Consequences of contextual factors on clinical reasoning in resident physicians

The inseparability of context and clinical reasoning

Early descriptions of clinical reasoning have described a dual process model that relies on analytical or nonanalytical approaches to develop a working diagnosis. In this classic research, clinical reasoning is portrayed as an individual-driven cognitive process based on gathering information from the patient encounter, forming mental representations that rely on previous experience and engaging developed patterns to drive working diagnoses and management plans. Indeed, approaches to patient safety, as well as teaching and assessing clinical reasoning focus on the individual clinician, often ignoring the complexity of the system surrounding the diagnostic process. More recent theories and evidence portray clinical reasoning as a dynamic collection of processes that takes place among and between persons across clinical settings. Yet, clinical reasoning, taken as both an individual and a system process, is insufficiently supported by theories of cognition based on individual clinicals and lacks the specificity needed to describe the phenomenology of clinical reasoning. In this review, we reinforce that the modern healthcare ecosystem - with its people, processes and technology - is the context in which health care encounters and clinical reasoning take place.

Assessing clinical reasoning skills following a virtual patient dizziness curriculum

OBJECTIVES

Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE).

METHODS

All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated.

RESULTS

Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04).

CONCLUSIONS

The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.

Exploratory Factor Analysis of a Computerized Case-Based F-Type Testlet Variant

A testlet is a cluster of questions related to a single content area. F-type testlet is a specific type of linear testlets that contains evolving scenarios. There is no study that carried out a factor analysis of an F-type testlet exam in the context of medical education and related disciplines. We aimed to determine to what extent disciplinary domains account for the variability of student performance on an online case-based F-type testlet variant. Final year undergraduate medical students (N = 441) participated in the online exam that consisted of ten case-based F-type testlets. Six of the testlets were pediatrics, four were internal medicine. Exploratory factor analysis was carried out. It revealed that the structure has two factors. Pediatrics testlets loaded factor 1 (loadings between 0.56 and 0.77), and internal medicine testlets loaded factor 2 (loadings between 0.65 and 0.79). The results showed that disciplinary domains account for the variability of the performance on F-type testlets. The results suggest that context specificity still exists in this type of exam. In order to more thoroughly evaluate the clinical reasoning skills of students, medical educators must still ensure that clinical reasoning exams include a comprehensive representation of all relevant content areas.

Context matters: toward a multilevel perspective on context in clinical reasoning and error

Context in diagnosis and management of patients is a vexing phenomenon in medicine and health professions education that can lead to unwanted variation in clinical reasoning performance and even errors that cause patient harm. Studies have examined individual-, team-, and system-level contextual factors, but the ways in which multiple contextual factors can interact, how both distracting and enabling factors can impact performance and error, and the boundaries between context and content information are not well understood. In this paper, we use a theory-based approach to enhance our understanding of context. We introduce a multilevel perspective on context that extends prior models of clinical reasoning and propose a micro-meso-macro framework to provide a more integrated understanding of how clinical reasoning is both influenced by and emerges from multiple contextual factors. The multilevel approach can also be used to study other social phenomena in medicine such as professionalism, learning, burnout, and implicit bias. We call for a new paradigm in clinical reasoning research and education that uses multilevel theory and analysis to enhance clinical reasoning performance expertise and improve the quality of patient care.

Planning a Collection of Virtual Patients to Train Clinical Reasoning: A Blueprint Representative of the European Population

Background: Virtual patients (VPs) are a suitable method for students to train their clinical reasoning abilities. We describe a process of developing a blueprint for a diverse and realistic VP collection (prior to VP creation) that facilitates deliberate practice of clinical reasoning and meets educational requirements of medical schools. Methods: An international and interdisciplinary partnership of five European countries developed a blueprint for a collection of 200 VPs in four steps: (1) Defining the criteria (e.g., key symptoms, age, sex) and categorizing them into disease-, patient-, encounter- and learner-related, (2) Identifying data sources for assessing the representativeness of the collection, (3) Populating the blueprint, and (4) Refining and reaching consensus. Results: The blueprint is publicly available and covers 29 key symptoms and 176 final diagnoses including the most prevalent medical conditions in Europe. Moreover, our analyses showed that the blueprint appears to be representative of the European population. Conclusions: The development of the blueprint required a stepwise approach, which can be replicated for the creation of other VP or case collections. We consider the blueprint an appropriate starting point for the actual creation of the VPs, but constant updating and refining is needed.

