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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; 30:1091-1101. [PMID: 38818694 DOI: 10.1111/jep.14023] [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: 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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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; 30:788-796. [PMID: 38825755 DOI: 10.1111/jep.13998] [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: 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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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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Kalam S, Selden N, Haycock K, Lowe T, Skaggs H, Dinh VA. Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients. Cureus 2023; 15:e40519. [PMID: 37461778 PMCID: PMC10350309 DOI: 10.7759/cureus.40519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED) using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans 83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.
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Affiliation(s)
- Sharmin Kalam
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, USA
| | | | - Korbin Haycock
- Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Tammy Lowe
- Nursing, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Heather Skaggs
- Nursing, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Vi Am Dinh
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, USA
- Internal Medicine, Division of Pulmonary and Critical Care, Loma Linda University Medical Center, Loma Linda, USA
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Sloane JF, Donkin C, Newell BR, Singh H, Meyer AND. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda. J Gen Intern Med 2023; 38:1526-1531. [PMID: 36697925 PMCID: PMC10160308 DOI: 10.1007/s11606-022-08019-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/29/2022] [Indexed: 01/27/2023]
Abstract
Interruptions are an inevitable occurrence in health care. Interruptions in diagnostic decision-making are no exception and can have negative consequences on both the decision-making process and well-being of the decision-maker. This may result in inaccurate or delayed diagnoses. To date, research specific to interruptions on diagnostic decision-making has been limited, but strategies to help manage the negative impacts of interruptions need to be developed and implemented. In this perspective, we first present a modified model of interruptions to visualize the interruption process and illustrate where potential interventions can be implemented. We then consider several empirically tested strategies from the fields of health care and cognitive psychology that can lay the groundwork for additional research to mitigate effects of interruptions during diagnostic decision-making. We highlight strategies to minimize the negative impacts of interruptions as well as strategies to prevent interruptions altogether. Additionally, we build upon these strategies to propose specific research priorities within the field of diagnostic safety. Identifying effective interventions to help clinicians better manage interruptions has the potential to minimize diagnostic errors and improve patient outcomes.
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Affiliation(s)
- Jennifer F Sloane
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- School of Psychology, University of New South Wales Sydney, Kensington, Australia.
| | - Chris Donkin
- School of Psychology, University of New South Wales Sydney, Kensington, Australia
- Ludwig Maximilian University of Munich, Munich, Germany
| | - Ben R Newell
- School of Psychology, University of New South Wales Sydney, Kensington, Australia
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Shikino K, Tsukamoto T, Noda K, Ohira Y, Yokokawa D, Hirose Y, Sato E, Mito T, Ota T, Katsuyama Y, Uehara T, Ikusaka M. Do clinical interview transcripts generated by speech recognition software improve clinical reasoning performance in mock patient encounters? A prospective observational study. BMC MEDICAL EDUCATION 2023; 23:272. [PMID: 37085837 PMCID: PMC10120240 DOI: 10.1186/s12909-023-04246-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 04/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND To investigate whether speech recognition software for generating interview transcripts can provide more specific and precise feedback for evaluating medical interviews. METHODS The effects of the two feedback methods on student performance in medical interviews were compared using a prospective observational trial. Seventy-nine medical students in a clinical clerkship were assigned to receive either speech-recognition feedback (n = 39; SRS feedback group) or voice-recording feedback (n = 40; IC recorder feedback group). All students' medical interviewing skills during mock patient encounters were assessed twice, first using a mini-clinical evaluation exercise (mini-CEX) and then a checklist. Medical students then made the most appropriate diagnoses based on medical interviews. The diagnostic accuracy, mini-CEX, and checklist scores of the two groups were compared. RESULTS According to the study results, the mean diagnostic accuracy rate (SRS feedback group:1st mock 51.3%, 2nd mock 89.7%; IC recorder feedback group, 57.5%-67.5%; F(1, 77) = 4.0; p = 0.049), mini-CEX scores for overall clinical competence (SRS feedback group: 1st mock 5.2 ± 1.1, 2nd mock 7.4 ± 0.9; IC recorder feedback group: 1st mock 5.6 ± 1.4, 2nd mock 6.1 ± 1.2; F(1, 77) = 35.7; p < 0.001), and checklist scores for clinical performance (SRS feedback group: 1st mock 12.2 ± 2.4, 2nd mock 16.1 ± 1.7; IC recorder feedback group: 1st mock 13.1 ± 2.5, 2nd mock 13.8 ± 2.6; F(1, 77) = 26.1; p < 0.001) were higher with speech recognition-based feedback. CONCLUSIONS Speech-recognition-based feedback leads to higher diagnostic accuracy rates and higher mini-CEX and checklist scores. TRIAL REGISTRATION This study was registered in the Japan Registry of Clinical Trials on June 14, 2022. Due to our misunderstanding of the trial registration requirements, we registered the trial retrospectively. This study was registered in the Japan Registry of Clinical Trials on 7/7/2022 (Clinical trial registration number: jRCT1030220188).
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Affiliation(s)
- Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan.
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Yoshiyuki Ohira
- Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Yuta Hirose
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Eri Sato
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Tsutomu Mito
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Takahiro Ota
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Yota Katsuyama
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-Ku, Chiba City, Chiba Pref, Japan
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Redmond S, Barwise A, Zornes S, Dong Y, Herasevich S, Pinevich Y, Soleimani J, LeMahieu A, Leppin A, Pickering B. Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders. Health Serv Insights 2022; 15:11786329221123540. [PMID: 36119635 PMCID: PMC9476244 DOI: 10.1177/11786329221123540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.
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Affiliation(s)
- Sarah Redmond
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Zornes
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allison LeMahieu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN, USA
| | - Aaron Leppin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Knowledge and Evaluation Research Unit (KER), Mayo Clinic, Rochester, MN, USA
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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How are Patient Order and Shift Timing Associated With Imaging Choices in the Emergency Department? Evidence From Niagara Health Administrative Data. Ann Emerg Med 2022; 80:392-400. [PMID: 35953385 DOI: 10.1016/j.annemergmed.2022.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE We assessed whether the timing and order of patients over emergency shifts are associated with receiving diagnostic imaging in the emergency department and characterized whether changes in imaging are associated with changes in patients returning to the ED. METHODS In this retrospective study, we used multivariate and instrumental variable regressions to examine how the timing and order of patients are associated with the use of diagnostic imaging. Outcomes include whether a patient receives a radiograph, a computed tomography (CT) scan, an ultrasound, and 7-day bouncebacks to the ED. The variables of interest are time and order during a physician's shift in which a patient is seen. RESULTS A total of 841,683 ED visits were examined from an administrative database of all ED visits to Niagara Health. Relative to the first patient, the probability of receiving a radiograph, CT, and ultrasound decreases by 6.4%, 9.1%, and 3.8% if a patient is the 15th patient seen during a shift. Relative to the first minute, the probability of receiving a radiograph, CT, or ultrasound increases by 1.9%, 2.7%, and 1.1% if a patient is seen in the 180th minute. Seven-day bounceback rates are not consistently associated with patient order or timing in a shift and imaging orders. CONCLUSION Imaging in the ED is associated with shift length and especially patient order, suggesting that physicians make different imaging decisions over the course of their shifts. Additional imaging does not translate into reductions in subsequent bouncebacks to the hospital.
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Zhang CJ, Walser E, Mierzwa A, Ott M. Learning Interrupted: Educational Impact of Interruptions on Surgical Residents. JOURNAL OF SURGICAL EDUCATION 2022; 79:875-884. [PMID: 35185000 DOI: 10.1016/j.jsurg.2022.01.009] [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: 07/03/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The complex workflow of surgical residents in the workplace-based learning environment makes interruptions an unavoidable aspect of clinical work. Interruptions have been shown to affect cognitive load, surgical performance, and medical error. The purpose of this study was to describe the effects of interruptions on surgical resident education. DESIGN Junior residents were observed by 2 trained observers using time-motion methodology between September 2018-August 2019. Interruptions were identified and coded retroactively based on predefined criteria. We captured key features of interruptions including frequency, duration, task interrupted, outcome, and learner perceived educational value. SETTING This study took place at London Health Sciences Centre in London, Ontario, Canada, a tertiary level academic health care center associated with the Schulich School of Medicine & Dentistry at Western University. PARTICIPANTS Junior residents on a General Surgery service were eligible for participation. Participation was voluntary. 8 residents were observed over 24 clinical periods. RESULTS A total of 278.2 hours of resident workflow were observed, and 229 interruptions were recorded. Interruptions account for 57.9 minutes/day of a surgical resident (SD = 60.7). Interruptions occur at a frequency of 0.82 interruptions/hour. Disruptive interruptions, that interfere with the continuation or completion of the original task, occur at a frequency of 0.11 interruptions/hour. Disruptive interruptions occurred at a higher frequency of 0.34 interruptions/hour during periods of feedback, coaching and informal teaching. DISCUSSION We observed that tasks of higher learner perceived educational value are often interrupted by tasks of lower learner perceived education value. Valuable educational experiences such as feedback, coaching and informal teaching are interrupted at a greater rate and experience disruptions at a disproportionate rate. We identified feedback, coaching and informal teaching as an education task vulnerable to disruptive interruptions that would benefit from interventions targeted toward preventing interruption. Suggested interventions include "formalizing" feedback, coaching and informal teaching.
