Teaching problem-solving--how are we doing?

Medical error, disclosure and patient safety: a global view of quality care

Medical errors are a prominent issue in health care. Numerous studies point at the high prevalence of adverse events, many of which are preventable. Although there is a range of severity in errors, they all cause harm, to the patient, to the system, or both. While errors have many causes, including human interactions and system inadequacies, the focus on individuals rather than the system has led to an unsuitable culture for improving patient safety. Important areas of focus are diagnostic procedures and clinical laboratories because their results play a major role in guiding clinical decisions in patient management. Proper disclosure of medical errors and adverse events is also a key area for improvement. Globally, system improvements are beginning to take place, however, in Canada, policies on disclosure, error reporting and protection for physicians remain non-uniform. Achieving a national standard with mandatory reporting, in addition to a non-punitive system is recommended to move forward.

Exploring situational awareness in diagnostic errors in primary care

OBJECTIVE

Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs), this study explored the use of the situational awareness (SA) framework from aviation human factors research.

METHODS

A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the USA. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process.

RESULTS

Of 254 cases meeting inclusion criteria, errors were found in 30 of 92 (32.6%) lung cancer cases and 56 of 167 (33.5%) colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, application of the SA framework provided insight into processes involved in attention management.

CONCLUSIONS

A framework of SA can help analyse and understand diagnostic errors in primary care settings that use EHRs.

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

CONTEXT

Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physician's most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward.

PURPOSE

This paper aims at exploring a comprehensive approach: the "dual-process theory", a model developed by cognitive psychologists over the last few years.

DISCUSSION

After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians' intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed.

[Training in iterative hypothesis testing as part of psychiatric education. A randomized study]

BACKGROUND

The improvement of medical education is at the center of efforts to reform the studies of medicine. Furthermore, an excellent teaching program for students is a quality feature of medical universities. Besides teaching of disease-specific contents, the acquisition of interpersonal and decision-making skills is important. However, the cognitive style of senior physicians leading to a diagnosis cannot easily be taught. Therefore, the following study aimed at examining whether specific training in iterative hypothesis testing (IHT) may improve the correctness of the diagnostic process.

MATERIALS AND METHODS

Seventy-one medical students in their 9th-11th terms were randomized to medical teaching as usual or to IHT training for 4 weeks. The intervention group received specific training according to the method of IHT. All students were examined by a multiple choice (MC) exam and additionally by simulated patients (SP). The SPs were instructed to represent either a patient with depression and comorbid anxiety and substance use disorder (SP1) or to represent a patient with depression, obsessive-compulsive disorder and acute suicidal tendencies (SP2).

RESULTS

All students identified the diagnosis of major depression in the SPs, but IHT-trained students recognized more diagnostic criteria. Furthermore, IHT-trained students recognized acute suicide tendencies in SP2 more often and identified more comorbid psychiatric disorders. The results of the MC exam were comparable in both groups. An analysis of the satisfaction with the different training programs revealed that the IHT training received a better appraisal.

CONCLUSIONS

Our results point to the role of IHT in teaching diagnostic skills. However, the results of the MC exam were not influenced by IHT training. Furthermore, our results show that students are in need of training in practical clinical skills.

Bridging the gap between clinical practice and diagnostic clinical epidemiology: pilot experiences with a didactic model based on a logarithmic scale

Rationale From general practitioners to academic staff, clinicians continue to have difficulties in applying clinical epidemiology in their everyday work. They do not fully understand the logical rules behind the numbers and they do not recognize these rules in their work. We present a new model where the pre-test and the post-test probabilities are converted to log10 of odds, and the likelihood ratio (LR) to its own log10. Methods Following Bayes' theorem, adding the log10LR to the log10 pre-test odds gives the log10 post-test odds, which can easily be represented on a logarithmic scale. In addition, by rounding the log10LR to half the unit, we create classes of discriminative power of tests, close to intuitive estimation. This model generates also a user-friendly diagram, adding considerably to the understanding of Bayes' theorem. We evaluated the effect of the rounding, the current use of the classical model and the acceptability of the new model. Results Rounding 10 disease characteristics to half the unit gives an absolute error of less than half a unit. After six explanations of Bayes' theorem, only 6/16 medical students were capable of answering simple questions about predictive value. When asked about weight of disease characteristics, no one of the 50 clinicians mentioned sensitivity, specificity, predictive value or LR. With the new model, more than 80% of trainees found medical decision making easier to understand and recognized the theory in their practice. Conclusions We conclude that our model of diagnostic clinical epidemiology offers a logical environment for an easy and rapid assessment of the evolution of disease probability with consecutive tests, providing a scientific format for 'qualitative' clinical estimations.