Failure to demonstrate effects of interruptions on diagnostic reasoning: three experiments

BACKGROUND

Diagnostic error is a major source of patient suffering. Researchshows that physicians experience frequent interruptions while being engaged with patients and indicate that diagnostic accuracy may be impaired as a result. Since most studies in the field are observational, there is as yet no evidence suggesting a direct causal link between being interrupted and diagnostic error. Theexperiments reported in this article were intended to assess this hypothesis.

METHODS

Three experiments were conducted to test the hypothesis that interruptions hurt diagnostic reasoning and increase time on task. In the first experiment (N = 42), internal medicine residents, while diagnosing vignettes of actual clinical cases were interrupted halfway with a task unrelated to medicine, solving word-spotting puzzles and anagrams. In the second experiment (N = 78), the interruptions were medically relevant ones. In the third experiment (N = 30), we put additional time pressure on the participants. In all these experiments, a control group diagnosed the cases without interruption. Dependent variables were diagnostic accuracy and amount of time spent on the vignettes.

RESULTS

In none of the experiments interruptions were demonstrated to influence diagnostic accuracy. In Experiment 1: Mean of interrupted group was 0.88 (SD = 0.37) versus non- interrupted group 0.91 (SD = 0.32). In Experiment 2: Mean of interrupted group was 0.95 (SD = 0.32) versus non-interrupted group 0.94 (SD = 0.38). In Experiment 3: Mean of interrupted group was 0.42 (SD = 0.12) versus non-interrupted group 0.37 (SD = 0.08). Although interrupted residents in all experiments needed more time to complete the diagnostic task, only in Experiment 2, this effect was statistically significant.

CONCLUSIONS

These three experiments, taken together, failed to demonstrate negative effects of interruptions on diagnostic reasoning. Perhaps physicians who are interrupted may still have sufficient cognitive resources available to recover from it most of the time.

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.

Clinical Reasoning in Forensic Psychiatry: Concepts, Processes, and Pitfalls

Forensic psychiatrists are often sought by the court of law to provide professional opinion on specific legal matters that have a major impact on the evaluee and possibly society at large. The quality of that opinion and recommendations rely on the quality of the analysis from the assessment results conducted by the psychiatrist. However, the definition and scope of a forensic psychiatric analysis is not clear. While existing literature on forensic psychiatric analysis generally includes organizing information, identifying relevant details, and formulating a set of forensic psychiatric opinions as components, there is no explicit and unified definition of these terms and process. This lack of clarity and guidelines may hinder forensic psychiatry from achieving its goal of providing objective information to the court or other relevant parties. Forensic psychiatric analysis exhibits numerous parallels to clinical reasoning in other fields of medicine. Therefore, this review aims to elaborate forensic psychiatric analysis through the lens of clinical reasoning, which has been developed by incorporating advances in cognitive sciences. We describe forensic psychiatric analysis through three prominent clinical reasoning theories: hypothetico-deductive model, illness script theory, and dual process theory. We expand those theories to elucidate how forensic psychiatrists use clinical reasoning not only to diagnose mental disorders, but also to determine mental capacities as requested by law. Cognitive biases are also described as potential threat to the accuracy of the assessment and analysis. Additionally, situated cognition theory helps elucidate how contextual factors influence risk of errors. Understanding the processes involved in forensic psychiatric analysis and their pitfalls can assist forensic psychiatrists to be aware of and try to mitigate their bias. Debiasing strategies that have been implemented in other fields of medicine to mitigate errors in clinical reasoning can be adapted for forensic psychiatry. This may also shape the training program of general psychiatrists and forensic psychiatrists alike.

Gasping for air: measuring patient education and activation skillsets in two clinical assessment contexts

Objective structured clinical examinations (OSCEs) provide a controlled, simulated setting for competency assessments, while unannounced simulated patients (USPs) measure competency in situ or real-world settings. This exploratory study describes differences in primary care residents’ skills when caring for the same simulated patient case in OSCEs versus in a USP encounter. Data reported describe a group of residents (n=20) who were assessed following interaction with the same simulated patient case in two distinct settings: an OSCE and a USP visit at our safety-net clinic from 2009 to 2010. In both scenarios, the simulated patient presented as an asthmatic woman with limited understanding of illness management. Residents were rated through a behaviourally anchored checklist on visit completion. Summary scores (mean % well done) were calculated by domain and compared using paired sample t-tests. Residents performed significantly better with USPs on 7 of 10 items and in two of three aggregate assessment domains (p<0.05). OSCE structure may impede assessment of activation and treatment planning skills, which are better assessed in real-world settings. This exploration of outcomes from our two assessments using the same clinical case lays a foundation for future research on variation in situated performance. Using both assessments during residency will provide a more thorough understanding of learner competency.

