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Yan L, Karamchandani K, Gaiser RR, Carr ZJ. Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review. Anesth Analg 2024; 139:68-77. [PMID: 37874227 DOI: 10.1213/ane.0000000000006666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.
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Affiliation(s)
- Luying Yan
- From the Yale University School of Medicine, New Haven, Connecticut
| | - Kunal Karamchandani
- Department of Anesthesiology
- University of Texas, Southwestern Medical School, Dallas, Texas
| | - Robert R Gaiser
- From the Yale University School of Medicine, New Haven, Connecticut
- Department of Anesthesiology
| | - Zyad J Carr
- From the Yale University School of Medicine, New Haven, Connecticut
- Department of Anesthesiology
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Monteiro S, Sherbino J, LoGiudice A, Lee M, Norman G, Sibbald M. The influence of viewing time on visual diagnostic accuracy: Less is more. MEDICAL EDUCATION 2024; 58:858-868. [PMID: 38625057 DOI: 10.1111/medu.15380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 02/17/2024] [Accepted: 02/23/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Understanding the factors that contribute to diagnostic errors is critical if we are to correct or prevent them. Some scholars influenced by the default interventionist dual-process theory of cognition (dual-process theory) emphasise a narrow focus on individual clinician's faulty reasoning as a significant contributor. In this paper, we examine the validity of claims that dual process theory is a key to error reduction. METHODS We examined the relationship between a clinical experience (staff and resident physicians) and viewing time on accuracy for categorising chest X-rays (CXRs) and electrocardiograms (ECGs). In two studies, participants categorised images as normal or abnormal, presented at viewing times of 175, 250, 500 and 1000 ms, to encourage System 1 processing. Study 2 extended viewing times to 1, 5, 10 and 20 s to allow time for System 2 processing and a diagnosis. Descriptives and repeated measures analysis of variance were used to analyse the proportion of true and false positive rates (TP and FP) as well as correct diagnoses. RESULTS In Study 1, physicians were able to detect abnormal CXRs (0.78) and ECGs (0.67) with relatively high accuracy. The effect of experience was found for ECGs only, as staff physicians (0.71, 95% CI = 0.66-0.75) had higher ECG TP than resident physicians (0.63, 95% CI = 0.58-0.68) in Study 1, and staff had lower ECG FP (0.10, 95% CI = 0.03-0.18) than resident physicians (0.27, 95% CI = 0.20-0.33) in Study 2. In other comparisons, experience was equivocal for ECG FPs and CXR TPs and FPs. In Study 2, overall diagnostic accuracy was similar for both ECGs and CXRs, (0.74). There were small interactions between experience and time for TP in ECGs and FP in CXRs, which are discussed further in the discussion and offer insights into the relationship between processing and experience. CONCLUSION Overall, our findings raise concerns about the practical application of models that link processing type to diagnostic error, or to specific diagnostic error reduction strategies.
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Affiliation(s)
- Sandra Monteiro
- McMaster Education Research, Innovation & Theory (MERIT) Program, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Education and Innovation, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sherbino
- McMaster Education Research, Innovation & Theory (MERIT) Program, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew LoGiudice
- Department of Psychology, Neuroscience & Behavior, McMaster University, Hamilton, Ontario, Canada
| | - Mark Lee
- McMaster Education Research, Innovation & Theory (MERIT) Program, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Geoff Norman
- McMaster Education Research, Innovation & Theory (MERIT) Program, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Matthew Sibbald
- McMaster Education Research, Innovation & Theory (MERIT) Program, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
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Parsons AS, Wijesekera TP, Olson APJ, Torre D, Durning SJ, Daniel M. Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research. MEDICAL TEACHER 2024:1-12. [PMID: 38835283 DOI: 10.1080/0142159x.2024.2359963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.
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Affiliation(s)
- Andrew S Parsons
- Medicine and Public Health, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Andrew P J Olson
- Medicine and Pediatrics, Medical Education Outcomes Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Dario Torre
- Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Steven J Durning
- Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michelle Daniel
- Emergency Medicine, University of California San Diego School of Medicine San Diego, CA, USA
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Norman G, Pelaccia T, Wyer P, Sherbino J. Dual process models of clinical reasoning: The central role of knowledge in diagnostic expertise. J Eval Clin Pract 2024. [PMID: 38825755 DOI: 10.1111/jep.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 04/09/2024] [Indexed: 06/04/2024]
Abstract
RATIONALE Research on diagnostic reasoning has been conducted for fifty years or more. There is growing consensus that there are two distinct processes involved in human diagnostic reasoning: System 1, a rapid retrieval of possible diagnostic hypotheses, largely automatic and based to a large part on experiential knowledge, and System 2, a slower, analytical, conscious application of formal knowledge to arrive at a diagnostic conclusion. However, within this broad framework, controversy and disagreement abound. In particular, many authors have suggested that the root cause of diagnostic errors is cognitive biases originating in System 1 and propose that educating learners about the types of cognitive biases and their impact on diagnosis would have a major influence on error reduction. AIMS AND OBJECTIVES In the present paper, we take issue with these claims. METHOD We reviewed the literature to examine the extent to which this theoretical model is supported by the evidence. RESULTS We show that evidence derived from fundamental research in human cognition and studies in clinical medicine challenges the basic assumptions of this theory-that errors arise in System 1 processing as a consequence of cognitive biases, and are corrected by slow, deliberative analytical processing. We claim that, to the contrary, errors derive from both System 1 and System 2 reasoning, that they arise from lack of access to the appropriate knowledge, not from errors of processing, and that the two processes are not essential to the process of diagnostic reasoning. CONCLUSIONS The two processing modes are better understood as a consequence of the nature of the knowledge retrieved, not as independent processes.
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Affiliation(s)
- Geoff Norman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Thierry Pelaccia
- Centre for Training and Research in Health Sciences Education (CFRPS), Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Peter Wyer
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jonathan Sherbino
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Olson A, Kämmer JE, Taher A, Johnston R, Yang Q, Mondoux S, Monteiro S. The inseparability of context and clinical reasoning. J Eval Clin Pract 2024; 30:533-538. [PMID: 38300231 DOI: 10.1111/jep.13969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 02/02/2024]
Abstract
Early descriptions of clinical reasoning have described a dual process model that relies on analytical or nonanalytical approaches to develop a working diagnosis. In this classic research, clinical reasoning is portrayed as an individual-driven cognitive process based on gathering information from the patient encounter, forming mental representations that rely on previous experience and engaging developed patterns to drive working diagnoses and management plans. Indeed, approaches to patient safety, as well as teaching and assessing clinical reasoning focus on the individual clinician, often ignoring the complexity of the system surrounding the diagnostic process. More recent theories and evidence portray clinical reasoning as a dynamic collection of processes that takes place among and between persons across clinical settings. Yet, clinical reasoning, taken as both an individual and a system process, is insufficiently supported by theories of cognition based on individual clinicals and lacks the specificity needed to describe the phenomenology of clinical reasoning. In this review, we reinforce that the modern healthcare ecosystem - with its people, processes and technology - is the context in which health care encounters and clinical reasoning take place.
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Affiliation(s)
- Andrew Olson
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Juliane E Kämmer
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Ahmed Taher
- Quality and Innovation, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Johnston
- Strategic Engagement and Advocacy, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Qian Yang
- Data Insights, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Shawn Mondoux
- Division of Education and Innovation, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sandra Monteiro
- Division of Education and Innovation, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Schmidt HG, Norman GR, Mamede S, Magzoub M. The influence of context on diagnostic reasoning: A narrative synthesis of experimental findings. J Eval Clin Pract 2024. [PMID: 38818694 DOI: 10.1111/jep.14023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024]
Abstract
AIMS AND OBJECTIVES Contextual information which is implicitly available to physicians during clinical encounters has been shown to influence diagnostic reasoning. To better understand the psychological mechanisms underlying the influence of context on diagnostic accuracy, we conducted a review of experimental research on this topic. METHOD We searched Web of Science, PubMed, and Scopus for relevant articles and looked for additional records by reading the references and approaching experts. We limited the review to true experiments involving physicians in which the outcome variable was the accuracy of the diagnosis. RESULTS The 43 studies reviewed examined two categories of contextual variables: (a) case-intrinsic contextual information and (b) case-extrinsic contextual information. Case-intrinsic information includes implicit misleading diagnostic suggestions in the disease history of the patient, or emotional volatility of the patient. Case-extrinsic or situational information includes a similar (but different) case seen previously, perceived case difficulty, or external digital diagnostic support. Time pressure and interruptions are other extrinsic influences that may affect the accuracy of a diagnosis but have produced conflicting findings. CONCLUSION We propose two tentative hypotheses explaining the role of context in diagnostic accuracy. According to the negative-affect hypothesis, diagnostic errors emerge when the physician's attention shifts from the relevant clinical findings to the (irrelevant) source of negative affect (for instance patient aggression) raised in a clinical encounter. The early-diagnosis-primacy hypothesis attributes errors to the extraordinary influence of the initial hypothesis that comes to the physician's mind on the subsequent collecting and interpretation of case information. Future research should test these mechanisms explicitly. Possible alternative mechanisms such as premature closure or increased production of (irrelevant) rival diagnoses in response to context deserve further scrutiny. Implications for medical education and practice are discussed.
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Affiliation(s)
- Henk G Schmidt
- Institute of Medical Education Research, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Geoffrey R Norman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Silvia Mamede
- Institute of Medical Education Research, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Mohi Magzoub
- Department of Medical Education, United Arab Emirates University, Al Ain, United Arab Emirates
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Södervik I, Hanski L, Boshuizen HPA, Katajavuori N. Clinical reasoning in pharmacy: What do eye movements and verbal protocols tell us about the processing of a case task? ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2024; 29:45-65. [PMID: 37273029 PMCID: PMC10240483 DOI: 10.1007/s10459-023-10242-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/14/2023] [Indexed: 06/06/2023]
Abstract
This study investigates pharmacy students' reasoning while solving a case task concerning an acute patient counselling situation in a pharmacy. Participants' (N = 34) reasoning processes were investigated with written tasks utilizing eye-tracking in combination with verbal protocols. The case was presented in three pages, each page being followed by written questions. Eye movements were recorded during case processing. Success in the task required differentiating the relevant information from the task redundant information, and initial activation of several scripts and verification of the most likely one, when additional information became available. 2nd (n = 16) and 3rd (n = 18)-year students' and better and worse succeeding students' processes were compared. The results showed that only a few 2nd-year students solved the case correctly, whereas almost all of the 3rd-year students were successful. Generally, the average total processing times of the case material did not differ between the groups. However, better-succeeding and 3rd-year students processed the very first task-relevant sentences longer, indicating that they were able to focus on relevant information. Differences in the written answers to the 2nd and 3rd question were significant, whereas differences regarding the first question were not. Thus, eye-tracking seems to be able to capture illness script activation during case processing, but other methods are needed to depict the script verification process. Based on the results, pedagogical suggestions for advancing pharmacy education are discussed.
