Adaptive expertise in medical decision making

Complex decision making in an intensive care environment: Perceived practice versus observed reality

RATIONALE

Advancing our understanding of how decisions are made in cognitively, socially and technologically complex hospital environments may reveal opportunities to improve healthcare delivery, medical education and the experience of patients, families and clinicians.

AIMS AND OBJECTIVES

Explore factors impacting clinician decision making in the Boston Children's Hospital Cardiac Intensive Care Unit.

METHODS

A convergent mixed methods design was used. Quantitative and qualitative data sources consisted of a faculty survey, direct observations of clinical rounds in a specific patient population identified by a clinical decision support system (CDSS) and semistructured interviews (SSIs). Deductive and inductive coding was used for qualitative data. Qualitative data were translated into images using social network analysis which illustrate the frequency and connectivity of the codes in each data set.

RESULTS

A total of 25 observations of eight faculty-led interprofessional teams were performed between 12 February and 31 March 2021. Individual patient characteristics were noted by faculty in SSIs to be the most important factor in their decision making, yet ethnographic observations suggested faculty cognitive traits, team expertise and value-based decisions were more heavily weighted. The development of expertise was impacted by role modeling. Decisions were perceived to be influenced by the system and environment.

CONCLUSIONS

Clinician perception of decision making was not congruent with the observed behaviours in a complicated and dynamic system. This study identifies important considerations in clinical curricula as well as the design and implementation of CDSS. Our method of using social network analysis to visualize components of decision making could be adopted to explore other complex environments.

Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review

OBJECTIVE

We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented.

DESIGN

We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance.

DATA SOURCES

We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022.

ELIGIBILITY CRITERIA

We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described.

DATA EXTRACTION AND SYNTHESIS

The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency.

RESULTS

Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes.

CONCLUSION

This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations.

PROSPERO REGISTRATION NUMBER

CRD42022369208.

Quantifying the Resilience of a Healthcare System: Entropy and Network Science Perspectives

In this study, we consider the human body and the healthcare system as two complex networks and use theories regarding entropy, requisite variety, and network centrality metrics with resilience to assess and quantify the strengths and weaknesses of healthcare systems. Entropy is used to quantify the uncertainty and variety regarding a patient's health state. The extent of the entropy defines the requisite variety a healthcare system should contain to be able to treat a patient safely and correctly. We use network centrality metrics to visualize and quantify the healthcare system as a network and assign the strengths and weaknesses of the network and of individual agents in the network. We apply organization design theories to formulate improvements and explain how a healthcare system should adjust to create a more robust and resilient healthcare system that is able to continuously deal with variations and uncertainties regarding a patient's health, despite possible stressors and disturbances at the healthcare system. In this article, these concepts and theories are explained and applied to a fictive and a real-life example. We conclude that entropy and network science can be used as tools to quantify the resilience of healthcare systems.

Attributes That Influence Human Decision-Making in Complex Health Services: Scoping Review

BACKGROUND

Humans currently dominate decision-making in both clinical health services and complex health services such as health policy and health regulation. Many assumptions inherent in health service models today are underpinned by Ramsey's Expected Utility Theory, a prominent theory in the field of economics that is rooted in rationality. Rational, evidence-based metrics currently dominate the culture of decision-making in health policy and regulation. However, as the COVID-19 pandemic has shown, rational metrics alone may not suffice in making better policy and regulatory decisions. There are ethical and moral considerations and other complex factors that cannot be reduced to evidence-based rationality alone. Therefore, this scoping review was undertaken to identify and map the attributes that influence human decision-making in complex health services.

OBJECTIVE

The objective is to identify and map the attributes that influence human decision-making in complex health services that have been reported in the peer-reviewed literature.

METHODS

This scoping review was designed to answer the following research question: what attributes have been reported in the literature that influence human decision-making in complex health services? A clear, reproducible methodology is provided. It is reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) standards and a recognized framework. As the topic of interest merited broad review to scope and understand literature from a holistic viewpoint, a scoping review of literature was appropriate here. Inclusion and exclusion criteria were developed, and a database search undertaken within 4 search systems-ProQuest, Scopus, PubMed, and Web of Science.

RESULTS

The results span 46 years, from 1976 to 2022. A total of 167 papers were identified. After removing duplicates, 81 papers remained. Of these, 77 papers were excluded based on the inclusion and exclusion criteria. The remaining 4 papers were found to be relevant. Citation tracking was undertaken, identifying 4 more relevant papers. Thus, a total of 8 papers were included. These papers were reviewed in detail to identify the human attributes mentioned and count the frequency of mentions. A thematic analysis was conducted to identify the themes.

CONCLUSIONS

The results highlight key themes that underline the complex and nuanced nature of human decision-making. The results suggest that rationality is entrenched and may influence the lexicon of our thinking about decision-making. The results also highlight the counter narrative of decision-making underpinned by uniquely human attributes. This may have ramifications for decision-making in complex health services today. The review itself takes a rational approach, and the methods used were suited to this.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/42353.