Enhancing Healthcare Decision-Making Process: Findings from Orthopaedic Field

In the healthcare field, the decision-making process is part of the broad spectrum of “clinical reasoning”, which is recognised as the whole process by which a physician decides about patients’ treatments and cares. Several clinicians’ intrinsic variables lead to this decisional path. Little is known about the inference of these variables in triggering biases in decisions about the post-discharge period in the surgical field. Accordingly, this research aims to understand if and how cognitive biases can affect orthopaedists in decision-making regarding the follow-up after knee and hip arthroplasty. To achieve this goal, an interview-based explorative case study was run. Three key-decisional orthopaedic surgeons were interviewed through a quality control tool aimed at monitoring the causes and effects of cognitive distortions. Coherently with the literature, eight biases come to light. All the interviewees agree on the presence of four common biases in orthopaedic surgery (Affect heuristic, Anchoring, Halo effect, Saliency). The other biases (Groupthink, Availability, Overconfidence, Confirmation), instead, depending on specific physicians’ intrinsic variables; namely: (i) working experience; (ii) working context. This finding contributes to the debate about the application of cognitive tools as leverage for improving the quality of clinical decision-making process and, indirectly, enhancing better healthcare outcomes.

Grounding judgement in context: A conceptual learning model of clinical reasoning

CONTEXT

Contemporary research on clinical reasoning focuses on cognitive problem-solving processes. However, the decisive role that clinical context plays in clinical reasoning is often overlooked. We explored how novice learners make sense of the patient encounter in the clinical situation. In particular, we examined medical students' own judgements concerning diagnostic and management decisions and how the clinical context impacts on this. We aimed to produce a conceptual model of how students learn clinical reasoning in the clinical environment.

METHOD

We used grounded theory methodology to develop a conceptual learning model. A total of 23 medical students in their third academic year were recruited. Qualitative data were gathered from semi-structured interviews, participant observations and field interviews, during clinical clerkships.

RESULTS

Learners participating in the clinical environment experienced tensions, called 'Disjunctions.' These disjunctions emerged in the context of the student-patient encounter and in particular in situations where an element from the interaction with the patient was perceived as being inconsistent with existing frames of reference. We categorised the sources of disjunctions into four subcategories: (a) observing the manifestations of clinical signs in reality; (b) fitting the symptoms to a diagnosis; (c) considering management decisions, and (d) communicating a medical decision to the patient. Disjunctions involved an affective component and were associated with feelings of uncertainty. These tensions provoked reactions from the learners, leading them to reassess and modify held assumptions in order to accommodate the encountered inconsistent elements. This facilitated changes in judgement. When making a judgement, participants learned to take into consideration situational elements.

CONCLUSIONS

Students experience disjunctions in the clinical environment as they encounter situations that challenge their frames of reference. These disjunctions carry significant learning potential. This study can contribute to knowledge concerning the role of the patient encounter in advancing clinical reasoning by transforming problematic habits of the mind.

Understanding context specificity: the effect of contextual factors on clinical reasoning

Background Situated cognition theory argues that thinking is inextricably situated in a context. In clinical reasoning, this can lead to context specificity: a physician arriving at two different diagnoses for two patients with the same symptoms, findings, and diagnosis but different contextual factors (something beyond case content potentially influencing reasoning). This paper experimentally investigates the presence of and mechanisms behind context specificity by measuring differences in clinical reasoning performance in cases with and without contextual factors. Methods An experimental study was conducted in 2018-2019 with 39 resident and attending physicians in internal medicine. Participants viewed two outpatient clinic video cases (unstable angina and diabetes mellitus), one with distracting contextual factors and one without. After viewing each case, participants responded to six open-ended diagnostic items (e.g. problem list, leading diagnosis) and rated their cognitive load. Results Multivariate analysis of covariance (MANCOVA) results revealed significant differences in angina case performance with and without contextual factors [Pillai's trace = 0.72, F = 12.4, df =(6, 29), p < 0.001, η p 2 = 0.72 $\eta _{\rm p}^2 = 0.72$ ], with follow-up univariate analyses indicating that participants performed statistically significantly worse in cases with contextual factors on five of six items. There were no significant differences in diabetes cases between conditions. There was no statistically significant difference in cognitive load between conditions. Conclusions Using typical presentations of common diagnoses, and contextual factors typical for clinical practice, we provide ecologically valid evidence for the theoretically predicted negative effects of context specificity (i.e. for the angina case), with large effect sizes, offering insight into the persistence of diagnostic error.