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Affiliation(s)
- Ilona Södervik
- Centre for University Teaching and Learning (HYPE), Faculty of Educational Sciences, University of Helsinki, Siltavuorenpenger 5B, 00170 Helsinki, Finland
| | - Leena Hanski
- Faculty of Pharmacy, University of Helsinki, Biocenter 2, PO Box 56, 00014 Helsinki, Finland
| | - Henny P. A. Boshuizen
- Faculty of Educational Sciences, Open University of the Netherlands, Valkenburgerweg 177, 6419 AT Heerlen, The Netherlands
| | - Nina Katajavuori
- Centre for University Teaching and Learning (HYPE), Faculty of Educational Sciences, University of Helsinki, Viikinkaari 9, 00140 Helsinki, Finland
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Bogaty C, Frambach J. The CanMEDS Competency Framework in laboratory medicine: a phenomenographic study exploring how professional roles are applied outside the clinical environment. CANADIAN MEDICAL EDUCATION JOURNAL 2024; 15:26-36. [PMID: 38528898 PMCID: PMC10961121 DOI: 10.36834/cmej.77140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Background The CanMEDS Competency Framework is an internationally recognized model used to outline the proficiencies of a physician. It has predominantly been studied in clinical environments but not all medical specialties take part in direct patient contact. In laboratory medicine, the role of the physician is to promote and enhance patient diagnostics by managing and overseeing the functions of a diagnostic laboratory. Methods This phenomenographic study explores the lived experiences of biochemistry, microbiology, and pathology residency program directors to better understand how they utilize the CanMEDS competencies. Eight laboratory medicine program directors from across Canada were individually interviewed using a semi-structured interview, and the data was analysed using inductive thematic analysis. Results The findings show that the current framework is disconnected from the unique context of laboratory medicine with some competencies appearing unrelatable using the current standardized definitions and expectations. Nevertheless, participants considered the framework to be an appropriate blueprint of the competencies necessary for their professional environment, but to make it accessible more autonomy is required to adapt the framework to their needs. Conclusion Newer renditions of the CanMEDS Competency Framework should better consider the realities of non-clinical disciplines.
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Affiliation(s)
- Chloe Bogaty
- Service de microbiologie et d'infectiologie, Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Quebec, Canada
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
| | - Janneke Frambach
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
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Beeler N, Ziegler E, Navarini AA, Kapur M. Factors related to the performance of laypersons diagnosing pigmented skin cancer: an explorative study. Sci Rep 2023; 13:22790. [PMID: 38123698 PMCID: PMC10733329 DOI: 10.1038/s41598-023-50152-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
It is important but challenging for prospective health professionals to learn the visual distinction between potentially harmful and harmless skin lesions, such as malignant melanomas and benign nevi. Knowledge about factors related to diagnostic performance is sparse but a prerequisite for designing and evaluating evidence-based educational interventions. Hence, this study explored how the characteristics of 240 skin lesions, the number of classified lesions and the response times of 137 laypeople were related to performance in diagnosing pigmented skin cancer. Our results showed large differences between the lesions, as some were classified correctly by more than 90% and others by less than 10% of the participants. A t-test showed that for melanomas, the correct diagnosis was provided significantly more often than for nevi. Furthermore, we found a significant Pearson correlation between the number of solved tasks and performance in the first 50 diagnostic tasks. Finally, t-tests for investigating the response times revealed that compared to true decisions, participants spent longer on false-negative but not on false-positive decisions. These results provide novel knowledge about performance-related factors that can be useful when designing diagnostic tests and learning interventions for melanoma detection.
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Affiliation(s)
- Nadja Beeler
- Professorship for Learning Sciences and Higher Education, ETH Zurich, Clausiusstrasse 59, 8092, Zurich, Switzerland.
| | - Esther Ziegler
- Professorship for Learning Sciences and Higher Education, ETH Zurich, Clausiusstrasse 59, 8092, Zurich, Switzerland
| | - Alexander A Navarini
- Department of Dermatology, University Hospital Basel, Burgfelderstrasse 101, 4055, Basel, Switzerland
| | - Manu Kapur
- Professorship for Learning Sciences and Higher Education, ETH Zurich, Clausiusstrasse 59, 8092, Zurich, Switzerland
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Choi JJ, Gribben J, Lin M, Abramson EL, Aizer J. Using an experiential learning model to teach clinical reasoning theory and cognitive bias: an evaluation of a first-year medical student curriculum. MEDICAL EDUCATION ONLINE 2023; 28:2153782. [PMID: 36454201 PMCID: PMC9718553 DOI: 10.1080/10872981.2022.2153782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Most medical students entering clerkships have limited understanding of clinical reasoning concepts. The value of teaching theories of clinical reasoning and cognitive biases to first-year medical students is unknown. This study aimed to evaluate the value of explicitly teaching clinical reasoning theory and cognitive bias to first-year medical students. METHODS Using Kolb's experiential learning model, we introduced dual process theory, script theory, and cognitive biases in teaching clinical reasoning to first-year medical students at an academic medical center in New York City between January and June 2020. Due to the COVID-19 pandemic, instruction was transitioned to a distance learning format in March 2020. The curriculum included a series of written clinical reasoning examinations with facilitated small group discussions. Written self-assessments prompted each student to reflect on the experience, draw conclusions about their clinical reasoning, and plan for future encounters involving clinical reasoning. We evaluated the value of the curriculum using mixed-methods to analyze faculty assessments, student self-assessment questionnaires, and an end-of-curriculum anonymous questionnaire eliciting student feedback. RESULTS Among 318 total examinations of 106 students, 254 (80%) had a complete problem representation, while 199 (63%) of problem representations were considered concise. The most common cognitive biases described by students in their clinical reasoning were anchoring bias, availability bias, and premature closure. Four major themes emerged as valuable outcomes of the CREs as identified by students: (1) synthesis of medical knowledge; (2) enhanced ability to generate differential diagnoses; (3) development of self-efficacy related to clinical reasoning; (4) raised awareness of personal cognitive biases. CONCLUSIONS We found that explicitly teaching clinical reasoning theory and cognitive biases using an experiential learning model provides first-year medical students with valuable opportunities for developing knowledge, skills, and self-efficacy related to clinical reasoning.
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Affiliation(s)
- Justin J. Choi
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jeanie Gribben
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Myriam Lin
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Erika L. Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Juliet Aizer
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
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Isbej L, Fuentes-Cimma J, Véliz Paiva C, Valladares-Pérez S, Riquelme A. A comprehensive approach to identify challenges for clinical reasoning development in undergraduate dental students and their potential solutions. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2023; 27:859-868. [PMID: 36458893 DOI: 10.1111/eje.12876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/05/2022] [Accepted: 10/30/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Clinical reasoning is a core competence in health professions that impacts the ability to solve patients' health problems. Due to its relevance, it is necessary to identify difficulties arising from different sources that affect clinical reasoning development in students. The aim of this study was to explore a comprehensive approach to identify challenges for clinical reasoning development in undergraduate dental students and their potential solutions. METHODS Mixed methods were used in four stages: (1) students and clinical teachers focus groups to identify challenges to clinical reasoning development; (2) literature review to explore potential solutions for these challenges; (3) Delphi technique for teacher consensus on pertinence and feasibility of solutions (1-5 scale); and (4) teachers' self-perception of their ability to implement the solutions. RESULTS Three categories and seven subcategories of challenges were identified: (I) educational context factors influencing the clinical reasoning process; (II) teacher's role in clinical reasoning development; and (III) student factors influencing the clinical reasoning process. From 134 publications identified, 53 were selected for review, resulting in 10 potential solutions. Through two Delphi rounds, teachers rated the potential solutions very highly in terms of relevance (4.50-4.85) and feasibility (3.50-4.29). Finally, a prioritisation ranking of these solutions was generated using their scores for relevance, feasibility, and teachers' self-perception of their ability to implement them. CONCLUSIONS The present comprehensive approach identified challenges for clinical reasoning development in dental students and their potential solutions, perceived as relevant and feasible by teachers, requiring further research and follow-up actions to address them.
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Affiliation(s)
- Lorena Isbej
- Faculty of Medicine, School of Dentistry, Pontificia Universidad Católica de Chile, Santiago, Chile
- Pharmacology and Toxicology Programme, Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
| | - Javiera Fuentes-Cimma
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
- Department of Health Sciences, Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Véliz Paiva
- Faculty of Medicine, School of Dentistry, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Arnoldo Riquelme
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Centre of Medical Education and Health Sciences, Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
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Isbell LM, Graber ML, Rovenpor DR, Liu G. Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment. Diagnosis (Berl) 2023; 10:257-266. [PMID: 37185165 DOI: 10.1515/dx-2020-0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 03/22/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Patients with mental illness are less likely to receive the same physical healthcare as those without mental illness and are less likely to be treated in accordance with established guidelines. This study employed a randomized experiment to investigate the influence of comorbid depression on diagnostic accuracy. METHODS Physicians were presented with an interactive vignette describing a patient with a complex presentation of pernicious anemia. They were randomized to diagnose either a patient with or without (control) comorbid depression and related behaviors. All other clinical information was identical. Physicians recorded a differential diagnosis, ordered tests, and rated patient likeability. RESULTS Fifty-nine physicians completed the study. The patient with comorbid depression was less likeable than the control patient (p=0.03, 95 % CI [0.09, 1.53]). Diagnostic accuracy was lower in the depression compared to control condition (59.4 % vs. 40.7 %), however this difference was not statistically significant χ2(1)=2.035, p=0.15. Exploratory analyses revealed that patient condition (depression vs. control) interacted with the number of diagnostic tests ordered to predict diagnostic accuracy (OR=2.401, p=0.038). Accuracy was lower in the depression condition (vs. control) when physicians ordered fewer tests (1 SD below mean; OR=0.103, p=0.028), but there was no difference for physicians who ordered more tests (1 SD above mean; OR=2.042, p=0.396). CONCLUSIONS Comorbid depression and related behaviors lowered diagnostic accuracy when physicians ordered fewer tests - a time when more possibilities should have been considered. These findings underscore the critical need to develop interventions to reduce diagnostic error when treating vulnerable populations such as those with depression.