Neurocognitive Correlates of Clinical Decision Making: A Pilot Study Using Electroencephalography

The development of sound clinical reasoning, while essential for optimal patient care, can be quite an elusive process. Researchers typically rely on a self-report or observational measures to study decision making, but clinicians' reasoning processes may not be apparent to themselves or outside observers. This study explored electroencephalography (EEG) to examine neurocognitive correlates of clinical decision making during a simulated American Board of Anesthesiology-style standardized oral exam. Eight novice anesthesiology residents and eight fellows who had recently passed their board exams were included in the study. Measures included EEG recordings from each participant, demographic information, self-reported cognitive load, and observed performance. To examine neurocognitive correlates of clinical decision making, power spectral density (PSD) and functional connectivity between pairs of EEG channels were analyzed. Although both groups reported similar cognitive load (p = 0.840), fellows outperformed novices based on performance scores (p < 0.001). PSD showed no significant differences between the groups. Several coherence features showed significant differences between fellows and residents, mostly related to the channels within the frontal, between the frontal and parietal, and between the frontal and temporal areas. The functional connectivity patterns found in this study could provide some clues for future hypothesis-driven studies in examining the underlying cognitive processes that lead to better clinical reasoning.

Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol

INTRODUCTION

Foot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers and at higher risk of limb amputations. Shortages of regulated healthcare have hindered efforts to provide foot care. Upskilling unregulated care providers (UCPs) to deliver foot screening seems a reasonable solution to reduce limb loss. UCPs can advocate for health equity and deliver appropriate care. There is a need, however, to understand how and why an educational intervention for UCPs providing foot screening for these high-risk groups may or may not work.

METHODS AND ANALYSIS

This realist review will follow the Realist And Meta-narrative Evidence Syntheses: Evolving Standards standards. First, we will develop an initial programme theory (PrT) based on exploratory searches and discussions with experts and stakeholders. Then, we will search MEDLINE, Embase, PsycINFO, ERIC, CINAHL and Scopus databases along with relevant sources of grey literature. The retrieved articles will be screened for studies focusing on planned educational interventions for UCPs related to diabetic foot assessment. Data regarding contexts, mechanisms and outcomes will be extracted and analysed using a realist analysis through an iterative process that includes data reviewing and consultation with our team. Finally, we will use these results to modify the initial PrT.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. The main output of this research will be an evidence-based PrT for upskilling programmes for UCPs. We will share our final PrT using text, tables and infographics to summarise our results and draw insights across papers/reports. For academic, clinical, social care and educational audiences, we will produce peer-reviewed journal articles, including those detailing the process and findings of the realist review and establishing our suggestions for effective upskilling programmes.

PROSPERO REGISTRATION NUMBER

CRD42022369208.

Errors in clinical diagnosis: a narrative review

Diagnostic errors are often caused by cognitive biases and sometimes by other cognitive errors, which are driven by factors specific to clinicians, patients, diseases, and health care systems. An experienced clinician diagnoses routine cases intuitively, effortlessly, and automatically through non-analytic reasoning and uses deliberate, cognitively effortful analytic reasoning to diagnose atypical or complicated clinical cases. However, diagnostic errors can never be completely avoided. To minimize the frequency of diagnostic errors, it is advisable to rely on multiple sources of information including the clinician's personal experience, expert opinion, principals of statistics, evidence-based data, and well-designed algorithms and guidelines, if available. It is also important to frequently engage in thoughtful, reflective, and metacognitive practices that can serve to strengthen the clinician's diagnostic skills, with a consequent reduction in the risk of diagnostic error. The purpose of this narrative review was to highlight certain factors that influence the genesis of diagnostic errors. Understanding the dynamic, adaptive, and complex interactions among these factors may assist clinicians, managers of health care systems, and public health policy makers in formulating strategies and guidelines aimed at reducing the incidence and prevalence of the phenomenon of clinical diagnostic error, which poses a public health hazard.

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.

Performance and Agreement When Annotating Chest X-ray Text Reports—A Preliminary Step in the Development of a Deep Learning-Based Prioritization and Detection System

A chest X-ray report is a communicative tool and can be used as data for developing artificial intelligence-based decision support systems. For both, consistent understanding and labeling is important. Our aim was to investigate how readers would comprehend and annotate 200 chest X-ray reports. Reports written between 1 January 2015 and 11 March 2022 were selected based on search words. Annotators included three board-certified radiologists, two trained radiologists (physicians), two radiographers (radiological technicians), a non-radiological physician, and a medical student. Consensus labels by two or more of the experienced radiologists were considered “gold standard”. Matthew’s correlation coefficient (MCC) was calculated to assess annotation performance, and descriptive statistics were used to assess agreement between individual annotators and labels. The intermediate radiologist had the best correlation to “gold standard” (MCC 0.77). This was followed by the novice radiologist and medical student (MCC 0.71 for both), the novice radiographer (MCC 0.65), non-radiological physician (MCC 0.64), and experienced radiographer (MCC 0.57). Our findings showed that for developing an artificial intelligence-based support system, if trained radiologists are not available, annotations from non-radiological annotators with basic and general knowledge may be more aligned with radiologists compared to annotations from sub-specialized medical staff, if their sub-specialization is outside of diagnostic radiology.