Integrating clinical practice guidelines into the routine of everyday practice

For years, the American College of Cardiology and the American Heart Association, along with other professional organizations, have produced clinical practice guidelines to improve the quality of cardiovascular care. Producing these comprehensive documents has required extraordinary effort, primarily from volunteer professionals. Quality improvement efforts based on these guidelines, however, have not fully engaged practicing physicians, as evidenced by studies of guideline adherence. The translation of the guidelines into routine practice remains a persistent challenge.Practitioners work in a complex and fast paced environment. In the routine of everyday practice, physicians, like all decision-makers, use cognitive shortcuts to help make rapid decisions under conditions of uncertainty. How practicing physicians package information in their working memory and use shortcuts called "heuristics" has implications for how clinical practice guidelines can most directly influence practice. Current guidelines are written as comprehensive review documents, but are not formatted to allow easy incorporation into the heuristics of everyday practice. Improving the interface between guidelines and routine practice may result in more rapid and appropriate translation of scientific evidence into practice.We describe the routine of everyday practice as a repetitive cycle where new scientific evidence is incorporated into the heuristics that drive daily medical decisions. Examining this cycle suggests ways to communicate guideline information more effectively and to improve practice routines. Recognizing the intuitive approaches that practicing physicians use to make rapid decisions may yield opportunities for responsive professional organizations and reflective practicing physicians to improve the quality of care.

Medical errors: an introduction to concepts

The prevalence of medical errors in health care systems has generated immense interest in recent years. The research on adverse events in hospitalized populations has consistently revealed high rates of adverse events. Some of these adverse events result from medical errors and a majority of these errors may be preventable. These errors can occur anywhere and at anytime in health care processes. The consequences of these errors may vary from little or no harm to being ultimately fatal to the patients. It is important to recognize that a degree of error is inevitable in any human task and human fallibility in health care should be accepted. The underlying precursors for many of these human errors may primarily be attributed to latent systemic factors inherent in today's increasingly complex health care system. The focus of adverse event analyses on individual shortcomings without appropriate attention to system issues leads to ineffective solutions. The cognitive influence on medical decision-making and error generation is also significant and should not be discounted.

Supporting the problem-based learning process in the clinical years: evaluation of an online Clinical Reasoning Guide

PURPOSE

Implementing problem-based learning (PBL) in the clinical years of a medical degree presents particular challenges. This study investigated the effectiveness of using an online Clinical Reasoning Guide to assist integration of PBL in the clinical setting and promote further development of students' clinical reasoning abilities.

METHOD

A total of 52 students in 6 PBL groups, together with their 6 clinical tutors, participated in the study. Data were analysed from videotaped observations of tutorial activity and follow-up, semistructured interviews.

RESULTS

From both the student facilitators' and the clinical tutors' perspectives, the Guide proved an effective tool for augmenting the PBL process in clinical settings and promoting the development of clinical reasoning. By combining computer-aided learning with collaborative PBL tutorials it promoted individual as well as collaborative reasoning. There is also evidence to suggest that the Guide prompted students to look more critically at their own, their colleagues' and other clinicians' reasoning processes.