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Affiliation(s)
- Linda M Isbell
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Mark L Graber
- Society to Improve Diagnosis in Medicine, Plymouth, MA, USA
- Stony Brook University, NY, USA
| | | | - Guanyu Liu
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
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Harendza S, Bußenius L, Gärtner J, Heuser M, Ahles J, Prediger S. "Fit for the finals" - project report on a telemedical training with simulated patients, peers, and assessors for the licensing exam. GMS JOURNAL FOR MEDICAL EDUCATION 2023; 40:Doc17. [PMID: 37361248 PMCID: PMC10285374 DOI: 10.3205/zma001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/11/2023] [Accepted: 02/06/2023] [Indexed: 06/28/2023]
Abstract
Background Undergraduate medical students take the licensing exam (M3) as a two-day oral-practical examination. The main requirements are to demonstrate history taking skills and coherent case presentations. The aim of this project was to establish a training in which students can test their communication skills during history taking and their clinical reasoning skills in focused case presentations. Methods In the newly developed training, final-year students took four telemedical histories in the role of physicians from simulated patients (SP). They received further findings for two SPs and presented these in a handover, in which they also received a handover of two SPs which they had not seen themselves. Each student presented one of the two received SPs in a case discussion with a senior physician. Feedback was given to the participants on their communication and interpersonal skills by the SPs with the ComCare questionnaire and on the case presentation by the senior physician. Sixty-two students from the universities of Hamburg and Freiburg in their final year participated in September 2022 and evaluated the training. Results Participants felt that the training was very appropriate for exam preparation. The SPs' feedback on communication and the senior physician's feedback on clinical reasoning skills received the highest ratings in importance to the students. Participants highly valued the practice opportunity for structured history taking and case presentation and would like to have more such opportunities in the curriculum. Conclusion Essential elements of the medical licensing exam can be represented, including feedback, in this telemedical training and it can be offered independent of location.
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Affiliation(s)
- Sigrid Harendza
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Lisa Bußenius
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Julia Gärtner
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Miriam Heuser
- Albert-Ludwigs-Universität Freiburg, Medizinische Fakultät, Studiendekanat, Freiburg, Germany
| | - Jonathan Ahles
- Albert-Ludwigs-Universität Freiburg, Medizinische Fakultät, Studiendekanat, Freiburg, Germany
| | - Sarah Prediger
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
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Mamede S, Schmidt HG. Deliberate reflection and clinical reasoning: Founding ideas and empirical findings. MEDICAL EDUCATION 2023; 57:76-85. [PMID: 35771936 PMCID: PMC10083910 DOI: 10.1111/medu.14863] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/15/2022] [Accepted: 06/26/2022] [Indexed: 06/15/2023]
Abstract
CONTEXT The idea that reflection improves reasoning and learning, since long present in other fields, emerged in the 90s in the medical education literature. Since then, the number of publications on reflection as a means to improve diagnostic learning and clinical problem-solving has increased steeply. Recently, concerns with diagnostic errors have raised further interest in reflection. Several approaches based on reflection have been proposed to reduce clinicians' errors during diagnostic reasoning. What reflection entails varies substantially, and most approaches still require empirical examination. PURPOSE The present essay aims to help clarify the role of deliberate reflection in diagnostic reasoning. Deliberate reflection is an approach whose effects on diagnostic reasoning and learning have been empirically studied over the past 15 years. The philosophical roots of the approach will be briefly examined, and the theory and practice of deliberate reflection, particularly its effectiveness, will be reviewed. Lessons learned and unresolved issues will be discussed. DISCUSSION The deliberate reflection approach originated from a conceptualization of the nature of reflection practice in medicine informed by Dewey's and Schön's work. The approach guides physicians through systematically reviewing the grounds of their initial diagnosis and considering alternatives. Experimental evidence has supported the effectiveness of deliberate reflection in increasing physicians' diagnostic performance, particularly in nonstraightforward diagnostic tasks. Deliberate reflection has also proved helpful to improve students' diagnostic learning and to facilitate learning of new information. The mechanisms behind the effects of deliberate reflection remain unclear. Tentative explanations focus on the activation/reorganisation of prior knowledge induced by deliberate reflection. Its usefulness depends therefore on the difficulty of the problem relative to the clinician's knowledge. Further research should examine variations in instructions on how to reflect upon a case, the value of further guidance while learning from deliberate reflection, and its benefits in real practice.
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Affiliation(s)
- Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus MC; Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
| | - Henk G. Schmidt
- Institute of Medical Education Research Rotterdam, Erasmus MC; Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
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Watsjold BK, Ilgen JS, Regehr G. An Ecological Account of Clinical Reasoning. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:S80-S86. [PMID: 35947479 DOI: 10.1097/acm.0000000000004899] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE The prevailing paradigms of clinical reasoning conceptualize context either as noise that masks, or as external factors that influence, the internal cognitive processes involved in reasoning. The authors reimagined clinical reasoning through the lens of ecological psychology to enable new ways of understanding context-specific manifestations of clinical performance and expertise, and the bidirectional ways in which individuals and their environments interact. METHOD The authors performed a critical review of foundational and current literature from the field of ecological psychology to explore the concepts of clinical reasoning and context as presented in the health professions education literature. RESULTS Ecological psychology offers several concepts to explore the relationship between an individual and their context, including affordance, effectivity, environment, and niche. Clinical reasoning may be framed as an emergent phenomenon of the interactions between a clinician's effectivities and the affordances in the clinical environment. Practice niches are the outcomes of historical efforts to optimize practice and are both specialty-specific and geographically diverse. CONCLUSIONS In this framework, context specificity may be understood as fundamental to clinical reasoning. This changes the authors' understanding of expertise, expert decision making, and definition of clinical error, as they depend on both the expert's actions and the context in which they acted. Training models incorporating effectivities and affordances might allow for antiableist formulations of competence that apply learners' abilities to solving problems in context. This could offer both new means of training and improve access to training for learners of varying abilities. Rural training programs and distance education can leverage technology to provide comparable experience to remote audiences but may benefit from additional efforts to integrate learners into local practice niches.
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Affiliation(s)
- Bjorn K Watsjold
- B.K. Watsjold is assistant professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4888-8857
| | - Jonathan S Ilgen
- J.S. Ilgen is professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4590-6570
| | - Glenn Regehr
- G. Regehr is professor, Department of Surgery, and senior scientist, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada; ORCID: https://orcid.org/0000-0002-3144-331X
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16
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Tio RA, Carvalho Filho MA, de Menezes Mota MF, Santanchè A, Mamede S. The Effect of Information Presentation Order on Residents' Diagnostic Accuracy of Online Simulated Patients With Chest Pain. J Grad Med Educ 2022; 14:475-481. [PMID: 35991113 PMCID: PMC9380632 DOI: 10.4300/jgme-d-21-01053.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/18/2022] [Accepted: 05/04/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Physicians may receive diagnostic information in different orders, and there is a lack of empirical evidence that the order of presentation may influence clinical reasoning. OBJECTIVE We investigated whether diagnostic accuracy of chest pain cases is influenced by the order of presentation of the history and electrocardiogram (EKG) to cardiology residents. METHODS We conducted an experimental study during a resident training in 2019. Twelve clinical cases were presented in 2 diagnostic rounds. Residents were randomly allocated to seeing the EKG first (EKGF) or the history first (HF). The mean diagnostic accuracy scores (range 0-1) and confidence level (0-100) in each diagnostic round and time needed to make the diagnosis were evaluated. RESULTS The final diagnostic accuracy was higher than the initial in both groups. After the first round, diagnostic accuracy was higher in HF (n=24) than in EKGF (n=28). Time taken to judge the history was comparable in both groups. Time taken to judge the EKG was shorter in HF (40±11 vs 64±13 seconds; P<.01). Time invested in the second round was significantly correlated with changing the initial diagnosis. A significant difference was observed in confidence ratings after the initial diagnosis, with EKGF reporting less confidence relative to HF. CONCLUSIONS The order in which history and EKG are presented influences the clinical reasoning process.
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Affiliation(s)
- René A. Tio
- René A. Tio, MD, PhD, is a Cardiologist, Department of Cardiology, Catharina Hospital Eindhoven, Netherlands, and Medical Education Researcher, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, University of Maastricht, Netherlands
| | - Marco A. Carvalho Filho
- Marco A. Carvalho Filho, MD, PhD, is a Medical Education Researcher, Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands, and Lifelong Learning, Education & Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, Netherlands
| | - Marcos F. de Menezes Mota
- Marcos F. de Menezes Mota, MS, is a Computer Scientist and PhD Candidate, Institute of Computing, University of Campinas, São Paulo, Brazil
| | - André Santanchè
- André Santanchè, PhD, is a Computer Scientist, Institute of Computing, University of Campinas, São Paulo, Brazil
| | - Sílvia Mamede
- Sílvia Mamede, MD, PhD, is a Medical Education Researcher, Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, Netherlands, and Associate Professor, Department of Psychology, Education, and Child Studies, Erasmus University, Rotterdam, Netherlands
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17
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Dyre L, Grierson L, Rasmussen KMB, Ringsted C, Tolsgaard MG. The concept of errors in medical education: a scoping review. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:761-792. [PMID: 35190892 DOI: 10.1007/s10459-022-10091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/05/2022] [Indexed: 06/14/2023]
Abstract
The purpose of this scoping review was to explore how errors are conceptualized in medical education contexts by examining different error perspectives and practices. This review used a scoping methodology with a systematic search strategy to identify relevant studies, written in English, and published before January 2021. Four medical education journals (Medical Education, Advances in Health Science Education, Medical Teacher, and Academic Medicine) and four clinical journals (Journal of the American Medical Association, Journal of General Internal Medicine, Annals of Surgery, and British Medical Journal) were purposively selected. Data extraction was charted according to a data collection form. Of 1505 screened studies, 79 studies were included. Three overarching perspectives were identified: 'understanding errors') (n = 31), 'avoiding errors' (n = 25), 'learning from errors' (n = 23). Studies that aimed at'understanding errors' used qualitative methods (19/31, 61.3%) and took place in the clinical setting (19/31, 61.3%), whereas studies that aimed at 'avoiding errors' and 'learning from errors' used quantitative methods ('avoiding errors': 20/25, 80%, and 'learning from errors': 16/23, 69.6%, p = 0.007) and took place in pre-clinical (14/25, 56%) and simulated settings (10/23, 43.5%), respectively (p < 0.001). The three perspectives differed significantly in terms of inclusion of educational theory: 'Understanding errors' studies 16.1% (5/31),'avoiding errors' studies 48% (12/25), and 'learning from errors' studies 73.9% (17/23), p < 0.001. Errors in medical education and clinical practice are defined differently, which makes comparisons difficult. A uniform understanding is not necessarily a goal but improving transparency and clarity of how errors are currently conceptualized may improve our understanding of when, why, and how to use and learn from errors in the future.