Learning strategy impacts medical diagnostic reasoning in early learners

Relating learned information to similar yet new scenarios, transfer of learning, is a key characteristic of expert reasoning in many fields including medicine. Psychological research indicates that transfer of learning is enhanced via active retrieval strategies. For diagnostic reasoning, this finding suggests that actively retrieving diagnostic information about patient cases could improve the ability to engage in transfer of learning to later diagnostic decisions. To test this hypothesis, we conducted an experiment in which two groups of undergraduate student participants learned symptom lists of simplified psychiatric diagnoses (e.g., Schizophrenia; Mania). Next, one group received written patient cases and actively retrieved the cases from memory and the other group read these written cases twice, engaging in a passive rehearsal learning strategy. Both groups then diagnosed test cases that had two equally valid diagnoses-one supported by "familiar" symptoms described in learned patient cases, and one by novel symptom descriptions. While all participants were more likely to assign higher diagnostic probability to those supported by the familiar symptoms, this effect was significantly larger for participants that engaged in active retrieval compared to passive rehearsal. There were also significant differences in performance across the given diagnoses, potentially due to differences in established knowledge of the disorders. To test this prediction, Experiment 2 compared performance on the described experiment between a participant group that received the standard diagnostic labels to a group that received fictional diagnostic labels, nonsense words designed to remove prior knowledge with each diagnosis. As predicted, there was no effect of diagnosis on task performance for the fictional label group. These results provide new insight on the impact of learning strategy and prior knowledge in fostering transfer of learning, potentially contributing to expert development in medicine.

The challenge of cognitive science for medical diagnosis

The historical tendency to view medicine as both an art and a science may have contributed to a disinclination among clinicians towards cognitive science. In particular, this has had an impact on the approach towards the diagnostic process which is a barometer of clinical decision-making behaviour and is increasingly seen as a yardstick of clinician calibration and performance. The process itself is more complicated and complex than was previously imagined, with multiple variables that are difficult to predict, are interactive, and show nonlinearity. They appear to characterise a complex adaptive system. Many aspects of the diagnostic process, including the psychophysics of signal detection and discrimination, ergonomics, probability theory, decision analysis, factor analysis, causal analysis and more recent developments in judgement and decision-making (JDM), especially including the domain of heuristics and cognitive and affective biases, appear fundamental to a good understanding of it. A preliminary analysis of factors such as manifestness of illness and others that may impede clinicians' awareness and understanding of these issues is proposed here. It seems essential that medical trainees be explicitly and systematically exposed to specific areas of cognitive science during the undergraduate curriculum, and learn to incorporate them into clinical reasoning and decision-making. Importantly, this understanding is needed for the development of cognitive bias mitigation and improved calibration of JDM in clinical practice.

The cognitive apprenticeship: advancing reasoning education by thinking aloud

Teaching clinical reasoning has long challenged educators because it requires familiarity with reasoning concepts, experience with describing thinking, and comfort with exposing uncertainty and error. We propose that teachers adopt the cognitive apprenticeship model and a method of disclosing uncertainty known as intellectual streaking. These approaches reflect a shift in the educator's mindset from transmitting medical knowledge to broadcasting cognition. We provide several examples to guide the adoption of these strategies and make recommendations for teachers and training programs to improve the teaching of clinical reasoning.

Exploring the development of adaptive expertise through the lens of threshold concepts

INTRODUCTION

While expert clinical practice requires a flexible approach to problem solving, evidence shows that medical clerks tend to focus on knowledge acquisition as the key to expertise. It is not until residency training that learners shift their understanding of expertise towards developing adaptive approaches to clinical problems. This raises the possibility that adaptive expertise is a threshold concept and that authentic clinical experiences involving complex problem solving are required to create the liminal state that enables transformation to an adaptive expertise mindset. With this possibility in mind, the current study examined the conceptualisations of expertise held by recently graduated physical therapists using the framework of threshold concepts as a sensitising lens.

METHODS

An exploratory qualitative study in the Constructivist Grounded Theory tradition was conducted, utilising 14 one-on-one semi-structured interviews with recently graduated physical therapists.

RESULTS

Most participants were in a transitional state regarding their conceptualisation of expertise, sometimes focusing on the acquisition of knowledge and routinisation of practice as their hallmark of expertise and at other times acknowledging the need for developing more dynamic and adaptive problem-solving approaches to patient care. These mixed responses were expressed not only in their framing of patient management but also in their reasons for valuing colleagues and in their approach to continuing professional development. Notably, many participants suggested that the interview itself was a key impetus to their reflecting on these issues.

CONCLUSION

Our findings suggest that participants were only beginning to transition into an adaptive expertise mindset upon entering practice, reinforcing the possibility that authentic practice may be an important impetus for recognising the limits of routine expertise. However, spontaneous comments from participants suggest that this transition might be better supported though active guided reflection in addition to meaningful clinical engagement with patients and colleagues.

Reflection Machines: Supporting Effective Human Oversight Over Medical Decision Support Systems

Human decisions are increasingly supported by decision support systems (DSS). Humans are required to remain "on the loop," by monitoring and approving/rejecting machine recommendations. However, use of DSS can lead to overreliance on machines, reducing human oversight. This paper proposes "reflection machines" (RM) to increase meaningful human control. An RM provides a medical expert not with suggestions for a decision, but with questions that stimulate reflection about decisions. It can refer to data points or suggest counterarguments that are less compatible with the planned decision. RMs think against the proposed decision in order to increase human resistance against automation complacency. Building on preliminary research, this paper will (1) make a case for deriving a set of design requirements for RMs from EU regulations, (2) suggest a way how RMs could support decision-making, (3) describe the possibility of how a prototype of an RM could apply to the medical domain of chronic low back pain, and (4) highlight the importance of exploring an RM's functionality and the experiences of users working with it.