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Affiliation(s)
- Chris J Zhang
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Eric Walser
- Division of General Surgery, Department of Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Anna Mierzwa
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Michael Ott
- Schulich School of Medicine, Western University, London, Ontario, Canada; Division of General Surgery, Department of Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada; Center for Education Research and Innovation, Schulich School of Medicine, Western University, London, Ontario, Canada; Department of Oncology, Faculty of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada.
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11
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Danesh V, Sasangohar F, Kallberg AS, Kean EB, Brixey JJ, Johnson KD. Systematic review of interruptions in the emergency department work environment. Int Emerg Nurs 2022; 63:101175. [PMID: 35843150 DOI: 10.1016/j.ienj.2022.101175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/05/2022] [Accepted: 05/04/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this systematic review is to describe the operationalization of interruptions measurement and to synthesize the evidence on the causes and consequences of interruptions in the emergency department (ED) work environment. METHODS This systematic review of studies explores the causes and consequences of interruptions in the ED. Of 2836 abstract/titles screened, 137 full-text articles were reviewed, and 44 articles met inclusion criteria of measuring ED interruptions. RESULTS All articles reported primary data collection, and most were cohort studies (n = 30, 68%). Conceptual or operational definitions of interruptions were included in 27 articles. Direct observation was the most common approach. In half of the studies, quantitative measures of interruptions in the ED were descriptive only, without measurements of interruptions' consequences. Twenty-two studies evaluated consequences, including workload, delays, satisfaction, and errors. Overall, relationships between ED interruptions and their causes and consequences are primarily derived from direct observation within large academic hospitals using heterogeneous definitions. Collective strengths of interruptions research in the ED include structured methods of naturalistic observation and definitions of interruptions derived from concept analysis. Limitations are conflicting and complex evaluations of consequences attributed to interruptions, including the predominance of descriptive reports characterizing interruptions without direct measurements of consequences. CONCLUSIONS The use of standardized definitions and measurements in interruptions research could contribute to measuring the impact and influence of interruptions on clinicians' productivity and efficiency as well as patients' outcomes, and thus provide a basis for intervention research.
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Affiliation(s)
- Valerie Danesh
- Center for Applied Health Research, Baylor Scott & White Health, 3500 Gaston Ave, Dallas, TX 75246, United States.
| | - Farzan Sasangohar
- Applied Cognitive Ergonomics Lab Texas, A&M University, Houston, TX, United States; Industrial and Systems Engineering, Texas A&M University, 4079 Emerging Technologies Building, 3131 TAMU, College Station, TX 77843, United States.
| | - Ann-Sofie Kallberg
- School of Health and Welfare, Dalarna University, Falun, Sweden; Department of Emergency Medicine, Falun Hospital, Dalarna University, SE-79188, Sweden.
| | - Emily B Kean
- University of Cincinnati, Health Sciences Library, 231 Albert Sabin Way, Cincinnati, OH 45267, United States.
| | - Juliana J Brixey
- Biomedical Informatics and Nursing, The University of Texas Health Science Center, 6901 Bertner Ave, Rm 629, Houston, TX 77030, United States.
| | - Kimberly D Johnson
- University of Cincinnati, College of Nursing, 234 Proctor Hall 3110 Vine St., Cincinnati, OH 45221, United States.
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12
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Coen M, Sader J, Junod-Perron N, Audétat MC, Nendaz M. Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic. Intern Emerg Med 2022; 17:979-988. [PMID: 34997906 PMCID: PMC8742156 DOI: 10.1007/s11739-021-02884-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022]
Abstract
Cognitive biases are systematic cognitive distortions, which can affect clinical reasoning. The aim of this study was to unravel the most common cognitive biases encountered in in the peculiar context of the COVID-19 pandemic. Case study research design. Primary care. Single centre (Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland). A short survey was sent to all primary care providers (N = 169) taking care of hospitalised adult patients with COVID-19. Participants were asked to describe cases in which they felt that their clinical reasoning was "disrupted" because of the pandemic context. Seven case were sufficiently complete to be analysed. A qualitative analysis of the clinical cases was performed and a bias grid encompassing 17 well-known biases created. The clinical cases were analyzed to assess for the likelihood (highly likely, plausible, not likely) of the different biases for each case. The most common biases were: "anchoring bias", "confirmation bias", "availability bias", and "cognitive dissonance". The pandemic context is a breeding ground for the emergence of cognitive biases, which can influence clinical reasoning and lead to errors. Awareness of these cognitive mechanisms could potentially reduce biases and improve clinical reasoning. Moreover, the analysis of cognitive biases can offer an insight on the functioning of the clinical reasoning process in the midst of the pandemic crisis.
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Affiliation(s)
- Matteo Coen
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.150338.c0000 0001 0721 9812Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Julia Sader
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988iEh2-Institute for Ethics, History, and the Humanities-Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Noëlle Junod-Perron
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988Institute of Primary Care (IuMFE), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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13
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Alajaji M, Saleh N, AlKhulaif AH, Mamede S, Rotgans JI, Sukkarieh H, AlHarbi N, Magzoub ME, Schmidt HG. Failure to demonstrate effects of interruptions on diagnostic reasoning: three experiments. BMC MEDICAL EDUCATION 2022; 22:182. [PMID: 35296302 PMCID: PMC8925158 DOI: 10.1186/s12909-022-03212-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 02/25/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Diagnostic error is a major source of patient suffering. Researchshows that physicians experience frequent interruptions while being engaged with patients and indicate that diagnostic accuracy may be impaired as a result. Since most studies in the field are observational, there is as yet no evidence suggesting a direct causal link between being interrupted and diagnostic error. Theexperiments reported in this article were intended to assess this hypothesis. METHODS Three experiments were conducted to test the hypothesis that interruptions hurt diagnostic reasoning and increase time on task. In the first experiment (N = 42), internal medicine residents, while diagnosing vignettes of actual clinical cases were interrupted halfway with a task unrelated to medicine, solving word-spotting puzzles and anagrams. In the second experiment (N = 78), the interruptions were medically relevant ones. In the third experiment (N = 30), we put additional time pressure on the participants. In all these experiments, a control group diagnosed the cases without interruption. Dependent variables were diagnostic accuracy and amount of time spent on the vignettes. RESULTS In none of the experiments interruptions were demonstrated to influence diagnostic accuracy. In Experiment 1: Mean of interrupted group was 0.88 (SD = 0.37) versus non- interrupted group 0.91 (SD = 0.32). In Experiment 2: Mean of interrupted group was 0.95 (SD = 0.32) versus non-interrupted group 0.94 (SD = 0.38). In Experiment 3: Mean of interrupted group was 0.42 (SD = 0.12) versus non-interrupted group 0.37 (SD = 0.08). Although interrupted residents in all experiments needed more time to complete the diagnostic task, only in Experiment 2, this effect was statistically significant. CONCLUSIONS These three experiments, taken together, failed to demonstrate negative effects of interruptions on diagnostic reasoning. Perhaps physicians who are interrupted may still have sufficient cognitive resources available to recover from it most of the time.
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Affiliation(s)
- Mai Alajaji
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Nada Saleh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ar Rimayah, Riyadh, 14611, Saudi Arabia
| | - Ali Hassan AlKhulaif
- Emergency Medicine Department, King Abdullah bin Abdulaziz University Hospital, Riyadh, 11564, Saudi Arabia
| | - Silvia Mamede
- Erasmus University, Institute of Medical Education Research Rotterdam, Erasmus Medical Centre, and Department of Psychology, Erasmus University Rotterdam, Rotterdam, P.O. Box 1738, 3000, DR, The Netherlands
| | - Jerome I Rotgans
- Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore City, 308232, Singapore
| | - Hatouf Sukkarieh
- College of Medicine, Alfaisal University, Takhassusi St, Riyadh, 11533, Saudi Arabia
| | - Nouf AlHarbi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ar Rimayah, Riyadh, 14611, Saudi Arabia
| | - Mohi Eldin Magzoub
- College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates
| | - Henk G Schmidt
- Department of Psychology, Erasmus University Rotterdam, P.O. Box 1738, 3000, DR, Rotterdam, The Netherlands.
