interpretation was used with higher frequency in abnormal cases while purposeful search was used more often for normal cases. Our assessment of processes could help guide the design of instructional environments with well-curated image banks and analytics to facilitate the novice's journey to expertise in image interpretation.

Assessment of clinical reasoning: three evolutions of thought

Although assessing clinical reasoning is almost universally considered central to medical education it is not a straightforward issue. In the past decades, our insights into clinical reasoning as a phenomenon, and consequently the best ways to assess it, have undergone significant changes. In this article, we describe how the interplay between fundamental research, practical applications, and evaluative research has pushed the evolution of our thinking and our practices in assessing clinical reasoning.

A Perspective from a Case Conference on Comparing the Diagnostic Process: Human Diagnostic Thinking vs. Artificial Intelligence (AI) Decision Support Tools

Artificial intelligence (AI) has made great contributions to the healthcare industry. However, its effect on medical diagnosis has not been well explored. Here, we examined a trial comparing the thinking process between a computer and a master in diagnosis at a clinical conference in Japan, with a focus on general diagnosis. Consequently, not only was AI unable to exhibit its thinking process, it also failed to include the final diagnosis. The following issues were highlighted: (1) input information to AI could not be weighted in order of importance for diagnosis; (2) AI could not deal with comorbidities (see Hickam’s dictum); (3) AI was unable to consider the timeline of the illness (depending on the tool); (4) AI was unable to consider patient context; (5) AI could not obtain input information by themselves. This comparison of the thinking process uncovered a future perspective on the use of diagnostic support tools.

Clinical Reasoning as a Core Competency

Diagnostic error is a challenging problem; addressing it effectively will require innovation across multiple domains of health care, including medical education. Diagnostic errors often relate to problems with clinical reasoning, which involves the cognitive and relational steps up to and including establishing a diagnostic and therapeutic plan with a patient. However, despite a call from the National Academies of Sciences for medical educators to improve the teaching and assessment of clinical reasoning, the creation of explicit, theory-informed clinical reasoning curricula, faculty development resources, and assessment tools has proceeded slowly in both undergraduate and graduate medical education. To accelerate the development of this critical element of health professions education and to promote needed research and innovation in clinical reasoning education, the Accreditation Council for Graduate Medical Education (ACGME) should revise its core competencies to include clinical reasoning. The core competencies have proven to be an effective means of expanding educational innovation across the United States and ensuring buy-in across a diverse array of institutions and disciplines. Reformulating the ACGME core competencies to include clinical reasoning would spark much-needed educational innovation and scholarship in graduate medical education, as well as collaboration across institutions in this vital aspect of physicianship, and ultimately, could contribute to a reduction of patient suffering by better preparing trainees to build individual, team-based, and system-based tools to monitor for and avoid diagnostic error.

What does research on clinical reasoning have to say to clinical teachers?

Clinical reasoning is a crucial determinant of physicians’ performance. It is key to arrive at a correct diagnosis, which substantially increases the chance of appropriate therapeutic decisions. Clinical teachers face the daily challenge of helping their students to develop clinical reasoning. To select appropriate teaching strategies, it may be useful to become acquainted with the results of the research on clinical reasoning that has been conducted over the last decades. This article synthesizes the findings of this research that help in particular to understand the cognitive processes involved in clinical reasoning, the trajectory that leads the student from novice to expert, and instructional approaches that have been shown to be useful to facilitating this trajectory. The focus of the article is the diagnostic process, because it is about it that most research has been conducted. This research indicates that there is not a particular reasoning strategy that is specific to expert physicians and could be taught to students. It is the availability of a large knowledge base organized in memory in illness scripts of different formats that explains the expert’s better performance. The more, the richer, and the more well-structured are the illness scripts a physician has stored in memory, the more he/she would be able to make accurate diagnoses. These scripts are formed gradually over the years of education. To help develop them, students should be exposed to a wide variety of clinical problems, with which they must interact actively. Instructional approaches that require students to systematically reflect on problems, analyzing differences and similarities between them, explaining underlying mechanisms, comparing and contrasting alternative diagnoses, have proved useful to help refine disease scripts. These approaches are valuable tools for teachers concerned with the development of their students clinical reasoning.