Making sense of adaptive expertise for frontline clinical educators: a scoping review of definitions and strategies

Adaptive expertise has been promoted as an emerging model of expertise in health professions education in response to the inherent complexities of patient care; however, as the concept increasingly influences the structure of professional training and practice, it creates the potential for misunderstandings of the definition and implications of adaptive expertise. To foster a common understanding of the concept, we conducted a scoping review to explore how adaptive expertise has been discussed within health professions education literature. Five databases-MedLine, PubMed, ERIC, CINAHL, and PsycINFO-were searched using the exact term "adaptive expertise", producing 212 unique articles. Fifty-eight articles met inclusion criteria. In the included articles, authors discussed the conceptual implications of adaptive expertise for health professions education, strategies for training for adaptive expertise, and research findings aimed at supporting the development of adaptive expertise or utilizing adaptive expertise as a theoretical framework. The goal of this scoping review is to establish a resource for frontline educators tasked with fostering the development of adaptive expertise in learners through education initiatives. A common understanding of adaptive expertise is essential to ensuring effective implementation in training programs.

The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning

PURPOSE

Adaptive expertise (AE) has been identified as a critical trait to cultivate in future physicians. The 4-phase master adaptive learner (MAL) conceptual model describes the learning skills and behaviors necessary to develop AE. Though prior work has elucidated skills and behaviors used by MALs in the initial planning phase of learning, most resident learners are not thought to be MALs. In this study, the authors investigated how these majority "typical" learners develop AE by exploring the strategies they used in the planning phase of learning.

METHOD

Participants were resident physicians at graduate medical education (GME) training programs located at 4 academic medical centers in the United States. Participants participated in semistructured individual interviews in 2021, and interview transcripts were analyzed using constant comparative analysis of grounded theory.

RESULTS

Fourteen subjects representing 8 specialties were interviewed, generating 152 pages of transcripts for analysis. Three themes were identified: "Typical" learners were challenged by the transition from structured undergraduate medical education learning to less-structured GME learning, lacked necessary skills to easily navigate this transition, and relied on trial and error to develop their learning skills.

CONCLUSIONS

Participants used trial and error to find learning strategies to help them manage the systemic challenges encountered when transitioning from medical school to residency. The success (or failure) of these efforts was tied to learners' efficacy with the self-regulated learning concepts of agency, metacognitive goal setting, and motivation. A conceptual model is provided to describe the impact of these factors on residents' ability to be adaptive learners, and actionable recommendations are provided to help educators' efforts to foster adaptive learning skills and behaviors. These findings also provided valuable evidence of validity of the MAL model that has thus far been lacking.

Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery

Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .

Exploring an EAP writing teacher's adaptive expertise and adaptive teaching practices from a CDST perspective

Teachers' adaptive expertise (TAE) has received increasing attention in the current English as foreign language (EFL) teaching field, however, it has seldom been examined with adaptive practices by teachers in on-going classes among existing literature. Adopting a mixed-method design with data triangulation, this study was conducted to explore the complexity of teachers' adaptive expertise (TAE) and adaptive teaching practices that an EAP writing teacher demonstrated in academic writing courses, from a Complex Dynamic Systems Theory (CDST) perspective. Semi-structured interviews, classroom observations, and questionnaires were arranged to collect qualitative and quantitative data from an EAP writing teacher and 43 EFL learners in a Chinese university. Thematic analysis and SPSS were mainly used in the current work for data analysis. Our findings confirmed (1) the complexity of TAE and ATP with specific features of non-linearity, interconnectedness, and self-organization, which are classic CDST characteristics; (2) the TAE evolved with meta-cognitive, cognitive, affective and social components that are intertwined and contributed to the teacher's adaptive teaching practices (ATP) in her academic writing course; (3) being facilitated by TAE, the teacher's adaptive teaching practices significantly enhanced EFL learners, learning motivation of academic writing and their learning efficiency. Findings of the current work pave the way for future studies in researching TAE and ATP with a thorough consideration of language teachers, students and contexts from the CDST perspective. Moreover, pedagogical contributions are highlighted through the detailed examinations of the EAP writing teacher's ATP, including the class design, teaching plans, and methods, which would be fruitful for the development of tertiary EAP writing research.

Neurodiversity in medical education: How can we improve postgraduate learning for neurodiverse doctors?

Recently, there has been an important drive to increase diversity in medical education, which could potentially translate to improved outcomes for patients. Despite this, evidence on how to support neurodiverse doctors is limited. In this article the author reflects on their experience of postgraduate medical education as a doctor with Attention Deficit Hyperactivity Disorder (ADHD) and considers how the learning environment can be improved to help neurodiverse doctors reach their potential. This includes increasing the diversity of senior role models, using a cognitive apprenticeship model, employing teaching strategies which allow learners to elaborate their individual thought processes, and providing appropriate timely feedback.