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Gilligan C, Brubacher SP, Powell MB. "We're All Time Poor": Experienced Clinicians' and Students' Perceptions of Challenges Related to Patient Communication. TEACHING AND LEARNING IN MEDICINE 2022; 34:1-12. [PMID: 33789547 DOI: 10.1080/10401334.2021.1893175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PHENOMENON Communication is a complex and essential element of clinical practice. It is widely accepted that communication skills can be taught and learned, but challenges remain for clinicians in achieving effective communication with patients. This study explored the patient-communication challenges faced by both medical students and experienced clinicians. APPROACH Semi-structured interviews were conducted with twenty medical students and nineteen experienced clinicians from a range of medical disciplines. Interviews were recorded and transcribed, and transcriptions subjected to thematic analysis and coding to quantify the challenges discussed. FINDINGS There was remarkable consistency in the challenges described by both groups of participants, with eight predominant challenges identified: time constraints and chaotic environments, rapport building, patient characteristics, reluctance, omissions, assumptions, decision-making, and keeping conversations focused. INSIGHTS Medical curricula often focus on communication challenges associated with complex or sensitive clinical situations, but many of the challenges identified occur in routine consultations. Both pre-service and post-graduate medical training should adopt strategies to help build students' and clinicians' skills in managing these challenges from the outset of training.
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Affiliation(s)
- Conor Gilligan
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sonja P Brubacher
- Centre for Investigative Interviewing, Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia
| | - Martine B Powell
- Centre for Investigative Interviewing, Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia
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15
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Representation, interaction and interpretation. Making sense of the context in clinical reasoning. MEDICAL EDUCATION 2022; 56:98-109. [PMID: 33932248 DOI: 10.1111/medu.14545] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/06/2021] [Accepted: 04/26/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised. AIMS Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning. DISCUSSION We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning. CONCLUSION The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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16
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Schauber SK, Hautz SC, Kämmer JE, Stroben F, Hautz WE. Do different response formats affect how test takers approach a clinical reasoning task? An experimental study on antecedents of diagnostic accuracy using a constructed response and a selected response format. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:1339-1354. [PMID: 33977409 PMCID: PMC8452553 DOI: 10.1007/s10459-021-10052-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 05/03/2021] [Indexed: 06/01/2023]
Abstract
The use of response formats in assessments of medical knowledge and clinical reasoning continues to be the focus of both research and debate. In this article, we report on an experimental study in which we address the question of how much list-type selected response formats and short-essay type constructed response formats are related to differences in how test takers approach clinical reasoning tasks. The design of this study was informed by a framework developed within cognitive psychology which stresses the importance of the interplay between two components of reasoning-self-monitoring and response inhibition-while solving a task or case. The results presented support the argument that different response formats are related to different processing behavior. Importantly, the pattern of how different factors are related to a correct response in both situations seem to be well in line with contemporary accounts of reasoning. Consequently, we argue that when designing assessments of clinical reasoning, it is crucial to tap into the different facets of this complex and important medical process.
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Affiliation(s)
- Stefan K Schauber
- Centre for Health Sciences Education, Faculty of Medicine, University of Oslo, Postboks 1161 Blindern, 0318, Oslo, Norway.
| | - Stefanie C Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Berne, 3010, Freiburgstrasse, Berne, Switzerland
| | - Juliane E Kämmer
- Center for Adaptive Rationality (ARC), Max Planck Institute for Human Development, Lentzeallee 94, 14195, Berlin, Germany
- AG Progress Test Medizin, Charité Medical School Berlin, Hannoversche Straße 19, 10115, Berlin, Germany
| | - Fabian Stroben
- AG Progress Test Medizin, Charité Medical School Berlin, Hannoversche Straße 19, 10115, Berlin, Germany
- Office of the Vice Dean for Teaching and Learning, Charité Universitätsmedizin, Berlin, Germany
| | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Berne, 3010, Freiburgstrasse, Berne, Switzerland
- Centre for Educational Measurement (CEMO), University of Oslo, Postboks 1161 Blindern, 0318, Oslo, Norway
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17
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Task Switching, Multitasking, and Errors: A Psychologic Perspective on the Impact of Interruptions. Ann Emerg Med 2021; 78:425-428. [PMID: 34420555 DOI: 10.1016/j.annemergmed.2021.07.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Indexed: 11/21/2022]
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18
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Chou FL, Abramson D, DiMaggio C, Hoven CW, Susser E, Andrews HF, Chihuri S, Lang BH, Ryan M, Herman D, Susser I, Mascayano F, Li G. Factors Related to Self-Reported Distress Experienced by Physicians During Their First COVID-19 Triage Decisions. Disaster Med Public Health Prep 2021; 16:1-8. [PMID: 34096486 PMCID: PMC8314063 DOI: 10.1017/dmp.2021.170] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/11/2021] [Accepted: 05/19/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of this study was to identify factors associated with distress experienced by physicians during their first coronavirus disease 2019 (COVID-19) triage decisions. METHODS An online survey was administered to physicians licensed in New York State. RESULTS Of the 164 physicians studied, 20.7% experienced severe distress during their first COVID-19 triage decisions. The mean distress score was not significantly different between physicians who received just-in-time training and those who did not (6.0 ± 2.7 vs 6.2 ± 2.8; P = 0.550) and between physicians who received clinical guidelines and those who did not (6.0 ± 2.9 vs 6.2 ± 2.7; P = 0.820). Substantially increased odds of severe distress were found in physicians who reported that their first COVID-19 triage decisions were inconsistent with their core values (adjusted odds ratio, 6.33; 95% confidence interval, 2.03-19.76) and who reported having insufficient skills and expertise (adjusted odds ratio 2.99, 95% confidence interval 0.91-9.87). CONCLUSION Approximately 1 in 5 physicians in New York experienced severe distress during their first COVID-19 triage decisions. Physicians with insufficient skills and expertise, and core values misaligned to triage decisions are at heightened risk of experiencing severe distress. Just-in-time training and clinical guidelines do not appear to alleviate distress experienced by physicians during their first COVID-19 triage decisions.
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Affiliation(s)
- Francisca L. Chou
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - David Abramson
- Program on Population Impact, Recovery and Resilience; School of Global Public Health, New York University, New York, New York, USA
| | - Charles DiMaggio
- Departments of Surgery and Population Health Science, New York University Langone Medical Center, New York, New York, USA
| | - Christina W. Hoven
- New York State Psychiatric Institute, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Ezra Susser
- New York State Psychiatric Institute, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Howard F. Andrews
- New York State Psychiatric Institute, New York, New York, USA
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Stanford Chihuri
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Barbara H. Lang
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Megan Ryan
- New York State Psychiatric Institute, New York, New York, USA
| | - Daniel Herman
- Silberman School of Social Work, City University of New York, New York, New York, USA
| | - Ida Susser
- Hunter College, City University of New York, New York, New York, USA
| | - Franco Mascayano
- New York State Psychiatric Institute, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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19
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Unravelling the polyphony in clinical reasoning research in medical education. J Eval Clin Pract 2021; 27:438-450. [PMID: 32573080 DOI: 10.1111/jep.13432] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 11/27/2022]
Abstract
RATIONALE Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion. AIMS AND OBJECTIVES We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses. METHODS A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review. RESULTS A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described. CONCLUSIONS Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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20
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Armendariz J, Tamayo C, Slade J, Belitskaya-Lévy I, Gray C, Allaudeen N. Interruptions to Attending Physician Rounds and Their Effect on Resident Education. J Grad Med Educ 2021; 13:266-275. [PMID: 33897961 PMCID: PMC8054601 DOI: 10.4300/jgme-d-20-00698.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/15/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Daily attending rounds (AR) are a cornerstone of teaching and patient care in academic health centers. Interruptions in health care are common and can cause increased risk of errors, incomplete work, and decreased decision-making accuracy. Interruptions to AR may diminish a trainee's capacity to learn and retain information. OBJECTIVE We characterized and quantified interruptions that occur during AR. METHODS We used a mixed-methods design combining a prospective observational study with a qualitative study. AR were observed January to March 2020 to characterize interruptions, followed by semi-structured interviews with the observed physicians to elucidate the effect of interruptions on workflow and the educational value of rounds. RESULTS There were 378 observed interruptions over the course of 30 AR sessions, averaging 12.6 (range 1-22, median 13) interruptions per rounding session. Bedside nursing staff was the most common source of interruptions (25%) and consultant recommendations was the most common topic of interruption (21%). Most interruptions occurred during patient presentations (76%), and the most common method of interaction was text message (24%). Most team members described negative effects of interruptions, including loss of focus and missing critical clinical information; some also reported that certain interruptions had positive effects on education and clinical care. Interns were more likely to report negative emotional reactions to interruptions. CONCLUSIONS AR are frequently interrupted for non-urgent topics by a variety of methods and sources. Negative effects included loss of focus, missed information, and increased stress. Proactive communication, particularly between physicians and nurses, was suggested to reduce interruptions.