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Affiliation(s)
- Liv Dyre
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University, Rigshospitalet, Ryesgade 53B, DK-2100, Copenhagen, Denmark.
| | - Lawrence Grierson
- Department of Family Medicine, Health Sciences Education Program, McMaster University, Toronto, Canada
| | - Kasper Møller Boje Rasmussen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University, Rigshospitalet, Ryesgade 53B, DK-2100, Copenhagen, Denmark
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | | | - Martin G Tolsgaard
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University, Rigshospitalet, Ryesgade 53B, DK-2100, Copenhagen, Denmark
- Department of Obstetrics, Copenhagen University, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
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18
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Norman G, Sherbino J, Varpio L. The scope of health professions education requires complementary and diverse approaches to knowledge synthesis. PERSPECTIVES ON MEDICAL EDUCATION 2022; 11:139-143. [PMID: 35389196 PMCID: PMC9240133 DOI: 10.1007/s40037-022-00706-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Geoffrey Norman
- McMaster Education Research, Innovation and Theory (MERIT) program, Hamilton, Ontario, Canada.
| | - Jonathan Sherbino
- McMaster Education Research, Innovation and Theory (MERIT) program, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lara Varpio
- McMaster Education Research, Innovation and Theory (MERIT) program, Hamilton, Ontario, Canada
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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19
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Cheng L, Senathirajah Y. Utilizing Clinical Data Visualizations in Electronic Health Record User Interfaces to Enhance Medical Student Diagnostic Reasoning: Randomized Experiment (Preprint). JMIR Hum Factors 2022; 10:e38941. [PMID: 37053000 PMCID: PMC10141282 DOI: 10.2196/38941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND In medicine, the clinical decision-making process can be described using the dual-process theory consisting of the fast, intuitive "System 1," commonly seen in seasoned physicians, and the slow, deliberative "System 2," associated with medical students. System-1-type diagnostic reasoning is thought to be less cognitively burdensome, thereby reducing physician error. To date, limited literature exists on inducing System-1-type diagnosis in medical students through cognitive heuristics, particularly while using modern electronic health record (EHR) interfaces. OBJECTIVE In this experimental pilot study, we aimed to (1) attempt to induce System-1-type diagnostic reasoning in inexperienced medical students through the acquisition of cognitive user interface heuristics and (2) understand the impact of clinical patient data visualizations on students' cognitive load and medical education. METHODS The participants were third- and fourth-year medical students recruited from the University of Pittsburgh School of Medicine who had completed 1+ clinical rotations. The students were presented 8 patient cases on a novel EHR, featuring a prominent data visualization designed to foster at-a-glance rapid case assessment, and asked to diagnose the patient. Half of the participants were shown 4 of the 8 cases repeatedly, up to 4 times with 30 seconds per case (Group A), and the other half of the participants were shown cases twice with 2 minutes per case (Group B). All participants were then asked to provide full diagnoses of all 8 cases. Finally, the participants were asked to evaluate and elaborate on their experience with the system; content analysis was subsequently performed on these user experience interviews. RESULTS A total of 15 students participated. The participants in Group A scored slightly higher on average than those in Group B, with a mean percentage correct of 76% (95% CI 0.68-0.84) versus 69% (95% CI 0.58-0.80), and spent on average 50% less time per question than Group B diagnosing patients (13.98 seconds vs 19.13 seconds, P=.03, respectively). When comparing the novel EHR design to previously used EHRs, 73% (n=11) of participants rated the new version on par or higher (3+/5). Ease of use and intuitiveness of this new system rated similarly high (mean score 3.73/5 and 4.2/5, respectively). In qualitative thematic analysis of poststudy interviews, most participants (n=11, 73%) spoke to "pattern-recognition" cognitive heuristic strategies consistent with System 1 decision-making. CONCLUSIONS These results support the possibility of inducing type-1 diagnostics in learners and the potential for data visualization and user design heuristics to reduce cognitive burden in clinical settings. Clinical data presentation in the diagnostic reasoning process is ripe for innovation, and further research is needed to explore the benefit of using such visualizations in medical education.
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Affiliation(s)
- Lucille Cheng
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Yalini Senathirajah
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
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20
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Ohta R, Maejma S, Sano C. Nurses’ Contributions in Rural Family Medicine Education: A Mixed-Method Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053090. [PMID: 35270782 PMCID: PMC8910758 DOI: 10.3390/ijerph19053090] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/25/2022] [Accepted: 03/04/2022] [Indexed: 01/27/2023]
Abstract
Family medicine residents frequently collaborate with nurses regarding clinical decisions and treatments, which contributes to their education. In rural areas, these residents experience a wider scope of practice by collaborating with nurses. However, nurses’ contributions to rural family medicine education have not been clarified. This study measured the contributions of 88 rural community hospital nurses to family medicine education using a quantitative questionnaire and interviews. The interviews were recorded, transcribed verbatim, and analyzed using the grounded theory approach. Nurses’ average clinical experience was 20.16 years. Nurses’ contributions to the roles of teacher and provider of emotional support were statistically lower among participants working in acute care wards than those working in chronic care wards (p = 0.024 and 0.047, respectively). The qualitative analysis indicated that rural nurses’ contributions to family medicine education focused on professionalism, interprofessional collaboration, and respect for nurses’ working culture and competence. Additionally, nurses struggled to educate medical residents amid their busy routine; this education should be supported by other professionals. Rural family medicine education should incorporate clinical nurses as educators for professionalism and interprofessional collaboration and as facilitators of residents’ transition to new workplaces. Subsequently, other professionals should be more actively involved in improving education quality.
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Affiliation(s)
- Ryuichi Ohta
- Community Care, Unnan City Hospital, 699-1221 96-1 Iida, Daito-cho, Unnan 699-1221, Japan
- Correspondence: ; Tel.: +81-9050605330
| | - Satoko Maejma
- Department of Nursing, Unnan City Hospital, 699-1221 96-1 Iida, Daito-cho, Unnan 699-1221, Japan;
| | - Chiaki Sano
- Department of Community Medicine Management, Faculty of Medicine, Shimane University, 89-1 Enya cho, Izumo 693-8501, Japan;
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21
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Kerr MV, Bryden P, Nguyen ET. Diagnostic Imaging and Mechanical Objectivity in Medicine. Acad Radiol 2022; 29:409-412. [PMID: 33485774 DOI: 10.1016/j.acra.2020.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND Before the advent of automatism in image-making practices, scientists, anatomists, and physicians artistically depicted simplified images for scientific atlas making. This technique conferred subjectivity to a supposedly objective scientific process, sparking confrontations between anatomists regarding accuracy that heralded a new concept in the late 19th century - mechanical objectivity - that would revolutionize scientific knowledge and the field of medicine OBJECTIVES: The purpose of this health history research study is to trace the evolution of mechanical objectivity from empirical studies of early anatomists in the 19th century to the advent of x-ray technology, digitization of imaging, and disruptive technological innovations such as artificial intelligence, while simultaneously unveiling the challenges of mitigating human bias, despite advancements in medical imaging practices. METHODS This narrative literature review was conducted using the Scopus® database under the guidance of both medical historians and practicing physicians to ensure its applicability and historical accuracy CONCLUSION: Despite a century-long quest for optimizing mechanical objectivity in diagnostic imaging to more accurately and efficiently interpret medical images, human bias remains an important factor. This historical review describes the development of medical imaging technologies over the last century with emphasis on the role played by human bias and subjectivity in a rapidly expanding field of medical imaging technology including artificial intelligence.
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22
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Patel SJ, Ipsaro A, Brady PW. Conversations on Diagnostic Uncertainty and Its Management Among Pediatric Acute Care Physicians. Hosp Pediatr 2022:e2021006076. [PMID: 35224634 DOI: 10.1542/hpeds.2021-006076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Diagnosis is a complex, iterative, and nonlinear process, often occurring over time. When presenting signs, symptoms, and diagnostic testing cannot be integrated into a diagnosis, clinicians are confronted with diagnostic uncertainty. Our aim was to study the self-reported cognitive, communication, and management behaviors of pediatric emergency medicine (PEM) and pediatric hospital medicine (PHM) physicians regarding diagnostic uncertainty. METHODS A qualitative study was conducted through focus groups with PEM and PHM physicians in a large academic pediatric medical center. Four focus groups were conducted. Interviews were recorded, deidentified, and transcribed by a team member. Thematic analysis was used to review the transcripts, highlight ideas, and organize ideas into themes. RESULTS Themes were categorized using the model of the diagnostic process from the National Academy of Sciences. "Red flags" and "gut feelings" were prominent during the information, integration, and interpretation phases. To combat diagnostic uncertainty, physicians employed strategies such as "the diagnostic pause" and having a set of "fresh eyes" to review the data. It was important to all clinicians to rule out any "cannot miss" diagnoses. Interphysician communication was direct; communication with patient and families about uncertainty was less direct because of physician concern of being thought of as untrustworthy. Contingency planning, "disposition over diagnosis" by ensuring patient safety, the "test of time," and availability of resources were techniques used by physicians to manage diagnostic uncertainty. CONCLUSIONS Physicians shared common mitigation strategies, which included consulting colleagues and targeting cannot miss diagnoses, but gaps remain regarding communicating diagnostic uncertainty to families.
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Affiliation(s)
- Shivani J Patel
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anna Ipsaro
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Patrick W Brady
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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23
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Fernández-Aguilar C, Martín-Martín JJ, Minué Lorenzo S, Fernández Ajuria A. Use of heuristics during the clinical decision process from family care physicians in real conditions. J Eval Clin Pract 2022; 28:135-141. [PMID: 34374182 DOI: 10.1111/jep.13608] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/20/2021] [Accepted: 07/26/2021] [Indexed: 01/05/2023]
Abstract
RATIONALE AIMS AND OBJECTIVES The available evidence on the use of heuristics and their relationship with diagnostic error in primary care is very limited. The aim of the study is to identify the use of unknown thought and specifically the possible use of Representativeness, Availability and overconfidence heuristics in the clinical practice of primary care physicians in cases of dyspnoea and to analyse their possible relationship with diagnostic error. METHODS A total of 371 patients consulting with new episodes of dyspnoea in Primary Care centres in Spain were registered. Based on specific operational definitions, the use of unconscious thinking and the use of heuristics during the diagnostic process were assessed. Subsequently, the association between their use and diagnostic error was analysed. RESULTS In 49.6% of cases, the confirmatory diagnosis coincided with the first diagnostic impression, suggesting the use of the representativeness heuristic in the diagnostic decision process. In 82.3% of the cases, the confirmatory diagnosis was among the three diagnostic hypotheses that were first identified by the general physicians, suggesting a possible use of the availability heuristic. In more than 50% of the cases, the physicians were overconfident in the certainty of their own diagnosis. Finally, a diagnostic error was identified in 9.9% of the recorded cases and no statistically significant correlation was found between the use of some unconscious thinking tools (such as the use of heuristics) and the diagnostic error. CONCLUSION Unconscious thinking manifested through the acceptance of the first diagnostic impression and the use of heuristics is commonly used by primary care physicians in the clinical decision process in the face of new episodes of dyspnoea; however, its influence on diagnostic error is not significant. The proposed explicit and reproducible methodology may inspire further studies to confirm these results.