Use of Inductive, Problem-Based Clinical Reasoning Enhances Diagnostic Accuracy in Final-Year Veterinary Students

Despite tremendous progression in the medical field, levels of diagnostic error remain unacceptably high. Cognitive failures in clinical reasoning are believed to be the major contributor to diagnostic error. There is evidence in the literature that teaching problem-based, inductive reasoning has the potential to improve clinical reasoning skills. In this study, 47 final-year veterinary medicine students at the Royal Veterinary College (RVC) were presented with a complex small animal medicine case. The participants were divided into two groups, one of which received a prioritized problem list in addition to the history, physical exam, and diagnostic test results provided to both groups. The students' written approaches to the case were then analyzed and assigned a diagnostic accuracy score (DAS) and an inductive reasoning score (IRS). The IRS was based on a series of predetermined characteristics consistent with the inductive reasoning framework taught at the RVC. No significant difference was found between the DAS scores of each group, indicating that the provision of a prioritized problem list did not impact diagnostic accuracy. However, a significant positive correlation between the IRS and DAS was illustrated for both groups of students, suggesting increased use of inductive reasoning is associated with increased diagnostic accuracy. These results contribute to a body of research proposing that inductive, problem-based reasoning teaching delivered in an additive model, can enhance the clinical reasoning skills of students and reduce diagnostic error.

Implementing an intervention to improve decision making around referral and admission to intensive care: Results of feasibility testing in three NHS hospitals

RATIONALE, AIMS, AND OBJECTIVES

Decisions about whether to refer or admit a patient to an intensive care unit (ICU) are clinically, organizationally, and ethically challenging. Many explicit and implicit factors influence these decisions, and there is substantial variability in how they are made, leading to concerns about access to appropriate treatment for critically ill patients. There is currently no guidance to support doctors making these decisions. We developed an intervention with the aim of supporting doctors to make more transparent, consistent, patient-centred, and ethically justified decisions. This paper reports on the implementation of the intervention at three NHS hospitals in England and evaluates its feasibility in terms of usage, acceptability, and perceived impact on decision making.

METHODS

A mixed method study including quantitative assessment of usage and qualitative interviews.

RESULTS

There was moderate uptake of the framework (28.2% of referrals to ICU across all sites during the 3-month study period). Organizational structure and culture affected implementation. Concerns about increased workload in the context of limited resources were obstacles to its use. Doctors who used it reported a positive impact on decision making, with better articulation and communication of reasons for decisions, and greater attention to patient wishes. The intervention made explicit the uncertainty inherent in these decisions, and this was sometimes challenging. The patient and family information leaflets were not used.

CONCLUSIONS

While it is feasible to implement an intervention to improve decision making around referral and admission to ICU, embedding the intervention into existing organizational culture and practice would likely increase adoption. The doctor-facing elements of the intervention were generally acceptable and were perceived as making ICU decision making more transparent and patient-centred. While there remained difficulties in articulating the clinical reasoning behind some decisions, the intervention offers an important step towards establishing a more clinically and ethically sound approach to ICU admission.

What Makes Some Diseases More Typical than Others? A Survey on the Impact of Disease Characteristics and Professional Background on Disease Typicality

Health professionals tend to perceive some diseases as more typical than others. If disease typicalities have implications for health professionals or health policy makers' handling of different diseases, then it is of great social, epistemic, and ethical interest. Accordingly, it is important to find out what makes health professionals rank diseases as more or less typical. This study investigates the impact of various factors on how typical various diseases are perceived to be by health professionals. In particular, we study the influence of broad disease categories, such as somatic versus psychological/behavioral conditions, and a wide range of more specific disease characteristics, as well as the health professional's own background. We find that professional background strongly impacted disease typicality. All professionals (MD, RN, physiotherapists and psychologists) considered somatic conditions to be more typical than psychological/behavioral. As expected, psychologists also found psychological/behavioral conditions to be more typical than did other groups. Professions of respondents could be well predicted from their individual typicality judgments, with the exception of physiotherapists and nurses who had very similar judgment profiles. We also demonstrate how various disease characteristics impact typicality for the different professionals. Typicality showed moderate to strong positive correlations with condition severity and mortality, and only non-severe conditions were rated as atypical. Hence, studying how different disease characteristics and occupational background influences health professionals' perception of disease typicality is the first and important step toward a more general study of how typicality influences disease handling.