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Affiliation(s)
- Julia Armendariz
- At the time of research, Julia Armendariz, MD, was an Internal Medicine Resident, Department of Medicine, Stanford University, and is now an Internal Medicine Physician, Veterans Affairs Palo Alto Health Care System
| | - Carla Tamayo
- At the time of research, Carla Tamayo, MD, was an Internal Medicine Resident, Department of Medicine, Stanford University, and is now an Internal Medicine Physician, San Juan, Puerto Rico
| | - Justin Slade
- At the time of research, Justin Slade, MD, was Physician Scholar in Quality and Patient Safety, Medical Service, Veterans Affairs Palo Alto Health Care System, and is now a Cardiology Fellow, Department of Cardiology, The Permanente Medical Group, San Francisco
| | - Ilana Belitskaya-Lévy
- Ilana Belitskaya-Lévy, PhD, is a Biostatistician, Cooperative Studies Program Coordinating Center, Veterans Affairs Palo Alto Health Care System
| | - Caroline Gray
- Caroline Gray, PhD, is Research Sociologist, Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System
| | - Nazima Allaudeen
- Nazima Allaudeen, MD, is Assistant Professor (Affiliated), Stanford School of Medicine, and Director of Quality Improvement, Inpatient Medicine, Veterans Affairs Palo Alto Health Care System
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Gopal DP, Chetty U, O'Donnell P, Gajria C, Blackadder-Weinstein J. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J 2021; 8:40-48. [PMID: 33791459 DOI: 10.7861/fhj.2020-0233] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bias is the evaluation of something or someone that can be positive or negative, and implicit or unconscious bias is when the person is unaware of their evaluation. This is particularly relevant to policymaking during the coronavirus pandemic and racial inequality highlighted during the support for the Black Lives Matter movement. A literature review was performed to define bias, identify the impact of bias on clinical practice and research as well as clinical decision making (cognitive bias). Bias training could bridge the gap from the lack of awareness of bias to the ability to recognise bias in others and within ourselves. However, there are no effective debiasing strategies. Awareness of implicit bias must not deflect from wider socio-economic, political and structural barriers as well ignore explicit bias such as prejudice.
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Affiliation(s)
- Dipesh P Gopal
- Barts and The London School of Medicine and Dentistry, London, UK
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22
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Augenstein T, Schneider A, Wehler M, Weigl M. Multitasking behaviors and provider outcomes in emergency department physicians: two consecutive, observational and multi-source studies. Scand J Trauma Resusc Emerg Med 2021; 29:14. [PMID: 33413575 PMCID: PMC7792086 DOI: 10.1186/s13049-020-00824-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022] Open
Abstract
Background Multitasking is a key skill for emergency department (ED) providers. Yet, potentially beneficial or debilitating effects for provider functioning and cognition are underexplored. We therefore aimed to investigate the role of multitasking for ED physicians’ work stress and situation awareness (SA). Methods Two consecutive, multi-source studies utilizing standardized expert observations in combination with physicians’ self-reports on stress and SA were set out in an academic ED. To control for ED workload, measures of patient acuity, patient counts, and ED staff on duty were included. Regression analyses estimated associations between observed proportion of time spent in multitasking with matched ED physicians’ reports on stress (study 1) and SA (study 2). Results ED physicians engaged between 18.7% (study 1) and 13.0% (study 2) of their worktime in multitasking. Self-reported as well as expert-observed multitasking were significantly associated. This confirms the internal validity of our observational approach. After controlling for ED workload, we found that physicians who engaged more frequently in multitasking perceived higher work stress (Beta = .02, 95%CI .001–.03; p = .01). In study 2, ED physicians with more frequent multitasking behaviors reported higher SA (B = .08, 95%CI .02–.14; p = .009). Conclusions Multitasking is often unavoidable in ED care. Our findings suggest that ED physicians’ multitasking increases stress experiences, yet, may facilitate professional’s experiences of situation awareness. Our results warrant further investigation into potentially ambivalent effects of ED providers’ multitasking in effectively sharing time between competing demands while maintaining performance and safety.
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Affiliation(s)
- Tobias Augenstein
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany.,Department of Emergency Medicine and Department of General, Visceral and Trauma Surgery, Academic Hospital Porz am Rhein, Urbacher Weg 19, 51149, Cologne, Germany
| | - Anna Schneider
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany.,Institute of Medical Sociology and Rehabilitation Science, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Markus Wehler
- Department of Emergency Medicine and Department of Medicine IV, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany. .,Institute for Patient Safety, University Hospital Bonn, Bonn, Germany.
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Wendt DJ, Tyson G. Diagnostic Accuracy in Australian Psychologists: Impact of Experience and Endorsement on the Anchoring Effect. AUSTRALIAN PSYCHOLOGIST 2020. [DOI: 10.1111/ap.12311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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25
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Griffith PB, Doherty C, Smeltzer SC, Mariani B. Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: A scoping review. J Am Assoc Nurse Pract 2020; 33:862-871. [PMID: 32773538 DOI: 10.1097/jxx.0000000000000479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The high prevalence of diagnostic errors by health care providers has prompted medical educators to examine cognitive biases and debiasing strategies in an effort to prevent these errors. The National Academy of Medicine hypothesized that explicit diagnostic reasoning education of all health care professionals can improve diagnostic accuracy. OBJECTIVES The purpose of this scoping review is to identify, analyze, and summarize the existing literature on student health care providers' use of cognitive debiasing strategies to reduce diagnostic error. DATA SOURCES The review was guided by the Joanna Briggs Institute methodology for scoping reviews. A systematic search of PubMed, CINAHL, PsychINFO, and Scopus databases for debiasing strategies in student provider education yielded 33 studies. CONCLUSIONS The 33 studies included in this review represent four categories of debiasing strategies: increased medical knowledge or experience (seven studies), guided reflection (eight studies), self-explanation of reasoning (nine studies), and checklists to expand diagnosis considerations (seven studies). The studies were inclusive of medical students and residents; no studies included nurse practitioner (NP) students. Guided reflection, the most clearly defined and implemented strategy, showed the most promise for improvement of diagnostic accuracy. Educational interventions were wide ranging in content and delivery but did yield a path for future research. IMPLICATIONS FOR PRACTICE There are myriad debiasing strategies student providers may use to mitigate cognitive bias. Structured reflection and education initiatives demonstrated the most consistent improvements in diagnostic accuracy. Future studies on debiasing strategies must include NP students to understand their response to these initiatives.
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Affiliation(s)
- Patricia B Griffith
- Biobehavioral Health Sciences Department, Adult Gerontology Acute Care Nurse Practitioner Program, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Caroline Doherty
- Biobehavioral Health Sciences Department, Adult Gerontology Acute Care Nurse Practitioner Program, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Suzanne C Smeltzer
- Richard and Marianne Kreider Endowed Professor in nursing for vulnerable populations, M. Louise Fitzpatrick College of Nursing, Center for Nursing Research, Villanova University, Villanova, Pennsylvania
| | - Bette Mariani
- M. Louise Fitzpatrick College of Nursing, Vice Dean for Academic Affairs, Villanova University, Villanova, Pennsylvania
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Chan TM, Mercuri M, Turcotte M, Gardiner E, Sherbino J, de Wit K. Making Decisions in the Era of the Clinical Decision Rule: How Emergency Physicians Use Clinical Decision Rules. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1230-1237. [PMID: 31789846 DOI: 10.1097/acm.0000000000003098] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Physicians are often asked to integrate clinical decision rules (CDRs) with their own cognitive processes to reach a diagnosis. Clinicians, researchers, and educators must understand these cognitive processes to evaluate and improve the diagnostic process. The authors sought to explore emergency physicians' diagnostic processes and to examine how they integrated CDRs into their reasoning using simulated cases (with chest pain or leg pain). METHOD From August 2015 to July 2016, 16 practicing emergency physicians from 3 teaching hospitals associated with McMaster University, Ontario, Canada, were interviewed via a novel "teach aloud" protocol. Six videos of simulated patients with chest pain, breathlessness, or leg discomfort were used as prompts for the physicians to demonstrate their diagnostic thinking. Using a constructivist grounded theory analysis, 3 investigators independently reviewed the interview transcripts, meeting regularly to discuss identified themes and subthemes until sufficiency was reached. RESULTS A model to describe how clinicians integrate their own decision making with CDRs was developed, showing that physicians engage in an iterative diagnostic process that repeatedly refines the differential diagnosis list. The steps in the diagnostic process were: refinement of the differential diagnosis, ordering a hierarchy of risk, the decision to test, choosing the tests, and interpreting test results. Physicians applied CDRs when they had already decided to test. CONCLUSIONS To date, CDRs assume a static, linear model of clinical decision making. Findings demonstrate that participants engaged in iterative and dynamic decision-making processes that changed throughout their patient encounter, contingent on multiple contextual features. Understanding these processes could inform future development of CDRs and educational strategies around these decision aids.