Gemeinsame Wissenskonstruktion in computervermittelter Kommunikation:

Zusammenfassung. Ziele dieser Studie sind die Analyse und die Förderung des Erwerbs anwendungsorientierten Wissens in kooperativen, computervermittelten Lernumgebungen. Dazu wurden zwei Kooperationsskripts zur Vorstrukturierung der Interaktion untersucht. Ein inhaltsbezogenes Kooperationsskript strukturiert Aktivitäten in einer bestimmten Sequenz hinsichtlich inhaltlicher Aspekte der Lernaufgabe. Ein interaktionsbezogenes Kooperationsskript schreibt den Gruppenmitgliedern bestimmte Rollen sowie rollenspezifische Interaktionen vor. Beide Kooperationsskripts wurden daraufhin untersucht, welchen Einfluss sie auf Prozesse und Ergebnisse gemeinsamer Wissenskonstruktion in einer computervermittelten Lernumgebung haben. Die Faktoren “inhaltsbezogenes Kooperationsskript“ und “interaktionsbezogenes Kooperationsskript“ wurden in einem 2×2-faktoriellen Design unabhängig voneinander variiert. 96 Studierende der Pädagogik nahmen an dem Experiment teil. Die Ergebnisse zeigen, dass interaktionsbezogene Kooperationsskripts die Partizipation und den Erwerb anwendungsorientierten Wissens fördern, während inhaltsbezogene Kooperationsskripts die fokussierte Wissensanwendung im Prozess der gemeinsamen Wissenskonstruktion unterstützen, den individuellen Wissenserwerb aber beeinträchtigen.

Medical student contact with patients on a surgery clerkship: is there a chance to learn?

BACKGROUND

Earlier studies of medical students on nonsurgical rotations have shown that clinical clerks usually first interact with their patients late in the clinical course. This would seem disadvantageous to the student's learning because they would have less opportunity to generate diagnoses or a management plan.

STUDY DESIGN

A questionnaire designed to assess the nature of medical student-patient interactions in all potential clinical sites was administered to third year medical students during their surgical clerkship. Students received questionnaires each day to evaluate their clinical experiences from the previous day.

RESULTS

The results from 311 student-patient encounters were collected and analyzed by clinical site as follows: outpatient clinics, outpatient surgery, inpatient surgery, day of surgery admission, inpatient consults, or emergency room consults. Students reported significantly more opportunities to elicit chief complaint, generate potential diagnosis, develop or suggest a management plan, and perform the initial examination when in the clinic setting.

CONCLUSIONS

Overall, students were given relatively few opportunities to be the first to interact with any patient in any setting. They infrequently had an opportunity to independently generate a hypothesis or generate a management plan. Currently, the clinic offers the best opportunity for the student to complete these processes.

Evaluation of student achievement and educational outcomes

Development of problem-solving skills is vital to professional education as is factual recall. Student mastery must be measured to document student achievement requiredfor completion of educational requirements and professional certification. These measurements also help determine if the educational process is meeting its goal of helping students develop critical cognitive skills for therapeutic problem solving. Testing student growth in the ability to solve problems is less understood. Stressing integration of information across disciplines to derive answers is also important. Test items should resemble the real-world task that students are expected to master. Thatisreallythe essence of content validity, which means faculty should be biased toward presenting information that way. This article is based on a symposium presented at the annual meeting of the American College of Clinical Pharmacology in September 1996. Symposium goals were to define purposes and uses of student evaluations by type and format, including application of techniques that improve evaluation, precision, and validity. Technical applications of computer-based learning and evaluation of problem-solving skills are described. Actual experience with evaluation of problem solving in the curriculum is discussed. The process by which a medical school developed and implemented an evaluation system for a new problem-based curriculum is presented, followed by a critique of the successes and problems encountered during the first year of implementation. Criteria that a well-constructed evaluation program must meet are explored. The approach and philosophy of national standardized testing centers are explained.