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Klasen JM, Teunissen PW, Driessen EW, Lingard LA. 'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors. MEDICAL TEACHER 2022; 44:196-205. [PMID: 34634990 DOI: 10.1080/0142159x.2021.1984408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Clinical supervisors acknowledge that they sometimes allow trainees to fail for educational purposes. What remains unknown is how supervisors decide whether to allow failure in a specific instance. Given the high stakes nature of these decisions, such knowledge is necessary to inform conversations about this educationally powerful and clinically delicate phenomenon. MATERIALS AND METHODS 19 supervisors participated in semi-structured interviews to explore how they view their decision to allow failure in clinical training. Following constructivist grounded theory methodology, the iteratively collected data and analysis were informed by theoretical sampling. RESULTS Recalling instances when they considered allowing residents to fail for educational purposes, supervisors characterized these as intuitive, in-the-moment decisions. In their post hoc reflections, they could articulate four factors that they believed influenced these decisions: patient, supervisor, trainee, and environmental factors. While patient factors were reported as primary, the factors appear to interact in dynamic and nonlinear ways, such that supervisory decisions about allowing failure may not be predictable from one situation to the next. CONCLUSIONS Clinical supervisors make many decisions in the moment, and allowing resident failure appears to be one of them. Upon reflection, supervisors understand their decisions to be shaped by recurring factors in the clinical training environment. The complex interplay among these factors renders predicting such decisions difficult, if not impossible. However, having a language for these dynamic factors can support clinical educators to have meaningful discussions about this high-stakes educational strategy.
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Affiliation(s)
- Jennifer M Klasen
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, University Hospital Basel, Basel, Switzerland
| | - Pim W Teunissen
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Erik W Driessen
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Lorelei A Lingard
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
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25
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Abstract
Research in cognitive psychology shows that expert clinicians make a medical diagnosis through a two step process of hypothesis generation and hypothesis testing. Experts generate a list of possible diagnoses quickly and intuitively, drawing on previous experience. Experts remember specific examples of various disease categories as exemplars, which enables rapid access to diagnostic possibilities and gives them an intuitive sense of the base rates of various diagnoses. After generating diagnostic hypotheses, clinicians then test the hypotheses and subjectively estimate the probability of each diagnostic possibility by using a heuristic called anchoring and adjusting. Although both novices and experts use this two step diagnostic process, experts distinguish themselves as better diagnosticians through their ability to mobilize experiential knowledge in a manner that is content specific. Experience is clearly the best teacher, but some educational strategies have been shown to modestly improve diagnostic accuracy. Increased knowledge about the cognitive psychology of the diagnostic process and the pitfalls inherent in the process may inform clinical teachers and help learners and clinicians to improve the accuracy of diagnostic reasoning. This article reviews the literature on the cognitive psychology of diagnostic reasoning in the context of cardiovascular disease.
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Affiliation(s)
- John E Brush
- Sentara Health Research Center, Norfolk, VA, USA
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jonathan Sherbino
- McMaster Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Geoffrey R Norman
- McMaster Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
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Rotgans JI. Learning to diagnose X-rays: a neuroscientific study of practice-related activation changes in the prefrontal cortex. Diagnosis (Berl) 2021; 9:255-264. [PMID: 34883007 DOI: 10.1515/dx-2021-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Medical expertise manifests itself by the ability of a physician to rapidly diagnose patients. How this expertise develops from a neural-activation perspective is not well understood. The objective of the present study was to investigate practice-related activation changes in the prefrontal cortex (PFC) as medical students learn to diagnose chest X-rays. METHODS The experimental paradigm consisted of a learning and a test phase. During the learning phase, 26 medical students were trained to diagnose four out of eight chest X-rays. These four cases were presented repeatedly and corrective feedback was provided. During the test phase, all eight cases were presented together with near- and far-transfer cases to examine whether participants' diagnostic learning went beyond simple rote recognition of the trained X-rays. During both phases, participants' PFC was scanned using functional near-infrared spectroscopy. Response time and diagnostic accuracy were recorded as behavioural indicators. One-way repeated measures ANOVA were conducted to analyse the data. RESULTS Results revealed that participants' diagnostic accuracy significantly increased during the learning phase (F=6.72, p<0.01), whereas their response time significantly decreased (F=16.69, p<0.001). Learning to diagnose chest X-rays was associated with a significant decrease in PFC activity (F=33.21, p<0.001) in the left dorsolateral prefrontal cortex, the orbitofrontal area, the frontopolar area and the frontal eye field. Further, the results of the test phase indicated that participants' diagnostic accuracy was significantly higher for the four trained cases, second highest for the near-transfer, third highest for the far-transfer cases and lowest for the untrained cases (F=167.20, p<0.001) and response time was lowest for the trained cases, second lowest for the near-transfer, third lowest for the far-transfer cases and highest for the untrained cases (F=9.72, p<0.001). In addition, PFC activity was lowest for the trained and near-transfer cases, followed by the far-transfer cases and highest for the untrained cases (F=282.38, p<0.001). CONCLUSIONS The results suggest that learning to diagnose X-rays is associated with a significant decrease in PFC activity. In terms of dual-process theory, these findings support the notion that students initially rely more on slow analytical system-2 reasoning. As expertise develops, system-2 reasoning transitions into faster and automatic system-1 reasoning.
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Affiliation(s)
- Jerome I Rotgans
- Nanyang Technological University, Lee Kong Chian School of Medicine, Singapore, Singapore
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Schaller-Paule MA, Steinmetz H, Vollmer FS, Plesac M, Wicke F, Foerch C. Lessons in clinical reasoning - pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error. Diagnosis (Berl) 2021; 8:515-524. [PMID: 33759405 DOI: 10.1515/dx-2019-0108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics - subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. CASE PRESENTATION A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient's dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. CONCLUSIONS Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.
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Affiliation(s)
- Martin A Schaller-Paule
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
| | - Helmuth Steinmetz
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
| | - Friederike S Vollmer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
| | - Melissa Plesac
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Felix Wicke
- Department of Psychosomatic Medicine and Psychotherapy, Johannes Gutenberg University Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
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McCleary N, Francis JJ, Campbell MK, Ramsay CR, Burton CD, Allan JL. Antibiotic prescribing for respiratory tract infection: exploring drivers of cognitive effort and factors associated with inappropriate prescribing. Fam Pract 2021; 38:740-750. [PMID: 33972999 DOI: 10.1093/fampra/cmab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antibiotics are over-prescribed for upper respiratory tract infection (URTI). It is unclear how factors known to influence prescribing decisions operate 'in the moment': dual process theories, which propose two systems of thought ('automatic' and 'analytical'), may inform this. OBJECTIVE(S) Investigate cognitive processes underlying antibiotic prescribing for URTI and the factors associated with inappropriate prescribing. METHODS We conducted a mixed methods study. Primary care physicians in Scotland (n = 158) made prescribing decisions for patient scenarios describing sore throat or otitis media delivered online. Decision difficulty and decision time were recorded. Decisions were categorized as appropriate or inappropriate based on clinical guidelines. Regression analyses explored relationships between scenario and physician characteristics and decision difficulty, time and appropriateness. A subgroup (n = 5) verbalized their thoughts (think aloud) whilst making decisions for a subset of scenarios. Interviews were analysed inductively. RESULTS Illness duration of 4+ days was associated with greater difficulty. Inappropriate prescribing was associated with clinical factors suggesting viral cause and with patient preference against antibiotics. In interviews, physicians made appropriate decisions quickly for easier cases, with little deliberation, reflecting automatic-type processes. For more difficult cases, physicians deliberated over information in some instances, but not in others, with inappropriate prescribing occurring in both instances. Some interpretations of illness duration and unilateral ear examination findings (for otitis media) were associated with inappropriate prescribing. CONCLUSION Both automatic and analytical processes may lead to inappropriate prescribing. Interventions to support appropriate prescribing may benefit from targeting interpretation of illness duration and otitis media ear exam findings and facilitating appropriate use of both modes of thinking.
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Affiliation(s)
- Nicola McCleary
- Aberdeen Health Psychology Group, University of Aberdeen, Aberdeen, UK.,Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa,Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jill J Francis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa,Canada.,School of Health Sciences, City University of London, London, UK.,School of Health Sciences, University of Melbourne, Melbourne, Australia
| | | | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Julia L Allan
- Aberdeen Health Psychology Group, University of Aberdeen, Aberdeen, UK.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Intensive Care Unit Decision-Making in Uncertain and Stressful Conditions Part 2: Cognitive Errors, Debiasing Strategies, and Enhancing Critical Thinking. Crit Care Clin 2021; 38:89-101. [PMID: 34794633 DOI: 10.1016/j.ccc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Diagnostic errors are considered a blind spot of health care delivery and occur in up to 15% of patient cases. Cognitive failures are a leading cause of diagnostic error and often occur as a result of overreliance on system 1 thinking. This narrative review describes why diagnostic errors occur by shedding additional light on systems 1 and 2 forms of thinking, reviews literature on debiasing strategies in medicine, and provides a framework for teaching critical thinking in the intensive care unit as a strategy to promote learner development and minimize cognitive failures.
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Pinnock R, Ritchie D, Gallagher S, Henning MA, Webster CS. The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:785-809. [PMID: 33389234 DOI: 10.1007/s10459-020-10022-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 12/21/2020] [Indexed: 06/12/2023]
Abstract
Despite a variety of definitions of mindfulness, over the past 20 years there have been increasing claims that mindful practice is helpful in improving the accuracy of clinical diagnosis. We performed a systematic review and evidence synthesis in order to: determine the nature and definitions of mindful practice and associated terms; evaluate the quality of evidence for the benefits of mindful practice; and conclude whether mindful practice may reduce diagnostic error. We screened 14397 refereed reports from the five common literature databases, to include 33 reports related to the use of mindful practice in clinical diagnosis. Our evidence synthesis contained no randomised controlled trials (level I evidence) of mindful practice, the majority of supporting evidence (26 reports or 79%) comprised conceptual commentary or opinion (level IV evidence). However, 2 supporting reports constituted controlled studies without randomisation (level IIa), 1 report was quasi-experimental (level IIb), and 4 reports were comparative studies (level III). Thus, we may tentatively conclude that mindful practice appears promising as a method of improving diagnostic accuracy, but that further definitive studies of efficacy are required. We identified a taxonomy of 71 terms related to mindful practice, 7 of which were deemed core terms due to being each cited 5 times or more. The 7 core terms appear to be sufficient to describe the findings at higher levels of evidence in our evidence synthesis, suggesting that future definitive studies of mindful practice should focus on these common core terms in order to promote more generalisable findings.