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Affiliation(s)
- Teresa M Chan
- T.M. Chan is associate professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, assistant dean, Program for Faculty Development, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada, and adjunct scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- M. Mercuri is assistant professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, and senior research associate, African Centre for Epistemology and Philosophy of Science, Department of Philosophy, University of Johannesburg, Johannesburg, South Africa
| | - Michelle Turcotte
- M. Turcotte is a medical student, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Emily Gardiner
- E. Gardiner is resident physician, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jonathan Sherbino
- J. Sherbino is professor, Division of Emergency Medicine, Department of Medicine, and assistant dean, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada
| | - Kerstin de Wit
- K. de Wit is assistant professor, Division of Emergency Medicine, Department of Medicine, and associate professor, Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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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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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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29
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Gossack‐Keenan K, De Wit K, Gardiner E, Turcotte M, Chan TM. Showing Your Thinking: Using Mind Maps to Understand the Gaps Between Experienced Emergency Physicians and Their Students. AEM EDUCATION AND TRAINING 2020; 4:54-63. [PMID: 31989071 PMCID: PMC6965674 DOI: 10.1002/aet2.10379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/17/2019] [Accepted: 07/17/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Clinical teaching faculty rely on schemas for diagnosis. When they attempt to teach medical students, there may be a gap in the interpretation because the students do not have the same schemas. The aim of this analysis was to explore expert thinking processes through mind maps, to help determine the gaps between an expert's mind map of their diagnostic thinking and how students interpret this teaching artifact. METHODS A novel mind-mapping approach was used to examine how emergency physicians (EPs) explain their clinical reasoning schemas. Nine EPs were shown two different videos of a student interviewing a patient with possible venous thromboembolism. EPs were then asked to explain their diagnostic approach using a mind map, as if they were thinking to a student. Later, another medical student interviewed the EPs to clarify the mind map and revise as needed. A coding framework was generated to determine the discrepancy between the EP-generated mind map and the novice's interpretation. RESULTS Every mind map (18 mind maps from nine individuals) contained some discrepancy between the expert's mind and novice's interpretation. From the qualitative analysis of the changes between the originally created mind map and the later revision, the authors developed a conceptual framework describing types of amendments that students might expect teachers to make in their mind maps: 1) substantive amendments, such as incomplete mapping; and 2) clarifications, such as the need to explain background for a mind map element. CONCLUSION Emergency physician teachers tend to make jumps in reasoning, most commonly including incomplete mapping and maps requiring clarifications. Educating EPs on these processes will allow modification of their teaching modalities to better suit learners.
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Affiliation(s)
| | - Kerstin De Wit
- Division of Emergency MedicineDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Emily Gardiner
- Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Michelle Turcotte
- Rady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Teresa M. Chan
- Division of Emergency MedicineDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
- MD ProgramUniversity of OttawaOttawaOntarioCanada
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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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Roosan D, Law AV, Karim M, Roosan M. Improving Team-Based Decision Making Using Data Analytics and Informatics: Protocol for a Collaborative Decision Support Design. JMIR Res Protoc 2019; 8:e16047. [PMID: 31774412 PMCID: PMC6906625 DOI: 10.2196/16047] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 01/25/2023] Open
Abstract
Background According to the September 2015 Institute of Medicine report, Improving Diagnosis in Health Care, each of us is likely to experience one diagnostic error in our lifetime, often with devastating consequences. Traditionally, diagnostic decision making has been the sole responsibility of an individual clinician. However, diagnosis involves an interaction among interprofessional team members with different training, skills, cultures, knowledge, and backgrounds. Moreover, diagnostic error is prevalent in the interruption-prone environment, such as the emergency department, where the loss of information may hinder a correct diagnosis. Objective The overall purpose of this protocol is to improve team-based diagnostic decision making by focusing on data analytics and informatics tools that improve collective information management. Methods To achieve this goal, we will identify the factors contributing to failures in team-based diagnostic decision making (aim 1), understand the barriers of using current health information technology tools for team collaboration (aim 2), and develop and evaluate a collaborative decision-making prototype that can improve team-based diagnostic decision making (aim 3). Results Between 2019 to 2020, we are collecting data for this study. The results are anticipated to be published between 2020 and 2021. Conclusions The results from this study can shed light on improving diagnostic decision making by incorporating diagnostics rationale from team members. We believe a positive direction to move forward in solving diagnostic errors is by incorporating all team members, and using informatics. International Registered Report Identifier (IRRID) DERR1-10.2196/16047
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Affiliation(s)
- Don Roosan
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Anandi V Law
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Mazharul Karim
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Moom Roosan
- Chapman University, School of Pharmacy, Irvine, CA, United States
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A Scoping Review of Physicians' Clinical Reasoning in Emergency Departments. Ann Emerg Med 2019; 75:206-217. [PMID: 31474478 DOI: 10.1016/j.annemergmed.2019.06.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Clinical reasoning is considered a core competency of physicians. Yet there is a paucity of research on clinical reasoning specifically in emergency medicine, as highlighted in the literature. METHODS We conducted a scoping review to examine the state of research on clinical reasoning in this specialty. Our team, composed of content and methodological experts, identified 3,763 articles in the literature, 95 of which were included. RESULTS Most studies were published after 2000. Few studies focused on the cognitive processes involved in decisionmaking (ie, clinical reasoning). Of these, many confirmed findings from the general literature on clinical reasoning; specifically, the role of both intuitive and analytic processes. We categorized factors that influence decisionmaking into contextual, patient, and physician factors. Many studies focused on decisions in regard to investigations and admission. Test ordering is influenced by physicians' experience, fear of litigation, and concerns about malpractice. Fear of litigation and malpractice also increases physicians' propensity to admit patients. Context influences reasoning but findings pertaining to specific factors, such as patient flow and workload, were inconsistent. CONCLUSION Many studies used designs such as descriptive or correlational methods, limiting the strength of findings. Many gray areas persist, in which studies are either scarce or yield conflicting results. The findings of this scoping review should encourage us to intensify research in the field of emergency physicians' clinical reasoning, particularly on the cognitive processes at play and the factors influencing them, using appropriate theoretical frameworks and more robust methods.
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Kilian M, Sherbino J, Hicks C, Monteiro SD. Understanding diagnosis through ACTion: evaluation of a point-of-care checklist for junior emergency medical residents. ACTA ACUST UNITED AC 2019; 6:151-156. [PMID: 30990784 DOI: 10.1515/dx-2018-0073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 03/22/2019] [Indexed: 11/15/2022]
Abstract
Background Avoiding or correcting a diagnostic error first requires identification of an error and perhaps deciding to revise a diagnosis, but little is known about the factors that lead to revision. Three aspects of reflective practice, seeking Alternative explanations, exploring the Consequences of missing these alternative diagnoses, identifying Traits that may contradict the provisional diagnosis, were incorporated into a three-point diagnostic checklist (abbreviated to ACT). Methods Seventeen first and second year emergency medicine residents from the University of Toronto participated. Participants read up to eight case vignettes and completed the ACT diagnostic checklist. Provisional and final diagnoses and all responses for alternatives, consequences, and traits were individually scored as correct or incorrect. Additionally, each consequence was scored on a severity scale from 0 (not severe) to 3 (very severe). Average scores for alternatives, consequences, and traits and the severity rating for each consequence were entered into a binary logistic regression analysis with the outcome of revised or retained provisional diagnosis. Results Only 13% of diagnoses were revised. The binary logistic regression revealed that three scores derived from the ACT tool responses were associated with the decision to revise: severity rating of the consequence for missing the provisional diagnosis, the percent correct for identifying consequences, and the percent correct for identifying traits (χ2 = 23.5, df = 6, p < 0.001). The other three factors were not significant predictors. Conclusions Decisions to revise diagnoses may be cued by the detection of contradictory evidence. Education interventions may be more effective at reducing diagnostic error by targeting the ability to detect contradictory information within patient cases.
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Affiliation(s)
- Michael Kilian
- Division of Emergency Medicine, North York General Hospital, Toronto, ON, Canada
| | - Jonathan Sherbino
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.,McMaster Faculty of Health Sciences Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
| | - Christopher Hicks
- Division of Emergency Medicine, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sandra D Monteiro
- McMaster Faculty of Health Sciences Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 5th Floor, 5002 A/E, Hamilton, ON L8S 4L8, Canada
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Daniel M, Rencic J, Durning SJ, Holmboe E, Santen SA, Lang V, Ratcliffe T, Gordon D, Heist B, Lubarsky S, Estrada CA, Ballard T, Artino AR, Sergio Da Silva A, Cleary T, Stojan J, Gruppen LD. Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:902-912. [PMID: 30720527 DOI: 10.1097/acm.0000000000002618] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore the existing menu of CR assessments. METHOD Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were sorted by assessment methods and reviewed by pairs of authors. Extracted data were used to construct descriptive appendixes, summarizing each method, including common stimuli, response formats, scoring, typical uses, validity considerations, feasibility issues, advantages, and disadvantages. RESULTS A total of 377 articles were included in the final synthesis. The articles broadly fell into three categories: non-workplace-based assessments (e.g., multiple-choice questions, extended matching questions, key feature examinations, script concordance tests); assessments in simulated clinical environments (objective structured clinical examinations and technology-enhanced simulation); and workplace-based assessments (e.g., direct observations, global assessments, oral case presentations, written notes). Validity considerations, feasibility issues, advantages, and disadvantages differed by method. CONCLUSIONS There are numerous assessment methods that align with different components of the complex construct of CR. Ensuring competency requires the development of programs of assessment that address all components of CR. Such programs are ideally constructed of complementary assessment methods to account for each method's validity and feasibility issues, advantages, and disadvantages.