The cognitive imperative: thinking about how we think

There are three domains of expertise required for consistently effective performance in emergency medicine (EM): procedural, affective, and cognitive. Most of the activity is performed in the cognitive domain. Studies in the cognitive sciences have focused on a number of common and predictable biases in the thinking process, many of which are relevant to the practice of EM. It is important to understand these biases and how they might influence clinical decision-making behavior. Among the specialities, EM provides a unique clinical milieu of inconstancy, uncertainty, variety, and complexity. Injury and illness are seen within narrow time windows, often under pressured ambient conditions. These operating characteristics force practitioners to adopt a distinctive blend of thinking strategies. Principal among them is the use of heuristics, a form of abbreviated thinking that often leads to successful outcomes but that occasionally may result in error. A number of opportunities exist to overcome interdisciplinary, linguistic, and other historical obstacles to develop a sound approach to understanding how we think in EM. This will lead to a better awareness of our cognitive processes, an improved capacity to teach effectively about cognitive strategies, and, ultimately, the minimization or avoidance of clinical error.

Diagnostic errors in three medical eras: a necropsy study

BACKGROUND

Studies comparing the accuracy of clinical diagnosis in unselected patients who died in hospital in different medical eras have shown no decline of errors in the main diagnosis. We assessed changes in diagnostic accuracy over 20 years.

METHODS

We analysed retrospectively diagnostic errors, with use of necropsy as the gold standard for diagnosis. We randomly selected 300 patients who died at a tertiary-care teaching hospital in Switzerland--100 in each of 1972, 1982, and 1992. We classified discrepancies between clinical diagnosis and necropsy findings as major and minor errors.

FINDINGS

The overall necropsy rate at the hospital stayed at around 90% for the whole period. During the study, the frequency of major discrepancies declined significantly (1972, 30%; 1982, 18%; 1992, 14%; p=0.007). The rate of minor diagnostic errors increased significantly from 23% in 1972 to 46% in 1992 (p<0.001). The increase in overall diagnostic accuracy occurred mainly because of a significant improvement in specificity for cardiovascular diseases (1972, 85%; 1982, 82%; 1992, 97%; p=0.034) and non-significantly improved sensitivity (1972, 69%; 1982, 82%; 1992, 86%; p=0.061). Sensitivity also improved for infectious diseases (1972, 25%; 1982, 67%; 1992, 86%; p=0.036). Sensitivity and specificity for neoplastic diseases were high originally and did not change. The total number of diagnostic procedures per year increased from 191 in 1972 to 259 in 1992, mainly because of non-invasive techniques, such as ultrasonography, and endoscopies.

INTERPRETATION

The frequency of major diagnostic errors in unselected patients who died in hospital was halved over 20 years, probably because of improved clinical skills and new diagnostic procedures.

Teaching problem-solving and clinical reasoning: 20 years experience with video-supported small-group learning

In the context of a curriculum reform the Faculty of Medicine of the University of Leuven, Belgium, introduced a new teaching project: video-supported small-group learning on problem-solving and clinical reasoning. The aim of this study is to reflect 20 years experience. The video-supported sessions for sixth-year medical students during their practical year in peripheral hospitals were constructed in four stages. The first stage is the video presentation of a case with history-taking and physical examination. The student and three tutors of internal medicine make notes and can ask further questions and perform additional physical examination acts after the video presentation. The coordinator of the course, who knows the patient, then simulates the patient and the doctor to answer the questions. The second stage consists of making up individually a synoptic problem list, integrating history and physical examination; a differential diagnosis list with the most likely diagnosis fitting the problem list; and a list with investigations to be asked for confirming the diagnosis. The third stage consists of three small student groups discussing the three lists requested in stage 2. Each small group of students, passively assisted by a tutor, has to come to the consensus lists. The fourth stage is the confrontation of the consensus lists of the three groups with the aim of coming to an overall agreement. At this stage tutors are more actively involved in the discussion. Several learning processes are involved in this way of teaching. During the first stage the students learn the traditional teaching 'see one, do one and teach one', a demonstration of a full history and physical examination. By asking for additional information they learn by a critical attitude and by developing a strategy of fact-finding. During the second and third stages, by making their lists and during the consensus processes, they learn the significance of individual findings, problem-framing and the synthesis of history and physical examination data in medical concepts. The third and fourth parts of the sessions bring up the process of clinical reasoning, formulation of a working hypothesis, the discussion of the pathophysiology of findings, clustering of problems and epidemiological considerations as incidence and prevalence. Finally, the exercise to select diagnostic tests gives the students the possibility of appreciating the value of sensitivity/specificity and risks, benefits and costs of diagnostic procedures. These video-supported clinical problem-solving and reasoning sessions were positively appraised by students, teachers and medical faculty over the years. Over 20 years, more than 90 cases have been recorded on video, with a widespread variation in diagnoses and clinical presentations. Small-group teaching with the aid of a video case, as described in this paper, can promote enjoyable learning for students and teachers.