The neurocognitive gains of diagnostic reasoning training using simulated interactive veterinary cases

The present longitudinal study ascertained training-associated transformations in the neural underpinnings of diagnostic reasoning, using a simulation game named “Equine Virtual Farm” (EVF). Twenty participants underwent structural, EVF/task-based and resting-state MRI and diffusion tensor imaging (DTI) before and after completing their training on diagnosing simulated veterinary cases. Comparing playing veterinarian versus seeing a colorful image across training sessions revealed the transition of brain activity from scientific creativity regions pre-training (left middle frontal and temporal gyrus) to insight problem-solving regions post-training (right cerebellum, middle cingulate and medial superior gyrus and left postcentral gyrus). Further, applying linear mixed-effects modelling on graph centrality metrics revealed the central roles of the creative semantic (inferior frontal, middle frontal and angular gyrus and parahippocampus) and reward systems (orbital gyrus, nucleus accumbens and putamen) in driving pre-training diagnostic reasoning; whereas, regions implicated in inductive reasoning (superior temporal and medial postcentral gyrus and parahippocampus) were the main post-training hubs. Lastly, resting-state and DTI analysis revealed post-training effects within the occipitotemporal semantic processing region. Altogether, these results suggest that simulation-based training transforms diagnostic reasoning in novices from regions implicated in creative semantic processing to regions implicated in improvised rule-based problem-solving.

Evidence-based medicine and problem based learning a critical re-evaluation

Evidence-based medicine (EBM) has been the subject of controversy since it was introduced in 1992. However, it has yet to be critically examined as an alternative paradigm for medical education, which is how it was proposed. This commentary examines EBM on the terms on which it was originally advanced and within the context that gave rise to it, the problem-based learning (PBL) environment at McMaster University in the 1970s and 80s. The EBM educational prescription is revealed to be aligned with the information processing psychology (IPP) model of learning through acquisition of general problem solving skills that characterized the early McMaster version of PBL. The IPP model has been identified in the literature as discordant with an alternative, constructivist, model that emerged at Maastricht University in the Netherlands over the subsequent period. Strengths and weaknesses of EBM are identified from the standpoint of the underlying cognitive theories. Principles are proposed with which to guide an educationally viable approach to learning and teaching the valuable skills included within the original EBM formula.

Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk

BACKGROUND

The accuracy with which surgeons can predict outcomes following surgery has not been explored in a systematic way. The aim of this review was to determine how accurately a surgeon's 'gut feeling' or perception of risk correlates with patient outcomes and available risk scoring systems.

METHODS

A systematic review was undertaken in accordance with PRISMA guidelines. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. Studies comparing surgeons' preoperative or postoperative assessment of patient outcomes were included. Studies that made comparisons with risk scoring tools were also included. Outcomes evaluated were postoperative mortality, general and operation-specific morbidity and long-term outcomes.

RESULTS

Twenty-seven studies comprising 20 898 patients undergoing general, gastrointestinal, cardiothoracic, orthopaedic, vascular, urology, endocrine and neurosurgical operations were included. Surgeons consistently overpredicted mortality rates and were outperformed by existing risk scoring tools in six of seven studies comparing area under receiver operating characteristic (ROC) curves (AUC). Surgeons' prediction of general morbidity was good, and was equivalent to, or better than, pre-existing risk prediction models. Long-term outcomes were poorly predicted by surgeons, with AUC values ranging from 0·51 to 0·75. Four of five studies found postoperative risk estimates to be more accurate than those made before surgery.