Effects of live and video simulation on clinical reasoning performance and reflection

Introduction

In recent years, researchers have recognized the need to examine the relative effectiveness of different simulation approaches and the experiences of physicians operating within such environments. The current study experimentally examined the reflective judgments, cognitive processing, and clinical reasoning performance of physicians across live and video simulation environments.

Methods

Thirty-eight physicians were randomly assigned to a live scenario or video case condition. Both conditions encompassed two components: (a) patient encounter and (b) video reflection activity. Following the condition-specific patient encounter (i.e., live scenario or video), the participants completed a Post Encounter Form (PEF), microanalytic questions, and a mental effort question. Participants were then instructed to re-watch the video (i.e., video condition) or a video recording of their live patient encounter (i.e., live scenario) while thinking aloud about how they came to the diagnosis and management plan.

Results

Although significant differences did not emerge across all measures, physicians in the live scenario condition exhibited superior performance in clinical reasoning (i.e., PEF) and a distinct profile of reflective judgments and cognitive processing. Generally, the live condition participants focused more attention on aspects of the clinical reasoning process and demonstrated higher level cognitive processing than the video group.

Conclusions

The current study sheds light on the differential effects of live scenario and video simulation approaches. Physicians who engaged in live scenario simulations outperformed and showed a distinct pattern of cognitive reactions and judgments compared to physicians who practiced their clinical reasoning via video simulation. Additionally, the current study points to the potential advantages of video self-reflection following live scenarios while also shedding some light on the debate regarding whether video-guided reflection, specifically, is advantageous. The utility of context-specific, micro-level assessments that incorporate multiple methods as physicians complete different parts of clinical tasks is also discussed.

Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process

Objectives

Uncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians’ clinical reasoning process.

Methods

In this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt’s clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.).

Results

Thirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection.

Conclusions

These results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.

Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy

Background

Placebo and nocebo effects embody psychoneurobiological phenomena where behavioural, neurophysiological, perceptive and cognitive changes occur during the therapeutic encounter in the healthcare context. Placebo effects are produced by a positive healthcare context; while nocebo effects are consequences of negative healthcare context. Historically, placebo, nocebo and context-related effects were considered as confounding elements for clinicians and researchers. In the last two decades this attitude started to change, and the understanding of the value of these effects has increased. Despite the growing interest, the knowledge and the awareness of using the healthcare context to trigger placebo and nocebo effects is currently limited and heterogeneous among physiotherapists, reducing their translational value in the physiotherapy field.

Objectives

To introduce the placebo, nocebo and context-related effects by: (1) presenting their psychological models; (2) describing their neurophysiological mechanisms; (3) underlining their impact for the physiotherapy profession; and (4) tracing lines for future researches.

Conclusion

Several psychological mechanisms are involved in placebo, nocebo and context-related effects; including expectation, learning processes (classical conditioning and observational learning), reinforced expectations, mindset and personality traits. The neurophysiological mechanisms mainly include the endogenous opioid, the endocannabinoid and the dopaminergic systems. Neuroimaging studies have identified different brain regions involved such as the dorsolateral prefrontal cortex, the rostral anterior cingulate cortex, the periaqueductal gray and the dorsal horn of spine. From a clinical perspective, the manipulation of the healthcare context with the best evidence-based therapy represents an opportunity to trigger placebo effects and to avoid nocebo effects respecting the ethical code of conduct. From a managerial perspective, stakeholders, organizations and governments should encourage the assessment of the healthcare context aimed to improve the quality of physiotherapy services. From an educational perspective, placebo and nocebo effects are professional topics that should be integrated in the university program of health and medical professions. From a research perspective, the control of placebo, nocebo and context-related effects offers to the scientific community the chance to better measure the impact of physiotherapy on different outcomes and in different conditions through primary studies.

Sequence matters: patterns in task-based clinical reasoning

Background

The cognitive pathways that lead to an accurate diagnosis and efficient management plan can touch on various clinical reasoning tasks (1). These tasks can be employed at any point during the clinical reasoning process and though the four distinct categories of framing, diagnosis, management, and reflection provide some insight into how these tasks map onto clinical reasoning, much is still unknown about the task-based clinical reasoning process. For example, when and how are these tasks typically used? And more importantly, do these clinical reasoning task processes evolve when patient encounters become complex and/or challenging (i.e. with contextual factors)?

Methods

We examine these questions through the lens of situated cognition, context specificity, and cognitive load theory. Sixty think-aloud transcripts from 30 physicians who participated in two separate cases – one with a contextual factor and one without – were coded for 26 clinical reasoning tasks (1). These tasks were organized temporally, i.e. when they emerged in their think-aloud process. Frequencies of each of the 26 tasks were aggregated, categorized, and visualized in order to analyze task category sequences.