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Affiliation(s)
- Ralph Pinnock
- Medical Education Unit, Dunedin School of Medicine, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand.
| | - Darren Ritchie
- Medical Education Unit, Dunedin School of Medicine, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand
| | - Steve Gallagher
- Medical Education Unit, Dunedin School of Medicine, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand
| | - Marcus A Henning
- Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Craig S Webster
- Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand
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Rosby LV, Schmidt HG, Tan GJS, Low-Beer N, Mamede S, Zwaan L, Rotgans JI. Promotion of knowledge transfer and retention in year 2 medical students using an online training exercise. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:1059-1074. [PMID: 33687584 PMCID: PMC8338856 DOI: 10.1007/s10459-021-10037-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/16/2021] [Indexed: 06/01/2023]
Abstract
It was recently shown that novice medical students could be trained to demonstrate the speed-to-diagnosis and diagnostic accuracy typical of System-1-type reasoning. However, the effectiveness of this training can only be fully evaluated when considering the extent to which knowledge transfer and long-term retention occur as a result, the former of which is known to be notoriously difficult to achieve. This study aimed to investigate whether knowledge learned during an online training exercise for chest X-ray diagnosis promoted either knowledge transfer or retention, or both. Second year medical students were presented with, and trained to recognise the features of four chest X-ray conditions. Subsequently, they were shown the four trained-for cases again as well as different representations of the same conditions varying in the number of common elements and asked to provide a diagnosis, to test for near-transfer (four cases) and far-transfer (four cases) of knowledge. They were also shown four completely new conditions to diagnose. Two weeks later they were asked to diagnose the 16 aforementioned cases again to assess for knowledge retention. Dependent variables were diagnostic accuracy and time-to-diagnosis. Thirty-six students volunteered. Trained-for cases were diagnosed most accurately and with most speed (mean score = 3.75/4, mean time = 4.95 s). When assessing knowledge transfer, participants were able to diagnose near-transfer cases more accurately (mean score = 2.08/4, mean time = 15.77 s) than far-transfer cases (mean score = 1.31/4, mean time = 18.80 s), which showed similar results to those conditions previously unseen (mean score = 0.72/4, mean time = 19.46 s). Retention tests showed a similar pattern but accuracy scores were lower overall. This study demonstrates that it is possible to successfully promote knowledge transfer and retention in Year 2 medical students, using an online training exercise involving diagnosis of chest X-rays, and is one of the few studies to provide evidence of actual knowledge transfer.
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Affiliation(s)
- Lucy V Rosby
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Henk G Schmidt
- Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Gerald J S Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Naomi Low-Beer
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | | | - Laura Zwaan
- Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jerome I Rotgans
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Brennan PA, Dalal A, Knighton J, Jones R, Oeppen RS. Pilot study to evaluate safety culture perception in the operating theatres of an acute NHS Trust using the National Air Traffic Services (NATS) App. Br J Oral Maxillofac Surg 2021; 59:1085-1089. [PMID: 34281735 DOI: 10.1016/j.bjoms.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/19/2022]
Abstract
An area critical to safety in an organisation is the perceived and actual culture. National Air Traffic Services (NATS) work closely with large safety-critical industries including various aviation companies to enable them to identify strengths and vulnerabilities with the aim of improving safe practice. NATS have developed a simple free downloadable self-assessment App that individuals can use to assess their own culture perception in their organisation. The App has 16 questions arranged in four domains but to our knowledge it has not been used to date in healthcare. As part of the initiatives to improve staff culture, we evaluated operating theatre colleagues' safety perception in our large acute NHS Trust in a pilot study using the NATS safety App. Staff downloaded the App to their smart device before completing it. Responses were sent anonymously through the App and collated by NATS. A total of 146 colleagues downloaded and completed the questionnaire. One hundred and seventeen staff (80%) felt encouraged to report safety concerns, but 86% (n=126) confirmed a lack of available support from healthcare managers. Only 43% of respondents (n=63) would find it easy to challenge colleagues if they observed unsafe behaviour. This pilot study has identified positive indicators of an evolving NHS safety culture, and some concerns about speaking up, support, and challenging colleagues without fear. These issues are known to occur across healthcare. Further work is needed in the NHS to provide a supportive environment to improve patient safety, and lower hierarchy in surgical teams.
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Affiliation(s)
- P A Brennan
- Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK.
| | - A Dalal
- Poole Hospital, Longfleet Road, Poole BH15 2JB, UK
| | - J Knighton
- Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
| | - R Jones
- Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
| | - R S Oeppen
- Southampton University Hospitals Trust, Tremona Road, Southampton SO16 6YD, UK
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Staal J, Alsma J, Mamede S, Olson APJ, Prins-van Gilst G, Geerlings SE, Plesac M, Sundberg MA, Frens MA, Schmidt HG, Van den Broek WW, Zwaan L. The relationship between time to diagnose and diagnostic accuracy among internal medicine residents: a randomized experiment. BMC MEDICAL EDUCATION 2021; 21:227. [PMID: 33882919 PMCID: PMC8061054 DOI: 10.1186/s12909-021-02671-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/08/2021] [Indexed: 05/02/2023]
Abstract
BACKGROUND Diagnostic errors have been attributed to cognitive biases (reasoning shortcuts), which are thought to result from fast reasoning. Suggested solutions include slowing down the reasoning process. However, slower reasoning is not necessarily more accurate than faster reasoning. In this study, we studied the relationship between time to diagnose and diagnostic accuracy. METHODS We conducted a multi-center within-subjects experiment where we prospectively induced availability bias (using Mamede et al.'s methodology) in 117 internal medicine residents. Subsequently, residents diagnosed cases that resembled those bias cases but had another correct diagnosis. We determined whether residents were correct, incorrect due to bias (i.e. they provided the diagnosis induced by availability bias) or due to other causes (i.e. they provided another incorrect diagnosis) and compared time to diagnose. RESULTS We did not successfully induce bias: no significant effect of availability bias was found. Therefore, we compared correct diagnoses to all incorrect diagnoses. Residents reached correct diagnoses faster than incorrect diagnoses (115 s vs. 129 s, p < .001). Exploratory analyses of cases where bias was induced showed a trend of time to diagnose for bias diagnoses to be more similar to correct diagnoses (115 s vs 115 s, p = .971) than to other errors (115 s vs 136 s, p = .082). CONCLUSIONS We showed that correct diagnoses were made faster than incorrect diagnoses, even within subjects. Errors due to availability bias may be different: exploratory analyses suggest a trend that biased cases were diagnosed faster than incorrect diagnoses. The hypothesis that fast reasoning leads to diagnostic errors should be revisited, but more research into the characteristics of cognitive biases is important because they may be different from other causes of diagnostic errors.
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Affiliation(s)
- J Staal
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands.
| | - J Alsma
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S Mamede
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - A P J Olson
- Division of General Internal Medicine, University of Minnesota, Section of Hospital Medicine, Minneapolis, USA
| | - G Prins-van Gilst
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S E Geerlings
- Department of Internal Medicine and Department of Infectious Diseases, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M Plesac
- Division of General Internal Medicine, University of Minnesota, Section of Hospital Medicine, Minneapolis, USA
| | - M A Sundberg
- Division of General Internal Medicine, University of Minnesota, Section of Hospital Medicine, Minneapolis, USA
| | - M A Frens
- Department of Neuroscience, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - H G Schmidt
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - W W Van den Broek
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - L Zwaan
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
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Groenier M, Christoph N, Smeenk C, Endedijk MD. The process of slowing down in clinical reasoning during ultrasound consultations. MEDICAL EDUCATION 2021; 55:242-251. [PMID: 32888219 PMCID: PMC7891410 DOI: 10.1111/medu.14365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 07/12/2020] [Accepted: 08/24/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES In clinical reasoning, clinicians need to switch between automatic and effortful reasoning to solve both routine and non-routine problems. This requires the ability to recognise when a problem is non-routine and adapt one's reasoning mode accordingly, that is to 'slow down' the reasoning process. In the current study, we explored the process of these transitions between automatic and effortful reasoning by radiologists who performed ultrasound examinations during consultations at the polyclinic. METHODS Manifestations of slowing down in clinical reasoning were explored in 41 out-patient consultations performed by five radiologists. Interviews before and after the consultations were combined with observations during the consultations to obtain proactively planned triggers, slowing down manifestations and situationally responsive initiators. Transcripts of the interviews and field notes of the observations were coded. The constant comparative method was used to classify slowing down manifestations. RESULTS In thirteen of the 41 consultations, slowing down moments were observed. Four manifestations of slowing down were identified: shifting, checking, searching and focusing. These manifestations mainly differed in how long radiologists maintained effortful reasoning, varying from very short periods (shifting and checking) to sustained periods (searching and focusing). Unexpected patient statements and ambiguous ultrasound images initiated the slowing down moments. DISCUSSION The results from this study contribute to understanding how clinicians transition from automatic to effortful reasoning. Also, this study revealed two sources of initiators of this transition in radiologists' consultations: statements made by the patient and conflicting or ambiguous visual information, in this case from ultrasound images. Natural variations in patient statements and visual information can be used as input of what might be meaningful variation in the domain of radiology education to support expertise development.
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Affiliation(s)
- Marleen Groenier
- Technical Medical CentreTechnical MedicineUniversity of TwenteEnschedeThe Netherlands
| | - Noor Christoph
- Center of Evidence Based EducationFaculty of MedicineAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Carmen Smeenk
- Center of Evidence Based EducationFaculty of MedicineAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Educational SciencesFaculty of Behavioral, Management, and Social SciencesUniversity of TwenteEnschedeThe Netherlands
| | - Maaike D. Endedijk
- Department of Educational SciencesFaculty of Behavioral, Management, and Social SciencesUniversity of TwenteEnschedeThe Netherlands
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Mouchabac S, Conejero I, Lakhlifi C, Msellek I, Malandain L, Adrien V, Ferreri F, Millet B, Bonnot O, Bourla A, Maatoug R. Improving clinical decision-making in psychiatry: implementation of digital phenotyping could mitigate the influence of patient’s and practitioner’s individual cognitive biases. DIALOGUES IN CLINICAL NEUROSCIENCE 2021; 23:52-61. [PMID: 35860175 PMCID: PMC9286737 DOI: 10.1080/19585969.2022.2042165] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High stake clinical choices in psychiatry can be impacted by external irrelevant factors. A strong understanding of the cognitive and behavioural mechanisms involved in clinical reasoning and decision-making is fundamental in improving healthcare quality. Indeed, the decision in clinical practice can be influenced by errors or approximations which can affect the diagnosis and, by extension, the prognosis: human factors are responsible for a significant proportion of medical errors, often of cognitive origin. Both patient’s and clinician’s cognitive biases can affect decision-making procedures at different time points. From the patient’s point of view, the quality of explicit symptoms and data reported to the psychiatrist might be affected by cognitive biases affecting attention, perception or memory. From the clinician’s point of view, a variety of reasoning and decision-making pitfalls might affect the interpretation of information provided by the patient. As personal technology becomes increasingly embedded in human lives, a new concept called digital phenotyping is based on the idea of collecting real-time markers of human behaviour in order to determine the ‘digital signature of a pathology’. Indeed, this strategy relies on the assumption that behaviours are ‘quantifiable’ from data extracted and analysed through connected tools (smartphone, digital sensors and wearable devices) to deduce an ‘e-semiology’. In this article, we postulate that implementing digital phenotyping could improve clinical reasoning and decision-making outcomes by mitigating the influence of patient’s and practitioner’s individual cognitive biases.