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Affiliation(s)
- Michelle Daniel
- M. Daniel is assistant dean for curriculum and associate professor of emergency medicine and learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: http://orcid.org/0000-0001-8961-7119. J. Rencic is associate program director of the internal medicine residency program and associate professor of medicine, Tufts University School of Medicine, Boston, Massachusetts; ORCID: http://orcid.org/0000-0002-2598-3299. S.J. Durning is director of graduate programs in health professions education and professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland. E. Holmboe is senior vice president of milestone development and evaluation, Accreditation Council for Graduate Medical Education, and adjunct professor of medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0003-0108-6021. S.A. Santen is senior associate dean and professor of emergency medicine, Virginia Commonwealth University, Richmond, Virginia; ORCID: http://orcid.org/0000-0002-8327-8002. V. Lang is associate professor of medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York; ORCID: http://orcid.org/0000-0002-2157-7613. T. Ratcliffe is associate professor of medicine, University of Texas Long School of Medicine at San Antonio, San Antonio, Texas. D. Gordon is medical undergraduate education director, associate residency program director of emergency medicine, and associate professor of surgery, Duke University School of Medicine, Durham, North Carolina. B. Heist is clerkship codirector and assistant professor of medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. S. Lubarsky is assistant professor of neurology, McGill University, and faculty of medicine and core member, McGill Center for Medical Education, Montreal, Quebec, Canada; ORCID: http://orcid.org/0000-0001-5692-1771. C.A. Estrada is staff physician, Birmingham Veterans Affairs Medical Center, and director, Division of General Internal Medicine, and professor of medicine, University of Alabama, Birmingham, Alabama; ORCID: https://orcid.org/0000-0001-6262-7421. T. Ballard is plastic surgeon, Ann Arbor Plastic Surgery, Ann Arbor, Michigan. A.R. Artino Jr is deputy director for graduate programs in health professions education and professor of medicine, preventive medicine, and biometrics pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: http://orcid.org/0000-0003-2661-7853. A. Sergio Da Silva is senior lecturer in medical education and director of the masters in medical education program, Swansea University Medical School, Swansea, United Kingdom; ORCID: http://orcid.org/0000-0001-7262-0215. T. Cleary is chair, Applied Psychology Department, CUNY Graduate School and University Center, New York, New York, and associate professor of applied and professional psychology, Rutgers University, New Brunswick, New Jersey. J. Stojan is associate professor of internal medicine and pediatrics, University of Michigan Medical School, Ann Arbor, Michigan. L.D. Gruppen is director of the master of health professions education program and professor of learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: http://orcid.org/0000-0002-2107-0126
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Soares WE, Price LL, Prast B, Tarbox E, Mader TJ, Blanchard R. Accuracy Screening for ST Elevation Myocardial Infarction in a Task-switching Simulation. West J Emerg Med 2019; 20:177-184. [PMID: 30643622 PMCID: PMC6324702 DOI: 10.5811/westjem.2018.10.39962] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/04/2018] [Accepted: 10/30/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Interruptions in the emergency department (ED) are associated with clinical errors, yet are important when providing care to multiple patients. Screening triage electrocardiograms (ECG) for ST-segment elevation myocardial infarction (STEMI) represent a critical interrupting task that emergency physicians (EP) frequently encounter. To address interruptions such as ECG interpretation, many EPs engage in task switching, pausing their primary task to address an interrupting task. The impact of task switching on clinical errors in interpreting screening ECGs for STEMI remains unknown. METHODS Resident and attending EPs were invited to participate in a crossover simulation trial. Physicians first completed a task-switching simulation in which they viewed patient presentations interrupted by clinical tasks, including screening ECGs requiring immediate interpretation before resuming the patient presentation. Participants then completed an uninterrupted simulation in which patient presentations and clinical tasks were completed sequentially without interruption. The primary outcome was accuracy of ECG interpretation for STEMI during task switching and uninterrupted simulations. RESULTS Thirty-five participants completed the study. We found no significant difference in accuracy of ECG interpretation for STEMI (task switching 0.89, uninterrupted 0.91, paired t-test p=0.21). Attending physician status (odds ratio [OR] [2.56], confidence interval [CI] [1.66-3.94], p<0.01) and inferior STEMI (OR [0.08], CI [0.04-0.14], p<0.01) were associated with increased and decreased odds of correct interpretation, respectively. Low self-reported confidence in interpretation was associated with decreased odds of correct interpretation in the task-switching simulation, but not in the uninterrupted simulation (interaction p=0.02). CONCLUSION In our simulation, task switching was not associated with overall accuracy of ECG interpretation for STEMI. However, odds of correct interpretation decreased with inferior STEMI ECGs and when participants self-reported low confidence when interrupted. Our study highlights opportunities to improve through focused ECG training, as well as self-identification of "high-risk" screening ECGs prone to error during interrupted clinical workflow.
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Affiliation(s)
- William E. Soares
- University of Massachusetts Medical School-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Lori L. Price
- Clinical and Translational Science Institute, Tufts Medical Center and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center Boston, Massachusetts
| | - Brendan Prast
- University of Massachusetts Medical School-Baystate, Academic Affairs, Springfield Massachusetts
| | - Elizabeth Tarbox
- University of Massachusetts Medical School-Baystate, Academic Affairs, Springfield Massachusetts
| | - Timothy J. Mader
- University of Massachusetts Medical School-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Rebecca Blanchard
- University of Massachusetts Medical School-Baystate, Academic Affairs, Springfield Massachusetts
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36
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Schnapp BH, Sun JE, Kim JL, Strayer RJ, Shah KH. Cognitive error in an academic emergency department. ACTA ACUST UNITED AC 2018; 5:135-142. [PMID: 30016277 DOI: 10.1515/dx-2018-0011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/18/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Medical error is a leading cause of death nationwide. While systems issues have been closely investigated as a contributor to error, little is known about the cognitive factors that contribute to diagnostic error in an emergency department (ED) environment.
Methods
Eight months of patient revisits within 72 h where patients were admitted on their second visit were examined. Fifty-two cases of confirmed error were identified and classified using a modified version of the Australian Patient Safety Foundation classification system for medical errors by a group of trained physicians.
Results
Faulty information processing was the most frequently identified category of error (45% of cases), followed by faulty verification (31%). Faulty knowledge (6%) and faulty information gathering (18%) occurred relatively infrequently. “Misjudging the salience of a finding” and “premature closure” were the individual errors that occurred most frequently (13%).
Conclusions
Despite the complex nature of diagnostic reasoning, cognitive errors of information processing appear to occur at higher rates than other errors, and in a similar pattern to an internal medicine service despite a different clinical environment. Further research is needed to elucidate why these errors occur and how to mitigate them.
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Affiliation(s)
- Benjamin H Schnapp
- University of Wisconsin, BerbeeWalsh Department of Emergency Medicine, 800 University Bay Drive, Madison, WI 53705, USA
| | - Jean E Sun
- The Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
| | - Jeremy L Kim
- St. David's South Austin Medical Center, Department of Emergency Medicine, Austin, TX, USA
| | - Reuben J Strayer
- Maimonidies Medical Center, Department of Emergency Medicine, New York, NY, USA
| | - Kaushal H Shah
- The Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
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ALQahtani DA, Rotgans JI, Mamede S, Mahzari MM, Al-Ghamdi GA, Schmidt HG. Factors underlying suboptimal diagnostic performance in physicians under time pressure. MEDICAL EDUCATION 2018; 52:1288-1298. [PMID: 30302783 DOI: 10.1111/medu.13686] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/08/2018] [Accepted: 07/04/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT Time pressure has been implicated in the suboptimal diagnostic performance of doctors and in increases in diagnostic errors. However, the reasons underlying these effects are not clear. The aim of this study was to investigate the influence of time pressure on physicians' diagnostic accuracy and to explore the mediating effects of perceived stress (emotional pathway) and number of plausible diagnostic hypotheses (cognitive pathway) on the proposed relationship. METHODS We conducted a randomised controlled experiment. A total of 75 senior internal medicine residents completed eight written clinical cases under conditions with (n = 40) or without (n = 35) time pressure. They were then asked to: (i) rate the overall stress experienced, and (ii) write down any alternative hypotheses they had thought of when diagnosing the cases. In a post hoc analysis, a mediation path analysis was performed to test the causal relationships between time pressure, perceived stress and number of alternative diagnoses. RESULTS Participants who were under time pressure spent less time diagnosing the cases (85.54 seconds versus 181.81 seconds; p< 0.001) and had a lower mean diagnostic accuracy score (0.44 versus 0.53; p = 0.01). In addition, they reported more stress (5.80 versus 4.69; p = 0.01) and generated fewer plausible tentative hypotheses (0.37 versus 0.51; p = 0.01). Two path coefficients were found to be statistically significant; the first path coefficient referred to the relationship between time pressure and perceived stress (standardised β = 0.25, p = 0.029), and the second negative path coefficient referred to the relationship between time pressure and number of plausible alternative hypotheses (standardised β = -0.32, p< 0.01). CONCLUSIONS Time pressure adversely influences physicians' diagnostic accuracy by increasing their stress response and reducing the number of plausible hypotheses as mediators.