Results

We found that (a) as expected, clinical tasks follow a general sequence, (b) contextual factors can distort this emerging sequence, and (c) the presence of contextual factors prompts more experienced physicians to clinically reason similar to that of less experienced physicians.

Conclusions

These findings add to the existing literature on context specificity in clinical reasoning and can be used to strengthen teaching and assessment of clinical reasoning.

The Linguistic Effects of Context Specificity: Exploring Affect, Cognitive Processing, and Agency in Physicians' Think-Aloud Reflections

Background The literature suggests that affect, higher-level cognitive processes (e.g. decision-making), and agency (the capacity to produce an effect) are important for reasoning; however, we do not know how these factors respond to context. Using situated cognition theory as a framework, and linguistic tools as a method, we explored the effects of context specificity [a physician seeing two patients with identical presentations (symptoms and findings), but coming to two different diagnoses], hypothesizing more linguistic markers of cognitive load in the presence of contextual factors (e.g. incorrect diagnostic suggestion). Methods In this comparative and exploratory study, 64 physicians each completed one case with contextual factors and one without. Transcribed think-aloud reflections were coded by Linguistic Inquiry and Word Count (LIWC) software for markers of affect, cognitive processes, and first-person pronouns. A repeated-measures multivariate analysis of variance was used to inferentially compare these LIWC categories between cases with and without contextual factors. This was followed by exploratory descriptive analysis of subcategories. Results As hypothesized, participants used more affective and cognitive process markers in cases with contextual factors and more I/me pronouns in cases without. These differences were statistically significant for cognitive processing words but not affective and pronominal words. Exploratory analysis revealed more negative emotions, cognitive processes of insight, and third-person pronouns in cases with contextual factors. Conclusions This study exposes linguistic differences arising from context specificity. These results demonstrate the value of a situated cognition view of patient encounters and reveal the utility of linguistic tools for examining clinical reasoning.

Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study

BACKGROUND

Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis.

OBJECTIVE

To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis.

DESIGN

Retrospective cohort study using multivariable analysis of clinical data.

PARTICIPANTS

A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection.

SETTING

Four university hospitals in California between 2014 and 2016.

MAIN OUTCOMES AND MEASURES

The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen.

KEY RESULTS

Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004).

CONCLUSIONS

Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.

It Totally Possibly Could Be: How a Group of Military Physicians Reflect on Their Clinical Reasoning in the Presence of Contextual Factors

Introduction

Contextual factors (eg, diagnostic suggestion and burnout) can affect physician clinical reasoning performance, leading to diagnostic error. Yet, contextual factors have only recently been studied and none of that work focused on how physicians appraise (ie, evaluate) the clinical situation as they reason. The purpose of this qualitative study was to use appraisal to describe the effect of contextual factors on clinical reasoning.

Materials and Methods

Physicians (n = 25) either viewed two video cases or participated in two live scenarios, one with contextual factors and one without. Afterwards, they completed a “think-aloud” reflection while reviewing the cases. Transcribed think-alouds were coded for appraisal markers, comparing cases with and without contextual factors.

Results

When contextual factors were present, participants expressed more emotional evaluation and uncertainty about those emotions. Across all types of cases, participants expressed uncertainty about the case and assessed what “could” or “would” have gone differently.

Conclusions

This study suggests that one major effect of contextual factors may be that they induce emotions, which may affect the process of clinical reasoning and diagnostic error. It also suggests that uncertainty may be common in clinical practice, and we should thus further explore its impact.

Why health professions education needs functional linguistics: the power of 'stealth words'

CONTEXT

Language is one of the primary modalities for teaching and learning in the health professions in contexts ranging from the more formal teaching relationships of medical school to the guided practice of trainees through continuing education and the deliberate practice of lifelong learning. Yet linguistic analysis, with the possible exception of discourse analysis, has not become a core methodological tool in the field of health professions education (HPE). The purpose of this paper is to argue for the more widespread adoption of one particular approach to linguistics, one that examines less of what learners and instructors say and looks more at how they say it: functional linguistics.

FUNCTIONAL LINGUISTICS

THE POWER OF 'STEALTH WORDS': This approach theorises and structures the functions of language, regularly focusing attention on 'stealth words' such as I, but and was. Drawing on a rich body of literature in linguistics, psychology, the learning sciences and some early work in HPE, we demonstrate how functional linguistic tools can be applied to better understand learners' and instructors' beliefs, reasoning processes, values and emotions.