The art and science of teaching rounds. A strategy for staff development

Teaching rounds can be a highly interactive, fluid process for developing staff nurses' critical thinking, assessment, and interpersonal skills. In this article, the authors describe how to conduct and evaluate teaching rounds using the example of Pain Management Teaching Rounds conducted by an advanced practice nurse on medical-surgical units of a large medical center. Qualitative and quantitative outcomes of the pain management rounds are discussed.

Clinical problem solving--the role of expert laboratory systems

The objective was to determine whether or not a laboratory based computer diagnostic program could aid the clinician in solving problems, outside his or her field of expertise, by expertly interpreting ¿Emergency Room' haematological and biochemical data and providing a list of possible diagnoses. The program, which uses Fuzzy Sets and pattern recognition as its Inference Mechanism coupled with a data base comprised of haematological and biochemical responses to disease collected over a period of 10 years in a teaching hospital, analysed data published in two leading journals--the 'Clinical Problem-Solving' section of the New England Journal of Medicine and the 'Lesson of the Week' feature of the British Medical Journal. It was found that the computer program often presented diagnoses not thought of by the clinician. With such a system, sometimes as few as three routine investigations suggested the diagnosis. The diagnostic accuracy could be improved with a more structured approach to ¿Emergency Room' laboratory investigations. It is concluded that the computer, programmed to recognize a disease by the pattern of its response to routine haematological and biochemical investigations, could contribute significantly to diagnosis.

Kabisa: an interactive computer-assisted training program for tropical diseases

In Europe, tropical pathology is usually taught in special short courses, intended for those planning to practise in developing countries. The theoretical knowledge to be assimilated during this short period is considerable, and turning such newly acquired knowledge into competence is difficult. Kabisa is a computer-based training program for tropical diseases. Instead of concentrating on strictly tropical diseases, students are trained in recognizing diseases in patients presenting randomly in an imaginary reference hospital in a developing country. Databases are compiled by experts from experiences in various parts of Africa, Asia and tropical America. Seven languages and three levels of competence can be chosen by the student. Updating of all databases is possible by teachers who want to describe a particular setting. A 'consistency checker' verifies the internal consistency of a new configuration. The logical engine is based upon both a 'cluster' and a Bayesian logic, with built-in corrections for related disease characteristics. This correction allows calculated probabilities to stay closer to real probabilities, and avoids the 'probability overshoot' that is inherent to 'idiot Bayes' calculations. The program provides training in diagnostic skills in an imaginary second-line setting in a tropical country. It puts tropical and cosmopolitan diseases in perspective and combines applied clinical epidemiology and pattern recognition within varying sets of presenting symptoms. Students are guided in searching for the most relevant disease characteristics, in ranking disease probability, and in deciding when to stop investigating.

The "Think Aloud" seminar for teaching clinical reasoning: a case study of a child with pharyngitis

The "Think Aloud" seminar is a group teaching method to assist pediatric nurse practitioner students to develop critical thinking and clinical reasoning skills. Seminar proceedings simulate the iterative clinical reasoning process that occurs in an actual clinic or office visit. Students' requests for subjective and objective data must be followed by the rationale as to why the information was requested. This method is effective for teaching and evaluating students' skills in differential diagnosis and management of common illness in children. The process will be demonstrated with the presenting symptom of a sore throat followed by a description of the procedures that are used. J Pediatr Health Care.