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Affiliation(s)
- Dalal A ALQahtani
- Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
| | - Jerome I Rotgans
- Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Silvia Mamede
- Department of Psychology, Erasmus Medical Centre, Institute of Medical Education Research Rotterdam, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Moeber M Mahzari
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghassan A Al-Ghamdi
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Henk G Schmidt
- Department of Psychology, Erasmus University Rotterdam, Rotterdam, the Netherlands
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Rosby LV, Rotgans JI, Tan G, Low-Beer N, Mamede S, Zwaan L, Schmidt H. Inducing System-1-type diagnostic reasoning in second-year medical students within 15 minutes. MEDICAL TEACHER 2018; 40:1030-1035. [PMID: 29421975 DOI: 10.1080/0142159x.2017.1418502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Purpose: Diagnostic reasoning literature debates the significance of "dual-process theory" and the importance of its constituent types of thinking: System-1and System-2. This experimental study aimed to determine whether novice medical students could be trained to utilize System-1 thinking when making diagnoses based on chest X-rays. Method: Second-year medical students were recruited and presented with a series of eight online chest X-rays cases. Participants were shown half of the cases repeatedly during a training phase and the other half only twice. During the final test phase, they were shown all eight cases, providing a diagnosis as a free text answer. Dependent variables were diagnostic accuracy and response time. Results: Thirty-two students participated. During the test phase, students responses were significantly more accurate and faster for cases which had been seen repeatedly during the training phase (mean score = 3.56/4, mean time = 2.34 s) compared with cases which had been seen only twice (mean score = 1.59/4, mean time = 7.50 s). Conclusion: This study demonstrates that it is possible to induce in novice students the speed-to-diagnosis and diagnostic accuracy typical of System-1-type reasoning. The full experimental design and the chest X-rays used may provide new opportunities to explore some of the issues surrounding dual-process theory.
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Affiliation(s)
- Lucy Victoria Rosby
- a Office of Medical Education, Lee Kong Chian School of Medicine , Nanyang Technological University , Singapore , Singapore
| | - Jerome I Rotgans
- b Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine , Nanyang Technological University , Singapore , Singapore
| | - Gerald Tan
- a Office of Medical Education, Lee Kong Chian School of Medicine , Nanyang Technological University , Singapore , Singapore
- c Department of Diagnostic Radiology , Tan Tock Seng Hospital , Singapore , Singapore
| | - Naomi Low-Beer
- a Office of Medical Education, Lee Kong Chian School of Medicine , Nanyang Technological University , Singapore , Singapore
| | - Silvia Mamede
- d Institute of Medical Education Research Rotterdam , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Laura Zwaan
- d Institute of Medical Education Research Rotterdam , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Henk Schmidt
- e Department of Psychology , Erasmus University Rotterdam , Rotterdam , The Netherlands
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Wright B, Martin GP, Ahmed A, Banerjee J, Mason S, Roland D. How the Availability of Observation Status Affects Emergency Physician Decisionmaking. Ann Emerg Med 2018; 72:401-409. [PMID: 29880439 DOI: 10.1016/j.annemergmed.2018.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 02/17/2018] [Accepted: 04/19/2018] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians' subsequent decisionmaking. METHODS We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding. RESULTS We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician's individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty. CONCLUSION Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, University of Iowa, Iowa City, IA.
| | - Graham P Martin
- SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jay Banerjee
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Damian Roland
- Pediatric Emergency Medicine Academic Group, University Hospitals of Leicester NHS Trust, Leicester, UK
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Monteiro S, Norman G, Sherbino J. The 3 faces of clinical reasoning: Epistemological explorations of disparate error reduction strategies. J Eval Clin Pract 2018. [PMID: 29532584 DOI: 10.1111/jep.12907] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
There is general consensus that clinical reasoning involves 2 stages: a rapid stage where 1 or more diagnostic hypotheses are advanced and a slower stage where these hypotheses are tested or confirmed. The rapid hypothesis generation stage is considered inaccessible for analysis or observation. Consequently, recent research on clinical reasoning has focused specifically on improving the accuracy of the slower, hypothesis confirmation stage. Three perspectives have developed in this line of research, and each proposes different error reduction strategies for clinical reasoning. This paper considers these 3 perspectives and examines the underlying assumptions. Additionally, this paper reviews the evidence, or lack of, behind each class of error reduction strategies. The first perspective takes an epidemiological stance, appealing to the benefits of incorporating population data and evidence-based medicine in every day clinical reasoning. The second builds on the heuristic and bias research programme, appealing to a special class of dual process reasoning models that theorizes a rapid error prone cognitive process for problem solving with a slower more logical cognitive process capable of correcting those errors. Finally, the third perspective borrows from an exemplar model of categorization that explicitly relates clinical knowledge and experience to diagnostic accuracy.
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Affiliation(s)
- Sandra Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,McMaster (Faculty of Health Sciences Program) Education Research, Innovation and Theory, McMaster University, Hamilton, Ontario, Canada
| | - Geoff Norman
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,McMaster (Faculty of Health Sciences Program) Education Research, Innovation and Theory, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sherbino
- McMaster (Faculty of Health Sciences Program) Education Research, Innovation and Theory, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Chan TM, Mercuri M, Van Dewark K, Sherbino J, Schwartz A, Norman G, Lineberry M. Managing Multiplicity: Conceptualizing Physician Cognition in Multipatient Environments. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:786-793. [PMID: 29210754 DOI: 10.1097/acm.0000000000002081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments. METHOD From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents. RESULTS The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories. CONCLUSIONS The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.
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Affiliation(s)
- Teresa M Chan
- T.M. Chan is assistant professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, program director, Clinician Educator Area of Focused Competence program, and adjunct scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada; ORCID: 0000-0001-6104-462X. M. Mercuri is assistant professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. K. Van Dewark is clinical instructor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada. J. Sherbino is associate professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, and assistant dean of education research, and director, McMaster Education Research, Innovation, and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. A. Schwartz is Michael Reese Endowed Professor of Medical Education, associate head, Department of Medical Education, and research professor, Department of Pediatrics, College of Medicine, University of Illinois at Chicago; ORCID: 0000-0003-3809-6637. G. Norman is professor emeritus, Department of Clinical Epidemiology Biostatistics, and founding member, Program for Education Research and Development, and scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. M. Lineberry is director, Simulation Research, Assessment, and Outcomes, Zamierowski Institute for Experiential Learning, and assistant professor, Department of Health Policy and Management, University of Kansas Medical Center, Kansas City, Kansas
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Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ 2018; 57:203-208. [PMID: 29614188 DOI: 10.3928/01484834-20180322-03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/25/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diagnostic reasoning is often used colloquially to describe the process by which nurse practitioners and physicians come to the correct diagnosis, but a rich definition and description of this process has been lacking in the nursing literature. METHOD A literature review was conducted with theoretical sampling seeking conceptual insight into diagnostic reasoning. RESULTS Four common themes emerged: Cognitive Biases and Debiasing Strategies, the Dual Process Theory, Diagnostic Error, and Patient Harm. Relevant cognitive biases are discussed, followed by debiasing strategies and application of the dual process theory to reduce diagnostic error and harm. CONCLUSION The accuracy of diagnostic reasoning of nurse practitioners may be improved by incorporating these items into nurse practitioner education and practice. [J Nurs Educ. 2018;57(4):203-208.].
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Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf 2017; 26:484-494. [PMID: 27530239 PMCID: PMC5502242 DOI: 10.1136/bmjqs-2016-005401] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/15/2016] [Accepted: 07/13/2016] [Indexed: 12/20/2022]
Abstract
Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.
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Affiliation(s)
- Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Gordon D Schiff
- General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark L Graber
- RTI International, Research Triangle Park, North Carolina, USA
- SUNY Stony Brook School of Medicine, Stony Brook, New York, USA
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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Brush JE, Sherbino J, Norman GR. How Expert Clinicians Intuitively Recognize a Medical Diagnosis. Am J Med 2017; 130:629-634. [PMID: 28238695 DOI: 10.1016/j.amjmed.2017.01.045] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Abstract
Research has shown that expert clinicians make a medical diagnosis through a process of hypothesis generation and verification. Experts begin the diagnostic process by generating a list of diagnostic hypotheses using intuitive, nonanalytic reasoning. Analytic reasoning then allows the clinician to test and verify or reject each hypothesis, leading to a diagnostic conclusion. In this article, we focus on the initial step of hypothesis generation and review how expert clinicians use experiential knowledge to intuitively recognize a medical diagnosis.