Creating a better learning environment: a qualitative study uncovering the experiences of Master Adaptive Learners in residency

BACKGROUND

Adaptive expertise is an important physician skill, and the Master Adaptive Learner (MAL) conceptual model describes learner skills and behaviors integral to the acquisition of adaptive expertise. The learning environment is postulated to significantly impact how MALs learn, but it is unclear how these successful learners experience and interact with it. This study sought to understand the authentic experience of MALs within the learning environment and translate those experiences into practical recommendations to improve the learning environment for all trainees.

METHODS

Following a constructivist paradigm, we conducted a thematic analysis of transcripts from focus groups composed of MALs to identify commonalities in experiences and practices of successful postgraduate trainees in the learning environment. Saturation was achieved after seven focus groups, consisting of thirty-eight participants representing fourteen specialties from four institutions. Researchers coded transcripts using constant comparison analysis, which served as the foundation for our thematic analysis.

RESULTS

We identified eight themes and situated them within a 4-component model of the learning environment. Four themes were identified within the personal component: (1) patients drive learning; (2) learning has no endpoint; (3) management of emotions is crucial for learning; (4) successful learning requires a structured approach. Two themes were identified in the social component: (5) positive social relationships are leveraged to maximize learning; (6) teaching facilitates personal learning. Two themes were identified in the organizational component: (7) transitions challenge learners to adapt; (8) the learning environment dictates goal setting strategy. No major themes were identified in the physical/virtual component, although participants frequently used technology when learning.

CONCLUSIONS

Master Adaptive Learners experience similar facilitators of, and barriers to, success in the learning environment. Overall, our data show that acquisition of many successful strategies and skills that support learning are relegated to the hidden curriculum of residency training. Educators could support a more effective learning environment for all trainees by: (1) highlighting patients as the focal point of learning, (2) building a professional 'learner' identity, (3) teaching learning skills, and (4) creating opportunities for collaborative learning.

System 2 Diagnostic Process for the Next Generation of Physicians: "Inside" and "Outside" Brain-The Interplay between Human and Machine

Improving diagnosis has been one of the most critical issues in medicine for the last two decades. In the context of the rise of digital health and its augmentation and human diagnostic thinking, it has become necessary to integrate the concept of digital diagnosis into dual-process theory (DPT), which is the fundamental axis of the diagnostic thinking process physicians. Particularly, since the clinical decision support system (CDSS) corresponds to analytical thinking (system 2) in DPT, it is necessary to redefine system 2 to include the CDSS. However, to the best of my knowledge there has been no concrete conceptual model based on this need. The innovation and novelty of this paper are that it redefines system 2 to include new concepts and shows the relationship among the breakdown of system 2. In this definition, system 2 is divided into “inside” and “outside” brains, where “inside” includes symptomatologic, anatomical, biomechanical–physiological, and etiological thinking approaches, and “outside” includes CDSS. Moreover, this paper discusses the actual and possible future interplay between “inside” and “outside.” The author envisions that this paper will serve as a cornerstone for the future development of system 2 diagnostic thinking strategy.

Physicians' cognitive approach to prognostication after cardiac arrest

OBJECTIVE

Elucidate how physicians formulate a neurological prognosis after cardiac arrest and compare differences between experts and general providers.

METHODS

We performed semi-structured interviews with experts in post-arrest care and general physicians. We created an initial model and interview guide based on professional society guidelines. Two authors independently coded interviews based on this initial model, then identified new topics not included in it. To describe individual physicians' cognitive approach to prognostication, we created a graphical representation. We summarized these individual "mental models" into a single overall model, as well as two models stratified by expertise.

RESULTS

We performed 36 interviews (17 experts and 19 generalists), most of whom practice in Europe (23) or North America (12). Participants described their approach to prognosis formulation as complex and iterative, with sequential and repeated data acquisition, interpretation, and prognosis formulation. Eventually, this cycle results in a final prognosis and treatment recommendation. Commonly mentioned factors were diagnostic test performance, time from arrest, patient characteristics. Participants also discussed factors rarely discussed in prognostication research including physician and hospital characteristics. We found no substantial differences between experts and general physicians.

CONCLUSION

Physicians' cognitive approach to neurologic prognostication is complex and influenced by many factors, including some rarely considered in current research. Understanding these processes better could inform interventions designed to aid physicians in prognostication.

Investigating cognitive factors and diagnostic error in a presentation of complicated multisystem disease

OBJECTIVES

To use a case review approach for investigating the types of cognitive error identifiable following a complicated patient admission with a multisystem disorder in an acute care setting where diagnosis was difficult and delayed.

METHODS

A case notes review was undertaken to explore the cognitive factors associated with diagnostic error in the case of an 18-year-old male presenting acutely unwell with myalgia, anorexia and vomiting. Each clinical interaction was analysed and identified cognitive factors were categorised using a framework developed by Graber et al.

RESULTS

Cognitive factors resulting in diagnostic errors most frequently occurred within the first five days of hospital admission. The most common were premature closure; failure to order or follow up an appropriate test; over-reliance on someone else's findings or opinion; over-estimating or underestimating usefulness or salience of a finding, and; ineffective, incomplete or faulty history and physical examination. Cognitive factors were particularly frequent around transitions of care and patient transfers from one clinical area to another. The presence of senior staff did not necessarily mitigate against diagnostic error from cognitive factors demonstrated by junior staff or diagnostic errors made out-of-hours.