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Affiliation(s)
- Stéphane Mouchabac
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Sorbonne Université, Hôpital de la Pitié Salpêtrière, iCRIN (Infrastructure for Clinical Research In Neurosciences), Brain Institute (ICM), INSERM, CNRS, Paris, France
| | - Ismael Conejero
- Department of Psychiatry, CHU Nîmes, University of Montpellier, Nîmes, France
- Inserm, Unit 1061 “Neuropsychiatry: Epidemiological and Clinical Research”, Montpellier, France
| | - Camille Lakhlifi
- PICNIC lab (Physiological investigation of clinically normal and impaired cognition), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Université de Paris, Sorbonne Université, Paris, France
| | - Ilyass Msellek
- Sorbonne Université, Hôpital de la Pitié Salpêtrière, iCRIN (Infrastructure for Clinical Research In Neurosciences), Brain Institute (ICM), INSERM, CNRS, Paris, France
| | - Leo Malandain
- University Hospital Cochin (site Tarnier), Paris, France
| | - Vladimir Adrien
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Sorbonne Université, Hôpital de la Pitié Salpêtrière, iCRIN (Infrastructure for Clinical Research In Neurosciences), Brain Institute (ICM), INSERM, CNRS, Paris, France
| | - Florian Ferreri
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Sorbonne Université, Hôpital de la Pitié Salpêtrière, iCRIN (Infrastructure for Clinical Research In Neurosciences), Brain Institute (ICM), INSERM, CNRS, Paris, France
| | - Bruno Millet
- Sorbonne Université, Hôpital de la Pitié Salpêtrière, iCRIN (Infrastructure for Clinical Research In Neurosciences), Brain Institute (ICM), INSERM, CNRS, Paris, France
| | - Olivier Bonnot
- Department of Child and Adolescent Psychiatry, CHU de Nantes, Nantes, France
- Pays de la Loire Psychology Laboratory, Nantes, France
| | - Alexis Bourla
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Sorbonne Université, Hôpital de la Pitié Salpêtrière, iCRIN (Infrastructure for Clinical Research In Neurosciences), Brain Institute (ICM), INSERM, CNRS, Paris, France
- Jeanne d'Arc Hospital, INICEA Korian, Saint-Mandé, France
| | - Redwan Maatoug
- Sorbonne Université, Hôpital de la Pitié Salpêtrière, iCRIN (Infrastructure for Clinical Research In Neurosciences), Brain Institute (ICM), INSERM, CNRS, Paris, France
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Langford BJ, Daneman N, Leung V, Langford DJ. Cognitive bias: how understanding its impact on antibiotic prescribing decisions can help advance antimicrobial stewardship. JAC Antimicrob Resist 2020; 2:dlaa107. [PMID: 34223057 DOI: 10.1093/jacamr/dlaa107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The way clinicians think about decision-making is evolving. Human decision-making shifts between two modes of thinking, either fast/intuitive (Type 1) or slow/deliberate (Type 2). In the healthcare setting where thousands of decisions are made daily, Type 1 thinking can reduce cognitive load and help ensure decision making is efficient and timely, but it can come at the expense of accuracy, leading to systematic errors, also called cognitive biases. This review provides an introduction to cognitive bias and provides explanation through patient vignettes of how cognitive biases contribute to suboptimal antibiotic prescribing. We describe common cognitive biases in antibiotic prescribing both from the clinician and the patient perspective, including hyperbolic discounting (the tendency to favour small immediate benefits over larger more distant benefits) and commission bias (the tendency towards action over inaction). Management of cognitive bias includes encouraging more mindful decision making (e.g., time-outs, checklists), improving awareness of one's own biases (i.e., meta-cognition), and designing an environment that facilitates safe and accurate decision making (e.g., decision support tools, nudges). A basic understanding of cognitive biases can help explain why certain stewardship interventions are more effective than others and may inspire more creative strategies to ensure antibiotics are used more safely and more effectively in our patients.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada.,Toronto East Health Network, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Dale J Langford
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Steenhof N, Woods NN, Mylopoulos M. Exploring why we learn from productive failure: insights from the cognitive and learning sciences. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2020; 25:1099-1106. [PMID: 33180211 DOI: 10.1007/s10459-020-10013-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/30/2020] [Indexed: 06/11/2023]
Abstract
Advances in Health Sciences Education (AHSE) has been at the forefront of the cognitive wave in health professions education for the past 25 years. One example is research on productive failure, a teaching strategy that asks learners to attempt to generate solutions to difficult problems before receiving instruction. This study compared the effectiveness of productive failure with indirect failure to further characterize the underpinning cognitive mechanisms of productive failure. Year one pharmacy students (N = 42) were randomly assigned to a productive failure or an indirect failure learning condition. The problem of estimating renal function based on serum creatinine was described to participants in the productive failure learning condition, who were then asked to generate a solution. Participants in the indirect failure condition learned about the same problem and were given incorrect solutions that other students had created, as well as the Cockcroft-Gault formula, and asked to compare and contrast the equations. Immediately thereafter all participants completed a series of tests designed to assess acquisition, application, and preparation for future learning (PFL). The tests were repeated after a 1-week delay. Participants in the productive failure condition outperformed those in the indirect failure condition, both on the immediate PFL assessment, and after a 1-week delay. These results emphasize the crucial role of generation in learning. When preparing novice students to learn new knowledge in the future, generating solutions to problems prior to instruction may be more effective than simply learning about someone else's mistakes. Struggle and failure are most productive when experienced personally by a learner because it requires the learner to engage in generation, which deepens conceptual understanding.
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Affiliation(s)
- Naomi Steenhof
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada.
- The Wilson Centre, University of Toronto and University Health Network, Toronto, Canada.
- The Institute for Education Research, University Health Network, Toronto, Canada.
| | - Nicole N Woods
- The Wilson Centre, University of Toronto and University Health Network, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
- The Institute for Education Research, University Health Network, Toronto, Canada
| | - Maria Mylopoulos
- The Wilson Centre, University of Toronto and University Health Network, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
- The Institute for Education Research, University Health Network, Toronto, Canada
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Hartigan S, Brooks M, Hartley S, Miller RE, Santen SA, Hemphill RR. Review of the Basics of Cognitive Error in Emergency Medicine: Still No Easy Answers. West J Emerg Med 2020; 21:125-131. [PMID: 33207157 PMCID: PMC7673867 DOI: 10.5811/westjem.2020.7.47832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022] Open
Abstract
Emergency physicians (EP) make clinical decisions multiple times daily. In some instances, medical errors occur due to flaws in the complex process of clinical reasoning and decision-making. Cognitive error can be difficult to identify and is equally difficult to prevent. To reduce the risk of patient harm resulting from errors in critical thinking, it has been proposed that we train physicians to understand and maintain awareness of their thought process, to identify error-prone clinical situations, to recognize predictable vulnerabilities in thinking, and to employ strategies to avert cognitive errors. The first step to this approach is to gain an understanding of how physicians make decisions and what conditions may predispose to faulty decision-making. We review the dual-process theory, which offers a framework to understand both intuitive and analytical reasoning, and to identify the necessary conditions to support optimal cognitive processing. We also discuss systematic deviations from normative reasoning known as cognitive biases, which were first described in cognitive psychology and have been identified as a contributing factor to errors in medicine. Training physicians in common biases and strategies to mitigate their effect is known as debiasing. A variety of debiasing techniques have been proposed for use by clinicians. We sought to review the current evidence supporting the effectiveness of these strategies in the clinical setting. This discussion of improving clinical reasoning is relevant to medical educators as well as practicing EPs engaged in continuing medical education.
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Affiliation(s)
- Sarah Hartigan
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Internal Medicine, Richmond, Virginia
| | - Michelle Brooks
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Internal Medicine, Richmond, Virginia
| | - Sarah Hartley
- University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan
| | - Rebecca E Miller
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Internal Medicine, Richmond, Virginia
| | - Sally A Santen
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Emergency Medicine, Richmond, Virginia
| | - Robin R Hemphill
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Emergency Medicine, Richmond, Virginia
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Smith CF, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract 2020; 70:e612-e621. [PMID: 32839162 PMCID: PMC7449376 DOI: 10.3399/bjgp20x712301] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice. AIM To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility. DESIGN AND SETTING Systematic review and meta-analysis of international research on GPs' gut feelings in primary care. METHOD Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings. RESULTS Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval. CONCLUSION GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers.
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Affiliation(s)
| | - Sarah Drew
- London School of Economics and Political Science, London
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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40
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Mamede S, Hautz WE, Berendonk C, Hautz SC, Sauter TC, Rotgans J, Zwaan L, Schmidt HG. Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1223-1229. [PMID: 31972673 DOI: 10.1097/acm.0000000000003153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Diagnostic errors have been attributed to failure to sufficiently reflect on initial diagnoses. However, evidence of the benefits of reflection is conflicting. This study examined whether reflection upon initial diagnoses on difficult cases improved diagnostic accuracy and whether reflection triggered by confrontation with case evidence was more beneficial than simply revising initial diagnoses. METHOD Participants were physicians in Bern, Switzerland, registered for the 2018 Swiss internal medicine certification exam. They diagnosed written clinical cases, providing an initial diagnosis by following the same instructions and returning to the case to provide a final diagnosis. The latter required different types of reflection depending on the physician's experimental condition: return without instructions, identify confirmatory evidence, identify contradictory evidence, or identify both confirmatory and contradictory evidence. The authors examined diagnostic accuracy scores (range 0-1) as a function of diagnostic phase and reflection type. RESULTS One hundred and sixty-seven physicians participated. Diagnostic accuracy scores did not significantly differ between the 4 groups of physicians in the initial (I) or the final (F) diagnostic phase (mean [95% CI]: return without instructions, I: 0.21 [0.17, 0.26], F: 0.23 [0.18, 0.28]; confirmatory evidence, I: 0.24 [0.19, 0.29], F: 0.31 [0.25, 0.37]; contradictory evidence, I: 0.22 [0.17, 0.26], F: 0.26 [0.22, 0.30]; confirmatory and contradictory evidence, I: 0.19 [0.15, 0.23], F: 0.25 [0.20, 0.31]). Regardless of type of reflection employed while revising the case, accuracy increased significantly between initial and final diagnosis, I: 0.22 (0.19, 0.24) vs F: 0.26 (0.24, 0.29); P < .001. CONCLUSIONS Physicians' diagnostic accuracy improved after reflecting upon initial diagnoses provided for difficult cases, independently of the evidence searched for while reflecting. The findings support the importance attributed to reflection in clinical teaching. Future research should investigate whether revising the case can become more beneficial by triggering additional reflection.