CONCLUSION

Surgeons consistently overestimate mortality risk and are outperformed by pre-existing tools; prediction of longer-term outcomes is also poor. Surgeons should consider the use of risk prediction tools when available to inform clinical decision-making.

Theories of truth and teaching clinical reasoning and problem solving

In this paper, we will first discuss two current meta-theories dealing with different, aspects of "truth". The first metatheory conceives of truth in terms of coherence (rationality, consistency): a body of knowledge is true when it contains no inconsistencies and has at least some credibility. The second metatheory conceives of truth as correspondence, i.e., empirical accuracy. The two metatheories supplement each other, but are also incommensurable, i.e., they cannot be expressed in each other's terms, for they employ completely different criteria to establish truth (Englebretsen in Bare facts and naked truths: a new correspondence theory of truth, Routledge, London, 2005). We will discuss both the role of both metatheories in medicine, in particular in medical education in a clinical context. In line with Hammond's view (Med Decis Mak 16(3):281-287, 1996a; Human judgment and social policy: irreducible uncertainty, inevitable error, unavoidable injustice, Oxford University Press, New York, 1996b), we will extend the two metatheories to two forms of competence: coherence competence and correspondence competence, and demonstrate that distinguishing these two forms of competence increases our insights as to the best way to teach undergraduate students clinical problem solving.

Experienced physician descriptions of intuition in clinical reasoning: a typology

Background

Diagnostic intuition is a rapid, non-analytic, unconscious mode of reasoning. A small body of evidence points to the ubiquity of intuition, and its usefulness in generating diagnostic hypotheses and ascertaining severity of illness. Little is known about how experienced physicians understand this phenomenon, and how they work with it in clinical practice.

Methods

Descriptions of how experienced physicians perceive their use of diagnostic intuition in clinical practice were elicited through interviews conducted with 30 physicians in emergency, internal and family medicine. Each participant was asked to share stories of diagnostic intuition, including times when intuition was both correct and incorrect. Multiple coders conducted descriptive analysis to analyze the salient aspects of these stories.

Results

Physicians provided descriptions of what diagnostic intuition is, when it occurs and what type of activity it prompts. From stories of correct intuition, a typology of four different types of intuition was identified: Sick/Not Sick, Something Not Right, Frame-shifting and Abduction. Most physician accounts of diagnostic intuition linked this phenomenon to non-analytic reasoning and emphasized the importance of experience in developing a trustworthy sense of intuition that can be used to effectively engage analytic reasoning to evaluate clinical evidence.

Conclusions

The participants recounted myriad stories of diagnostic intuition that alerted them to unusual diagnoses, previous diagnostic error or deleterious trajectories. While this qualitative study can offer no conclusions about the representativeness of these stories, it suggests that physicians perceive clinical intuition as beneficial for correcting and advancing diagnoses of both common and rare conditions.

Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error

Background Heuristics and cognitive biases are thought to play an important role in diagnostic medical error. How to systematically determine and capture these kinds of errors remains unclear. Morbidity and mortality rounds (MMRs) are generally focused on reducing medical error by identifying and correcting systems failures. However, they may also provide an educational platform for recognizing and raising awareness on cognitive errors. Methods A total of 49 MMR cases spanning the period 2008-2015 in our pathology department were examined for the presence of cognitive errors and/or systems failures by eight study participant raters who were trained on a subset of 16 of these MMR cases (excluded from the main study analysis) to identify such errors. The Delphi method was used to obtain group consensus on error classification on the remaining 33 study cases. Cases with <75% inter-rater agreement were subjected to subsequent rounds of Delphi analysis. Inter-rater agreement at each round was determined by Fleiss' kappa values. Results Thirty-six percent of the cases presented at our pathology MMRs over an 8-year period were found to contain errors likely due to cognitive bias. Conclusions These data suggest that the errors identified in our pathology MMRs represent not only systems failures but may also be composed of a significant proportion of cognitive errors. Teaching trainees and health professionals to correctly identify different types of cognitive errors may present an opportunity for quality improvement interventions in the interests of patient safety.