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Affiliation(s)
- John E Brush
- Department of Internal Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, Va.
| | - Jonathan Sherbino
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Geoffrey R Norman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Jones J, Wilkins M, Caird J, Kaba A, Cheng A, Ma IWY. An experimental study on the impact of clinical interruptions on simulated trainee performances of central venous catheterization. Adv Simul (Lond) 2017; 2:5. [PMID: 29450006 PMCID: PMC5806486 DOI: 10.1186/s41077-017-0038-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 02/01/2017] [Indexed: 11/23/2022] Open
Abstract
Background Interruptions are common in the healthcare setting. This experimental study compares the effects of interruptions on simulated performances of central venous catheterization during a highly versus minimally complex portion of the task. Methods Twenty-six residents were assigned to interruptions during tasks that are (1) highly complex: establishing ultrasound-guided venous access (experimental group, n = 15) or (2) minimally complex: skin cleansing (control group, n = 11). Primary outcomes were (a) performance scores at three time points measured with a validated checklist, (b) time spent on the respective tasks, and (c) number of attempts to establish venous access. Results Repeated measure analyses of variances of performance scores over time indicated no main effect of time or group. The interaction between time and group was significant: F (2, 44) = 4.28, p = 0.02, and partial eta2 = 0.16, indicating a large effect size. The experimental group scores decreased steadily over time, while the control group scores increased with time. The experimental group required longer to access the vein (148 s; interquartile range (IQR) 60 to 361 vs. 44 s; IQR 27 to 133 s; p = 0.034). Median number of attempts to establish venous access was higher in the experimental group (2, IQR 1–7 vs. 1, IQR 1–2; p = 0.03). Conclusions Interruptions during a highly complex task resulted in a consistent decrement in performance scores, longer time required to perform the task, and a higher number of venous access attempts than interruptions during a minimally complex tasks. We recommend avoiding interrupting trainees performing bedside procedures.
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Affiliation(s)
- Jessica Jones
- 1W21C, University of Calgary, Calgary, Canada.,2Department of Psychology, University of Calgary, Calgary, Canada
| | - Matthew Wilkins
- 1W21C, University of Calgary, Calgary, Canada.,2Department of Psychology, University of Calgary, Calgary, Canada.,3Faculty of Law, University of British Columbia, Vancouver, Canada
| | - Jeff Caird
- 1W21C, University of Calgary, Calgary, Canada.,2Department of Psychology, University of Calgary, Calgary, Canada.,4Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Alyshah Kaba
- 1W21C, University of Calgary, Calgary, Canada.,4Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Adam Cheng
- 5Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Irene W Y Ma
- 1W21C, University of Calgary, Calgary, Canada.,4Department of Community Health Sciences, University of Calgary, Calgary, Canada.,6Department of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1 Canada
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Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:23-30. [PMID: 27782919 DOI: 10.1097/acm.0000000000001421] [Citation(s) in RCA: 272] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases. However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases. Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes. In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits?The literature suggests that both Type 1 and Type 2 processes contribute to errors. Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established. Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits.
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Affiliation(s)
- Geoffrey R Norman
- G.R. Norman is emeritus professor, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. S.D. Monteiro is assistant professor, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. J. Sherbino is associate professor, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. J.S. Ilgen is associate professor, Department of Medicine, University of Washington School of Medicine, Seattle, Washington. H.G. Schmidt is professor, Department of Psychology, Erasmus University, Rotterdam, the Netherlands. S. Mamede is associate professor, Department of Psychology, Erasmus University, Rotterdam, the Netherlands
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Young JQ, van Dijk SM, O'Sullivan PS, Custers EJ, Irby DM, Ten Cate O. Influence of learner knowledge and case complexity on handover accuracy and cognitive load: results from a simulation study. MEDICAL EDUCATION 2016; 50:969-78. [PMID: 27562896 DOI: 10.1111/medu.13107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/29/2016] [Accepted: 04/06/2016] [Indexed: 05/25/2023]
Abstract
CONTEXT The handover represents a high-risk event in which errors are common and lead to patient harm. A better understanding of the cognitive mechanisms of handover errors is essential to improving handover education and practice. OBJECTIVES This paper reports on an experiment conducted to study the effects of learner knowledge, case complexity (i.e. cases with or without a clear diagnosis) and their interaction on handover accuracy and cognitive load. METHODS Participants were 52 Dutch medical students in Years 2 and 6. The experiment employed a repeated-measures design with two explanatory variables: case complexity (simple or complex) as the within-subject variable, and learner knowledge (as indicated by illness script maturity) as the between-subject covariate. The dependent variables were handover accuracy and cognitive load. Each participant performed a total of four simulated handovers involving two simple cases and two complex cases. RESULTS Higher illness script maturity predicted increased handover accuracy (p < 0.001) and lower cognitive load (p = 0.007). Case complexity did not independently affect either outcome. For handover accuracy, there was no interaction between case complexity and illness script maturity. For cognitive load, there was an interaction effect between illness script maturity and case complexity, indicating that more mature illness scripts reduced cognitive load less in complex cases than in simple cases. CONCLUSIONS Students with more mature illness scripts performed more accurate handovers and experienced lower cognitive load. For cognitive load, these effects were more pronounced in simple than complex cases. If replicated, these findings suggest that handover curricula and protocols should provide support that varies according to the knowledge of the trainee.
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Affiliation(s)
- John Q Young
- Department of Psychiatry, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY, USA
| | - Savannah M van Dijk
- Centre for Research and Development of Education, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Patricia S O'Sullivan
- Research and Development of Medical Education, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Eugene J Custers
- Centre for Research and Development of Education, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - David M Irby
- Research and Development of Medical Education, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Olle Ten Cate
- Centre for Research and Development of Education, University Medical Centre Utrecht, Utrecht, The Netherlands
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ALQahtani DA, Rotgans JI, Mamede S, ALAlwan I, Magzoub MEM, Altayeb FM, Mohamedani MA, Schmidt HG. Does Time Pressure Have a Negative Effect on Diagnostic Accuracy? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:710-6. [PMID: 26826069 DOI: 10.1097/acm.0000000000001098] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE Studies suggest time pressure has negative effects on physicians' working conditions and may lead to suboptimal patient care and medical errors. Experimental evidence supporting this is lacking, however. This study investigated the effect of time pressure on diagnostic accuracy. METHOD In 2013, senior internal medicine residents at three hospitals in Saudi Arabia were divided randomly into two groups: a time-pressure condition and a control condition without time pressure. Both groups diagnosed eight written clinical cases presented on computers. In the time-pressure condition, after completing each case, participants received information that they were behind schedule. Response time was recorded, and diagnostic accuracy was scored. RESULTS The 23 participants in the time-pressure condition spent significantly less time diagnosing the cases (mean = 96.00 seconds) than the 19 control participants (mean = 151.97 seconds) (P < .001). Participants under time pressure had a significantly lower diagnostic accuracy score (mean = 0.33; 95% CI, 0.23-0.43) than participants without time pressure (mean = 0.51; 95% CI, 0.42-0.60) (F[1, 41] = 6.90, P = .012, η = 0.15). This suggests participants in the time-pressure condition made on average 37% more errors than control participants. CONCLUSIONS Time pressure has a negative impact on diagnostic performance. The authors propose that the effect of time pressure on diagnostic accuracy is moderated by both the case difficulty level and the physician's level of experience. Post hoc analyses demonstrated that time pressure affects diagnostic accuracy only if cases are not too difficult and physicians' expertise level is intermediate.
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Affiliation(s)
- Dalal A ALQahtani
- D.A. ALQahtani is lecturer and medical education specialist, Department of Oral Medicine and Diagnostic Sciences (DDS), College of Dentistry-King Saud University, Riyadh, Saudi Arabia. J.I. Rotgans is assistant professor, National Institute of Education, Nanyang Technological University, Singapore. S. Mamede is associate professor, Institute of Medical Education Research Rotterdam, Erasmus Medical Center, and Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands. I. ALAlwan is professor and assistant vice president for educational affairs, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. M.E.M. Magzoub is professor, Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. F.M. Altayeb is research assistant, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. M.A. Mohamedani is research coordinator, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. H.G. Schmidt is professor, Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Carpenter CR, Raja AS, Brown MD. Overtesting and the Downstream Consequences of Overtreatment: Implications of "Preventing Overdiagnosis" for Emergency Medicine. Acad Emerg Med 2015; 22:1484-92. [PMID: 26568269 DOI: 10.1111/acem.12820] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 12/15/2022]
Abstract
Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.
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Affiliation(s)
- Christopher R. Carpenter
- Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Ali S. Raja
- Department of Emergency Medicine; Brigham & Women's Hospital; Boston MA
| | - Michael D. Brown
- Emergency Medicine; Michigan State University College of Medicine; Grand Rapids MI
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