FUNCTIONAL LINGUISTICS AND REFLECTION

AN APPLICATION OF STEALTH WORDS: A brief qualitative analysis of one tool - analysis of the generic use of 'you' to mean 'one' or 'anyone' - demonstrates how functional linguistics can offer insight into physicians' bids for credibility and alignment as they think aloud about their clinical reasoning.

FUNCTIONAL LINGUISTICS AND HPE

FUTURE DIRECTIONS: Finally, we offer suggestions for how functional linguistic tools might address questions and gaps in four active research areas in HPE: reflection; emotion and reasoning; learning in simulated contexts, and self-regulated learning.

CONCLUSIONS

We argue that the words used by learners, instructors and practitioners in the health professions as they move through undergraduate and graduate training into practice can offer clues that will help researchers, instructors and colleagues to better support them.

Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings

INTRODUCTION

There is a need for educational resources supporting the practice and assessment of the complex processes of clinical reasoning in the inpatient setting along a continuum of physician experience levels.

METHODS

Using participatory design, we created a scenario-based simulation integrating diagnostic ambiguity, contextual factors, and rising patient acuity to increase complexity. Resources include an open-ended written exercise and think-aloud reflection protocol to elicit diagnostic and management reasoning and reflection on that reasoning. Descriptive statistics were used to analyze the initial implementation evaluation results.

RESULTS

Twenty physicians from multiple training stages and specialties (interns, residents, attendings, family physicians, internists, surgeons) underwent the simulated scenario. Participants engaged in clinical reasoning processes consistent with the design, considering a total of 19 differential diagnoses. Ten participants provided the correct leading diagnosis, tension pneumothorax, with an additional eight providing pneumothorax and all participants offering relevant supporting evidence. There was also good evidence of management reasoning, with all participants either performing an intervention or calling for assistance and reflecting on management plans in the think-aloud. The scenario was a reasonable approximation of clinical practice, with a mean authenticity rating of 4.15 out of 5. Finally, the scenario presented adequate challenge, with interns and residents rating it as only slightly more challenging (means of 7.83 and 7.17, respectively) than attendings (mean of 6.63 out of 10).

DISCUSSION

Despite the challenges of scenario complexity, evaluation results indicate that this resource supports the observation and analysis of diagnostic and management reasoning of diverse specialties from interns through attendings.

Clinical Reasoning in Physical Therapy: A Concept Analysis

BACKGROUND

Physical therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research.

OBJECTIVE

The objective was to conceptualize a broad description of physical therapists' clinical reasoning grounded in the published literature and to unify understanding for future work related to teaching, assessment, and research.

DESIGN/METHODS

The design included a systematic concept analysis using Rodgers' evolutionary methodology. A concept analysis is a research methodology in which a concept's characteristics and the relation between features of the concept are clarified.

RESULTS

Based on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management.

LIMITATIONS

Although a comprehensive approach was intended, it is possible that the search methods or reduction of the literature were incomplete or key sources were mistakenly excluded.

CONCLUSIONS

A description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice.

A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions

BACKGROUND

Cognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error).

METHODS

Using the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures.

RESULTS

Among 14 participants, there were 3 cognitive disposition to respond categories - Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities - with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070).

CONCLUSION

This study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.

Understanding uncertainty in medicine: concepts and implications in medical education

In an era of high technology and low trust, acknowledging and coping with uncertainty is more crucial than ever. Medical uncertainty has been considered an innate feature of medicine and medical practice. An intolerance to uncertainty increases physicians' stress and the effects of burnout and may be a potential threat to patient safety. Understanding medical uncertainty and acquiring proper coping strategies has been regarded to be a core clinical competency for medical graduates and trainees. Integrating intuition and logic and creating a culture that acknowledges medical uncertainty could be suggested ways to teach medical uncertainty. In this article, the authors describe the concepts of medical uncertainty, its influences on physicians and on medical students toward medical decision making, the role of tolerance/intolerance to uncertainty, and proposed strategies to improve coping with medical uncertainty.

Context and clinical reasoning : Understanding the medical student perspective

INTRODUCTION

Studies have shown that a physician's clinical reasoning performance can be influenced by contextual factors. We explored how the clinical reasoning performance of medical students was impacted by contextual factors in order to expand upon previous findings in resident and board certified physicians. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of medical students in order to describe what impact the presence of contextual factors has on their reasoning performance.

METHODS

Seventeen medical student participants viewed three video recordings of clinical encounters portraying straightforward diagnostic cases in internal medicine with explicit contextual factors inserted. Participants completed a computerized post-encounter form as well as a think-aloud protocol. Three authors analyzed verbatim transcripts from the think-aloud protocols using a constant comparative approach. After iterative coding, utterances were analyzed and grouped into categories and themes.