CONCLUSIONS

Cognitive factors are a significant cause of diagnostic error within the first five days after admission, especially around transitions of care between different clinical settings and providers. Medical education interventions need to ensure clinical reasoning training supports individuals and teams to develop effective strategies for mitigating cognitive factors when faced with uncertainty over complex patients presenting with non-specific symptoms in order to reduce diagnostic error.

Decision Making in Obstetric Anesthesia

Obstetric anesthesiologists provide care under unique conditions, where frequently unscheduled cases demand flexibility in thinking and acting. And although most obstetric patients may be healthy, they can quickly deteriorate, necessitating rapid team diagnostic and treatment interventions. Examining decision making is a critical step in improving care to these patients. This article reviews evidence-based models of decision making both with individuals and with teams, and presents strategies to improve decision making under any circumstance.

Exploring antibiotic prescribing in public and private primary care settings in Singapore: a qualitative analysis informing theory and evidence-based planning for value-driven intervention design

BACKGROUND

Singapore's healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems.

AIM

To explore processes underpinning decision-making for antibiotic prescribing, by considering doctors' experiences in different primary care settings.

METHODS

Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model, informing solutions to appropriate antibiotic prescribing.

RESULTS

Given Singapore's lack of national guidelines for antibiotic prescribing in primary care, practices are currently non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding interventions to improve antibiotic prescribing practices. These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions, or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change.

CONCLUSIONS

These VALUE dimensions are recommended as potentially transferable to diverse contexts, and the model as implementation tool to be tested empirically and updated accordingly.

Narrowing the mindware gap in medicine

Medical error is now recognized as one of the leading causes of death in the United States. Of the medical errors, diagnostic failure appears to be the dominant contributor, failing in a significant number of cases, and associated with a high degree of morbidity and mortality. One of the significant contributors to diagnostic failure is the cognitive performance of the provider, how they think and decide about the process of diagnosis. This thinking deficit in clinical reasoning, referred to as a mindware gap, deserves the attention of medical educators. A variety of specific approaches are outlined here that have the potential to close the gap.

A Cognitive Autopsy Approach Towards Explaining Diagnostic Failure

Diagnostic failure has emerged as one of the most significant threats to patient safety. It is important to understand the antecedents of such failures both for clinicians in practice as well is those in training. A consensus has developed in the literature that the majority of failures are due to individual or system factors or some combination of the two. A major source of variance in individual clinical performance is cognitive and affective biases; however, their role in clinical decision making has been difficult to assess partly because they are difficult to investigate experimentally. A significant drawback has been that experimental manipulations appear to confound the assessment of the context surrounding the diagnostic process itself. We conducted an exercise on selected actual cases of diagnostic errors to explore the effect of biases in the ‘real world’ emergency medicine (EM) context.

Thirty anonymized EM cases were analysed in depth through a process of root cause analysis that included an assessment of error-producing conditions (EPCs), knowledge-based errors, and how clinicians were thinking and deciding during each case. A prominent feature of the exercise was the identification of the occurrence of and interaction between specific cognitive and affective biases, through a process called cognitive autopsy. The cases covered a broad range of diagnoses across a wide variety of disciplines. A total of 24 discrete cognitive and affective biases that contributed to misdiagnosis were identified and their incidence recorded. Five to six biases were detected per case, and observed on 168 occasions across the 30 cases. Thirteen EPCs were identified. Knowledge-based errors were rare, occurring in only five definite instances. The ordinal position in which biases appeared in the diagnostic process was recorded. This experiment provides a baseline for investigating and understanding the critical role that biases play in clinical decision making as well as providing a credible explanation for why diagnoses fail.

Relationship between mindfulness, stress, and performance in medical students in pediatric emergency simulations

Objectives: Pediatric teams of emergency departments work under extreme stress, which affects high-level cognitive functions, specifically attention and memory. Therefore, the methods of stress management are being sought. Mindfulness as a process of intentionally paying attention to each moment with acceptance of each experience without judgment can potentially contribute to improving the performance of medical teams. Medical simulation is a technique that creates a situation to allow persons to experience a representation of a real event for the purpose of education. It has been shown that emergency medicine simulation may create a high physiological fidelity environment similarly to what is observed in a real emergency room. The aim of our study was to determine whether the technical and non-technical skills of medical students in the course of pediatric high fidelity simulations are related to their mindfulness and stress. Participants and methods: A total of 166 standardized simulations were conducted among students of medicine in three simulation centers of medical universities, assessing: stress sensation (subjectively and heart rate/blood pressure), technical (checklists) and non-technical skills (Ottawa scale) and mindfulness (five facet mindfulness questionnaire): ClinicalTrials.gov ID: NCT03761355. Results: The perception of stress among students was lower and more motivating if they were more mindful. Mindfulness of students correlated positively with avoiding fixation error. In the consecutive simulations the leaders' non-technical skills improved, although no change was noted in their technical skills. Conclusion: The results of our research indicate that mindfulness influence the non-technical skills and the perception of stress of medical students during pediatric emergency simulations. Further research is needed to show whether mindfulness training leads to improvement in this field.