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Affiliation(s)
- Sílvia Mamede
- S. Mamede is associate professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, Rotterdam, the Netherlands; ORCID: https://orcid.org/0000-0003-1187-2392
| | - Wolf E Hautz
- W.E. Hautz is assistant professor of medical education and chief of service, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-2445-984X
| | - Christoph Berendonk
- C. Berendonk is deputy head, Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-3740-9358
| | - Stefanie C Hautz
- S.C. Hautz is educational consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0003-4715-8465
| | - Thomas C Sauter
- T.C. Sauter is senior consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-6646-5789
| | - Jerome Rotgans
- J. Rotgans is assistant professor, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Laura Zwaan
- L. Zwaan is assistant professor, Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, the Netherlands
| | - Henk G Schmidt
- H.G. Schmidt is professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, the Netherlands
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Hyland ME. A reformulated contextual model of psychotherapy for treating anxiety and depression. Clin Psychol Rev 2020; 80:101890. [PMID: 32682187 PMCID: PMC7352110 DOI: 10.1016/j.cpr.2020.101890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022]
Abstract
This paper describes a reformulated contextual model that uses cognitive theory (dual process theory), motivation theory (personality) and behavioral adaptation (self-correcting control systems) to show how anxiety and depression are caused, treated and prevented by an interaction between people and contexts. Depression and anxiety are the result of implicit beliefs (not cognitions) that all experience is unrewarding and threatening, these being components of the implicit belief that life is bad. Implicit beliefs are formed automatically from contextual cues and in healthy individuals are consistent with rational appraisal. They become more negative than reality through a process of adaptation when behaviors, directed by rational thinking, repeatedly create cues that signify lack of reward or threat. Such behaviors occur when social or other obligations lead people to choose behaviors that fail to satisfy their own unique goals in life and approach threatening situations, contrary to their automatic reactions. Therapeutic interventions and lifestyle change reverse these adaptive processes by positive experiences that create positive implicit beliefs, a change effected in different ways by contextual and specific mechanisms both of which correct the same fault of negative implicit beliefs. Effective therapeutic relationships and interventions are achieved by detecting and responding to a patient's unique needs and goals and their associated implicit beliefs. Mental health requires not only that people experience life as good as defined by their own goals and beliefs but also the avoidance of contexts where social and other pressures induce people to behave in ways inconsistent with their automatically generated feelings.
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Affiliation(s)
- Michael E Hyland
- Plymouth Marjon University, Derriford Road, Plymouth PL6 8BH, United Kingdom; University of Plymouth, Drakes Circus, Plymouth PL4 8AA, United Kingdom.
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42
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Pelaccia T, Messman AM, Kline JA. Misdiagnosis and failure to diagnose in emergency care: Causes and empathy as a solution. PATIENT EDUCATION AND COUNSELING 2020; 103:1650-1656. [PMID: 32169322 DOI: 10.1016/j.pec.2020.02.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/06/2020] [Accepted: 02/27/2020] [Indexed: 06/10/2023]
Abstract
Diagnostic error is the most frequent cause of allegations of negligence in emergency care in the United States and is estimated to contribute to the death of hundreds of thousands of patients worldwide each year. In this special contribution, we elucidate the cognitive mechanisms that emergency physicians use to make decisions and identify how these mechanisms can become sources of diagnostic error. The discussion centers on the appraisal of proposed methods to reduce the risk of diagnostic error, including debiasing strategies and a brief discussion of the theoretical basis for interventions to improve clinician empathy.
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Affiliation(s)
- Thierry Pelaccia
- Center for Training and Research in Health Sciences Education (CFRPS), University of Strasbourg, 67085 Strasbourg, France; Prehospital Emergency Care Service (SAMU 67), Strasbourg University Hospital, France.
| | - Anne M Messman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA.
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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44
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Monteiro SD, Sherbino J, Schmidt H, Mamede S, Ilgen J, Norman G. It's the destination: diagnostic accuracy and reasoning. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2020; 25:19-29. [PMID: 31332589 DOI: 10.1007/s10459-019-09903-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/09/2019] [Indexed: 06/10/2023]
Abstract
While multiple theories exist to explain the diagnostic process, there are few available assessments that reliably determine diagnostic competence in trainees. Most methods focus on aspects of the process of diagnostic reasoning, such as the relation between case features and diagnostic hypotheses. Inevitably, detailed elucidation of aspects of the process requires substantial time per case and limits the number of cases that can be examined given a limited testing time. Shifting assessment to the outcome of diagnostic reasoning, accuracy of the diagnosis, may serve as a reliable measure of diagnostic competence and would allow increased sampling across cases. The present study is a retrospective analysis of 7 large studies, conducted by 3 research teams, that all used a series of brief written cases to examine the outcome of diagnostic reasoning-the diagnosis. The studies involved over 600 clinicians ranging from final year medical students to practicing emergency physicians. For 4 studies with usable reliability data, reliability for a 2 h test ranged from .63 to .94. On average speeded tests were more reliable (.85 vs. .73).To achieve a reliability of .75 required an average test time of 1.11 h for speeded tests and 1.99 for unspeeded tests. The measure was shown to be positively correlated with both written knowledge tests and measures of problem solving derived from OSCE performance tests. This retrospective analysis provides evidence to support the implementation of outcome-based assessments of clinical reasoning.
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Affiliation(s)
- Sandra D Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, ON, Canada.
| | - Jonathan Sherbino
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, ON, Canada
- Division of Emergency Medicine, McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, ON, Canada
| | - Henk Schmidt
- Department of Psychology, Erasmus School of Social and Behavioural Sciences, Erasmus University, Rotterdam, The Netherlands
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Silvia Mamede
- Department of Psychology, Erasmus School of Social and Behavioural Sciences, Erasmus University, Rotterdam, The Netherlands
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jonathan Ilgen
- Division of Emergency Medicine, School of Medicine, Center for the Leadership and Innovation in Medical Education, University of Washington, Seattle, WA, USA
| | - Geoff Norman
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, ON, Canada
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45
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Abstract
Accuracy in diagnosis trumps all other elements in clinical decision making. If diagnosis is inaccurate, management is likely to prove futile if not dangerous. Knowledge of physiology provides a periscope for identifying abnormalities beneath the skin responsible for clinical manifestations on the surface. Expert diagnosticians suspect disorders based on pattern recognition and automatic retrieval of knowledge stored in memory. A superior diagnostician looks at the same findings other clinicians see but thinks of causes that others have not imagined. Solving clinical mysteries depends on a clinician's power of imagination, not the capacity to recite an algorithm or apply a protocol.
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46
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Redelmeier DA, Ng K. Approach to making the availability heuristic less available. BMJ Qual Saf 2020; 29:528-530. [PMID: 31959715 DOI: 10.1136/bmjqs-2020-010831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Donald A Redelmeier
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin Ng
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Monteiro S, Sherbino J, Sibbald M, Norman G. Critical thinking, biases and dual processing: The enduring myth of generalisable skills. MEDICAL EDUCATION 2020; 54:66-73. [PMID: 31468581 DOI: 10.1111/medu.13872] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/10/2018] [Accepted: 02/13/2019] [Indexed: 06/10/2023]
Abstract
CONTEXT The myth of generalisable thinking skills in medical education is gaining popularity once again. The implications are significant as medical educators decide on how best to use limited resources to prepare trainees for safe medical practice. This myth-busting critical review cautions against the proliferation of curricular interventions based on the acquisition of generalisable skills. STRUCTURE This paper begins by examining the recent history of general thinking skills, as defined by research in cognitive psychology and medical education. We describe three distinct epochs: (a) the Renaissance, which marked the beginning of cognitive psychology as a discipline in the 1960s and 1970s and was paralleled by educational reforms in medical education focused on problem solving and problem-based learning; (b) the Enlightenment, when an accumulation of evidence in psychology and in medical education cast doubt on the assumption of general reasoning or problem-solving skill and shifted the focus to consideration of the role of knowledge in expert clinical performance; and (c) the Counter-Enlightenment, in the current time, when the notion of general thinking skills has reappeared under different guises, but the fundamental problems related to lack of generality of skills and centrality of knowledge remain. CONCLUSIONS The myth of general thinking skills persists, despite the lack of evidence. Progress in medical education is more likely to arise from devising strategies to improve the breadth and depth of experiential knowledge.
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Affiliation(s)
- Sandra Monteiro
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- McMaster Education Research, Innovation and Theory Programme, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sherbino
- McMaster Education Research, Innovation and Theory Programme, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Sibbald
- McMaster Education Research, Innovation and Theory Programme, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Geoff Norman
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- McMaster Education Research, Innovation and Theory Programme, McMaster University, Hamilton, Ontario, Canada
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48
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Wyer PC. Evidence-based medicine and problem based learning a critical re-evaluation. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:865-878. [PMID: 31617018 DOI: 10.1007/s10459-019-09921-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/21/2019] [Indexed: 06/10/2023]
Abstract
Evidence-based medicine (EBM) has been the subject of controversy since it was introduced in 1992. However, it has yet to be critically examined as an alternative paradigm for medical education, which is how it was proposed. This commentary examines EBM on the terms on which it was originally advanced and within the context that gave rise to it, the problem-based learning (PBL) environment at McMaster University in the 1970s and 80s. The EBM educational prescription is revealed to be aligned with the information processing psychology (IPP) model of learning through acquisition of general problem solving skills that characterized the early McMaster version of PBL. The IPP model has been identified in the literature as discordant with an alternative, constructivist, model that emerged at Maastricht University in the Netherlands over the subsequent period. Strengths and weaknesses of EBM are identified from the standpoint of the underlying cognitive theories. Principles are proposed with which to guide an educationally viable approach to learning and teaching the valuable skills included within the original EBM formula.
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Affiliation(s)
- Peter C Wyer
- Department of Emergency Medicine, Columbia University Medical Center, NYC, 622 W 168th Street, New York, NY, 10032, USA.
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49
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Shafer G, Singh H, Suresh G. Diagnostic errors in the neonatal intensive care unit: State of the science and new directions. Semin Perinatol 2019; 43:151175. [PMID: 31488330 DOI: 10.1053/j.semperi.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Diagnostic errors remain understudied in neonatology. The limited available evidence, however, suggests that diagnostic errors in the neonatal intensive care unit (NICU) result in significant and long-term consequences. In this narrative review, we discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. We then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error. This multifactorial causation has limited the development of methodology to measure diagnostic errors as well as strategies to mitigate and prevent their adverse effects. We recommend research focused on the frequency and etiology of diagnostic error in the NICU as well as potential mitigation strategies to advance this important field in neonatal intensive care.
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Affiliation(s)
- Grant Shafer
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, 6621 Fanning Street, Suite W6104, Houston, TX 77020, United States.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, United States
| | - Gautham Suresh
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, United States
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50
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Abstract
Cognitive bias is increasingly recognised as an important source of medical error, and is both ubiquitous across clinical practice yet incompletely understood. This increasing awareness of bias has resulted in a surge in clinical and psychological research in the area and development of various 'debiasing strategies'. This paper describes the potential origins of bias based on 'dual process thinking', discusses and illustrates a number of the important biases that occur in clinical practice, and considers potential strategies that might be used to mitigate their effect.
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Affiliation(s)
- E D O'Sullivan
- Department of Renal Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK,
| | - S J Schofield
- Centre for Medical Education, University of Dundee, UK
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