RESULTS

Six categories and ten associated themes emerged, which demonstrated overlap with findings from previous studies in resident and attending physicians. Four overlapping categories included emotional disturbances, behavioural inferences about the patient, doctor-patient relationship, and difficulty with closure. Two new categories emerged to include anchoring and misinterpretation of data.

DISCUSSION

The presence of contextual factors appeared to impact clinical reasoning performance in medical students. The data suggest that a contextual factor can be innate to the clinical scenario, consistent with situated cognition theory. These findings build upon our understanding of clinical reasoning performance from both a theoretical and practical perspective.

How to tell a patient's story? Influence of the case narrative design on the clinical reasoning process in virtual patients

BACKGROUND

Virtual patients (VPs) are narrative-based educational activities to train clinical reasoning in a safe environment. Our aim was to explore the influence of the design of the narrative and level of difficulty on the clinical reasoning process, diagnostic accuracy and time-on-task.

METHODS

In a randomized controlled trial, we analyzed the clinical reasoning process of 46 medical students with six VPs in three different variations: (1) patients showing a friendly behavior, (2) patients showing a disruptive behavior and (3) a version without a patient story.

RESULTS

For easy VPs, we did not see a significant difference in diagnostic accuracy. For difficult VPs, the diagnostic accuracy was significantly higher for participants who worked on the friendly VPs compared to the other two groups. Independent from VP difficulty, participants identified significantly more problems and tests for disruptive than for friendly VPs; time on task was comparable for these two groups. The extrinsic motivation of participants working on the VPs without a patient story was significantly lower than for the students working on the friendly VPs.

CONCLUSIONS

Our results indicate that the measured VP difficulty has a higher influence on the clinical reasoning process and diagnostic accuracy than the variations in the narratives.

Billing by residents and attending physicians in family medicine: the effects of the provider, patient, and visit factors

BACKGROUND

Medical billing and coding are critical components of residency programs since they determine the revenues and vitality of residencies. It has been suggested that residents are less likely to bill higher evaluation and management (E/M) codes compared with attending physicians. The purpose of this study is to assess the variation in billing patterns between residents and attending physicians, considering provider, patient, and visit characteristics.

METHOD

A retrospective cohort study of all established outpatient visits at a family medicine residency clinic over a 5-year period was performed. We employed the logistic regression methodology to identify residents' and attending physicians' variations in coding E/M service levels. We also employed Poisson regression to test the sensitivity of our result.

RESULTS

Between January 5, 2009 and September 25, 2015, 98,601 visits to 116 residents and 18 attending physicians were reviewed. After adjusting for provider, patient, and visit characteristics, residents billed higher E/M codes less often compared with attending physicians for comparable visits. In comparison with attending physicians, the odds ratios for billing higher E/M codes were 0.58 (p = 0.01), 0.56 (p = 0.01), and 0.63 (p = 0.01) for the third, second, and first years of postgraduate training, respectively. In addition to the main factors of patient age, medical conditions, and number of addressed problems, the gender of the provider was also implicated in the billing variations.

CONCLUSION

Residents are less likely to bill higher E/M codes than attending physicians are for similar visits. While these variations are known to contribute to lost revenues, further studies are required to explore their effect on patient care in relation to attendings' direct involvement in higher E/M-coded versus their indirect involvement in lower E/M-coded visits.

The role of emotion in clinical decision making: an integrative literature review

BACKGROUND

Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM.

METHODS

A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning.

RESULTS

Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement.

CONCLUSIONS

Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a clear theoretical framework and educational preparation may not reflect the importance of emotional competence to effective CDM.

Exploring examinee behaviours as validity evidence for multiple-choice question examinations

CONTEXT

Clinical-vignette multiple choice question (MCQ) examinations are used widely in medical education. Standardised MCQ examinations are used by licensure and certification bodies to award credentials that are meant to assure stakeholders as to the quality of physicians. Such uses are based on the interpretation of MCQ examination performance as giving meaningful information about the quality of clinical reasoning. There are several assumptions foundational to these interpretations and uses of standardised MCQ examinations. This study explores the implicit assumption that cognitive processes elicited by clinical-vignette MCQ items are like the processes thought to occur with 'real-world' clinical reasoning as theorised by dual-process theory.