A scoping review of adaptive expertise in education

Adaptive expertise encompasses efficiency and innovation; however little is known about the state of research of adaptive expertise in medical education. Our scoping review summarizes existing evidence in the conceptual frameworks, development, and measurement for adaptive expertise. We searched Pubmed, MEDLINE, ERIC, CINAHL and PsycINFO for original research articles published from 1986 onwards in English. Given the heterogeneity of the studies, no quantitative syntheses were conducted and the articles were summarized qualitatively. Of the 48 articles that met inclusion criteria, 19 examined conceptual frameworks, 24 explored interventions supporting development and 5 examined measurement. Conceptual frameworks are consistent within and beyond health professions education. Factors influencing development include: predisposing factors such as knowledge (ability to integrate knowledge and innovate), beliefs and attitudes (high motivation and humility), enabling factors such as skills (people skills, implementing reflection and scholarly activities), resources such as curricular enablers (providing variability of cases, allowing flexibility to generate solutions, critical appraisal of textbooks) and reinforcing factors such as mentor-guided feedback and constant curricular review. Two validated measurement tools exist for adaptive expertise. Substantial research opportunities exist in studying interventions involving the development of adaptive expertise. Notable gaps exist in the development and validation of measurement tools.

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.

Artificial Intelligence and Clinical Decision Making: The New Nature of Medical Uncertainty

Estimates in a 1989 study indicated that physicians in the United States were unable to reach a diagnosis that accounted for their patient's symptoms in up to 90% of outpatient patient encounters. Many proponents of artificial intelligence (AI) see the current process of moving from clinical data gathering to medical diagnosis as being limited by human analytic capability and expect AI to be a valuable tool to refine this process. The use of AI fundamentally calls into question the extent to which uncertainty in medical decision making is tolerated. Uncertainty is perceived by some as fundamentally undesirable and thus, for them, optimal decision making should be based on minimizing uncertainty. However, uncertainty cannot be reduced to zero; thus, relative uncertainty can be used as a metric to weigh the likelihood of various diagnoses being correct and the appropriateness of treatments. Here, the authors make the argument, using as examples the experiences of 2 AI systems, IBM Watson on Jeopardy and Watson for Oncology, that medical decision making based on relative uncertainty provides a better lens for understanding the application of AI to medicine than one that minimizes uncertainty. This approach to uncertainty has significant implications for how health care leaders consider the benefits and trade-offs of AI-assisted and AI-driven decision tools and ultimately integrate AI into medical practice.

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors

OBJECTIVES

Few studies describe the impact of antimicrobial stewardship programs (ASPs) on recognizing and preventing diagnostic errors. Handshake stewardship (HS-ASP) is a novel ASP model that prospectively reviews hospital-wide antimicrobial usage with recommendations made in person to treatment teams. The purpose of this study was to determine if HS-ASP could identify and intervene on potential diagnostic errors for children hospitalized at a quaternary care children's hospital.

METHODS

Previously self-identified "Great Catch" (GC) interventions by the Children's Hospital Colorado HS-ASP team from 10/2014 through 5/2018 were retrospectively reviewed. Each GC was categorized based on the types of recommendations from HS-ASP, including if any diagnostic recommendations were made to the treatment team. Each GC was independently scored using the "Safer Dx Instrument" to determine presence of diagnostic error based on a previously determined cut-off score of ≤1.50. Interrater reliability for the instrument was measured using a randomized subset of one third of GCs.

RESULTS

During the study period, there were 162 GC interventions. Of these, 65 (40%) included diagnostic recommendations by HS-ASP and 19 (12%) had a Safer Dx Score of ≤1.50, (Κ=0.44; moderate agreement). Of those GCs associated with diagnostic errors, the HS-ASP team made a diagnostic recommendation to the primary treatment team 95% of the time.

CONCLUSIONS

Handshake stewardship has the potential to identify and intervene on diagnostic errors for hospitalized children.

Reducing Diagnostic Error in the Intensive Care Unit. Engaging Uncertainty When Teaching Clinical Reasoning

As medicine continues to advance with improvements in technology, factual information has become more easily available at the bedside. Nevertheless, diagnostic error remains a salient concern for the medical community and public. To address this problem, two fundamental characteristics of the physician remain important: curiosity and the ability to apply critical reasoning to solve problems, often in the setting of imperfect knowledge and uncertainty. Historically, the teaching and recall of factual information, illness scripts, and pattern recognition are emphasized early in medical education. Students are often left with the impression that there is a single correct answer for every question; discussions of uncertainty are rare. Consequently, discomfort with uncertainty is common among doctors. As attention to explicit teaching of clinical reasoning increases, one must consider how to incorporate uncertainty into that teaching and to transform the clinical learning environment to embrace uncertainty. The authors propose the use of several simple methods easily employed in the critical care setting to make uncertainty explicit by changing the language used for expressing differential diagnosis, incorporating probabilities into daily sign-outs, and by implementing inductive reasoning when teaching critical thinking to offer learners a strategy for working through unknown problems; these approaches may normalize uncertainty, improve comfort with it, and reduce the impact of cognitive bias in decision-making. Comfort with uncertainty may result not only in improved clinical experiences for learning by transforming a once negative cognitive experience to a positive one but also in reduced susceptibility to thinking errors.

Relationship between Executive Functions, Mindfulness, Stress, and Performance in Pediatric Emergency Simulations

Over the past decade, high-fidelity medical simulation has become an accepted and widely used teaching method in pediatrics. Both simulation and work in the real conditions of emergency departments are accompanied by stress that affects the executive functions of participants. One of the methods for reducing stress among medical students and healthcare professionals is the practice of mindfulness. The aim of this study was to examine whether executive functions, mindfulness, and stress are related to the technical and non-technical skills of medical students participating in medical simulations in pediatrics. The study included 153 final-year medical students. A total of 306 high-fidelity simulations of life-threatening situations involving children were conducted. Results: Stress and the coping mechanism of the participants were correlated to their skills during pediatric simulations. Some components of mindfulness, such as non-judgment and conscious action, were positively related to the skills of medical team leaders. Executive functions correlated with the non-technical skills and mindfulness of the medical students. Conclusions: Stress, mindfulness, and executive functions modeled the behavior and skills of medical students during pediatric simulations of life-threatening events. Further research in this area may prove whether mindfulness training will improve learning outcomes in pediatric emergency medicine.

The complex phenomenon of dysrational antibiotics prescribing decisions in German primary healthcare: a qualitative interview study using dual process theory

Background

Antibiotic prescription rates in primary care in Germany are moderate, but still considered too high. The ARena study (Sustainable reduction of antibiotic-induced antimicrobial resistance) was initiated to foster awareness and understanding of the growing challenge and promotes rational antibiotics use for acute, non-complicated and self-limiting infections.

Methods

The present study was performed as part of the process evaluation of the ARena study. Interviews were conducted with a purposive sample of physicians participating in the ARena study to identify factors relevant to primary care physicians' decision-making when prescribing antibiotics for acute non-complicated infections. Generated data were audio-recorded. Pseudonymized verbatim transcripts were coded using a pre-defined framework. The Dual Process Theory was applied to provide understanding of individual health professional factors that induce dysrational prescribing decisions.

Results

Based on medical as well as non-medical considerations, physicians developed habits in decision making on antibiotics prescribing. They acknowledged inadequate antibiotics prescribing for acute, non-complicated infections in situations involving uncertainty regarding diagnosis, prognosis, continuity of care, patient expectations and when not knowing the patient. Educative efforts empowered physicians to override habitual prescribing. A theory-driven model provides transparency as to how dysrational prescribing decisions occur and suggests remedy by providing new experiences and new recognizable patterns through educative efforts.

Conclusions

Educational interventions may only change prescribing behaviours if they result in active rational rather than routine-based decision-making on antibiotics prescribing.

Trial registration

ISRCTN, ISRCTN58150046.

Reflection Of Reflections: Building Diagnostic Expertise

The ability to make a correct diagnosis is one of the physicians’ core competencies. In view of continuous medical education, the way to establish and maintain this expertise has been explored. Reflection has been reported to serve as an effective measure of remediating individual diagnostic skill. This article highlights three reflections which are reflection in action, reflection on action, and reflection for action, evidenced by past reports. Applying these reflections allows physicians to revisit the link between fundamental and interdisciplinary medical knowledge in conjunction with prior experience, thereby developing enhanced levels of diagnostic expertise and mastery.

Case reports of diagnostic error: liposarcoma mistaken for hematoma in an obese female with concurrent ipsilateral thrombosis on rivaroxaban

We report the case of a morbidly obese 49-year-old female found to have a 16×14×10 cm high grade myxoid liposarcoma of the thigh initially diagnosed as a hematoma. Recent initiation of rivaroxaban for a coincident ipsilateral popliteal vein thrombosis placed hematoma high in the differential diagnosis. Despite its large size, the mass was not directly appreciable on physical exam due to excess adjacent adipose tissue. Diagnostic success was achieved only after anchoring bias was abandoned and adaptive expertise was applied.

The adaptive medical curriculum: A model for continuous improvement

This paper describes the medical curriculum designed to foster adaptive expertise. Engaging in the formal and informal curriculum, students learn to achieve desired outcomes in novel situations, perform comfortably with uncertainty, and are often recognized for creative problem-solving. Students learn by asking and answering their own and others' questions. They readily operate at the metacognitive level, anticipating events, self-monitoring, and checking decisions and emotions. A key function of the reflective process is to identify gaps or shortcomings in the thinking process. The adaptive learner shifts into reflective thinking when confronted with complex contextual and situational demands. We are only beginning to understand how to create educational pathways to foster adaptive learning. An essential focus is the adaptive teacher who frames learning and assessment around predictive analytics, reflective spaced practice, and authentic learning material. To be effective, the teacher must engage the learner outside the formal classroom in the parallel curriculum. A major premise is that learning occurs individually and together with peers, teachers, and team members in multiple contexts. During the learning process, the learner readily operates at the metacognitive level, anticipating behavior, self-monitoring and assessing, and checking theirs and others decisions and emotions. The adaptive medical curriculum provides the pathway for such learning.

Adaptive medical education research

This commentary reflects on what the four research articles in this issue of Medical Teacher tell us about adaptive learning and how adaptive medical education research can be conducted. Adaptive medical education researchers must think disruptively and embrace nontraditional collaborations, research methods, and means of dissemination in pursuit of evidence that enhances adaptive learning.