METHODS

Fourteen participants (three medical students, five residents and six staff physicians) completed three sets of five timed MCQ items (total 15) from the Medical Knowledge Self-Assessment Program (MKSAP). Upon answering a set of MCQs, each participant completed a retrospective think aloud (TA) protocol. Using constant comparative analysis (CCA) methods sensitised by dual-process theory, we performed a qualitative thematic analysis.

RESULTS

Examinee behaviours fell into three categories: clinical reasoning behaviours, test-taking behaviours and reactions to the MCQ. Consistent with dual-process theory, statements about clinical reasoning behaviours were divided into two sub-categories: analytical reasoning and non-analytical reasoning. Each of these categories included several themes.

CONCLUSIONS

Our study provides some validity evidence that test-takers' descriptions of their cognitive processes during completion of high-quality clinical-vignette MCQs align with processes expected in real-world clinical reasoning. This supports one of the assumptions important for interpretations of MCQ examination scores as meaningful measures of clinical reasoning. Our observations also suggest that MCQs elicit other cognitive processes, including certain test-taking behaviours, that seem 'inauthentic' to real-world clinical reasoning. Further research is needed to explore if similar themes arise in other contexts (e.g. simulated patient encounters) and how observed behaviours relate to performance on MCQ-based assessments.

Do virtual patients prepare medical students for the real world? Development and application of a framework to compare a virtual patient collection with population data

BACKGROUND

An important aspect of virtual patients (VPs), which are interactive computer-based patient scenarios, is authenticity. This includes design aspects, but also how a VP collection represents a patient population and how a patient is presented in a VP scenario. Therefore, our aim was to analyze VP scenarios integrated into the combined internal medicine and surgery curriculum at the University of Munich (LMU) and compare the results with data from the population in Germany.

METHOD

We developed a coding framework with four main categories: patient data, patient representation, diagnoses, and setting. Based on the framework we analyzed 66 VP and compared the results with data from the German healthcare system.

RESULTS

Especially in the categories of patient data and patient representation, the VPs presented an unrealistic image of the real world; topics such as unemployment, disability, or migration background were almost non-existent. The diagnoses of the VPs and the onset of diseases were comparable with the healthcare data.

CONCLUSIONS

An explanation for the lack of representativeness of the patient data and representation might be a trend to create VPs based on fictional patient stories with VP authors trying to minimize complexity and cognitive load for the students. We suggest raising awareness among VP authors concerning personalized representations of patients without overwhelming their students. Our framework can support educators to assess the authenticity and diversity of a VP collection.

Transforming Medical Assessment: Integrating Uncertainty Into the Evaluation of Clinical Reasoning in Medical Education

In an age where practicing physicians have access to an overwhelming volume of clinical information and are faced with increasingly complex medical decisions, the ability to execute sound clinical reasoning is essential to optimal patient care. The authors propose two concepts that are philosophically paramount to the future assessment of clinical reasoning in medicine: assessment in the context of "uncertainty" (when, despite all of the information that is available, there is still significant doubt as to the best diagnosis, investigation, or treatment), and acknowledging that it is entirely possible (and reasonable) to have more than "one correct answer." The purpose of this article is to highlight key elements related to these two core concepts and discuss genuine barriers that currently exist on the pathway to creating such assessments. These include acknowledging situations of uncertainty, creating clear frameworks that define progressive levels of clinical reasoning skills, providing validity evidence to increase the defensibility of such assessments, considering the comparative feasibility with other forms of assessment, and developing strategies to evaluate the impact of these assessment methods on future learning and practice. The authors recommend that concerted efforts be directed toward these key areas to help advance the field of clinical reasoning assessment, improve the clinical care decisions made by current and future physicians, and have positive outcomes for patients. It is anticipated that these and subsequent efforts will aid in reaching the goal of making future assessment in medical education more representative of current-day clinical reasoning and decision making.

Creating authentic video scenarios for use in prehospital research

Video scenarios have been used to explore clinical reasoning during interviews in Think Aloud studies. This study used nominal group technique with experts to create video scenarios to explore the ways paramedics think and reason when caring for children who are sick or injured. At present there is little research regarding paramedics' clinical reasoning with respect to performing non-urgent procedures on children. A core expert panel identified the central structure of a prehospital clinical interaction and the range of contextual factors that may influence a paramedic's clinical reasoning [the way in which information is gathered, interpreted and analysed by clinicians]. The structure and contextual factors were then incorporated into two filmed scenarios. A second panel of clinical practice experts, then critiqued the body language, spoken word and age appropriate behaviours of those acting in the video scenarios and compared them against their own experience of clinical practice to confirm authenticity. This paper reports and reflects on the use of nominal group technique to create authentic video scenarios for use in prehospital research.