Thinking styles and doctors' knowledge and behaviours relating to acute coronary syndromes guidelines

The Importance of Incorporating Human Factors in the Design and Implementation of Artificial Intelligence for Skin Cancer Diagnosis in the Real World

Artificial intelligence (AI) algorithms have been shown to diagnose skin lesions with impressive accuracy in experimental settings. The majority of the literature to date has compared AI and dermatologists as opponents in skin cancer diagnosis. However, in the real-world clinical setting, the clinician will work in collaboration with AI. Existing evidence regarding the integration of such AI diagnostic tools into clinical practice is limited. Human factors, such as cognitive style, personality, experience, preferences, and attitudes may influence clinicians' use of AI. In this review, we consider these human factors and the potential cognitive errors, biases, and unintended consequences that could arise when using an AI skin cancer diagnostic tool in the real world. Integrating this knowledge in the design and implementation of AI technology will assist in ensuring that the end product can be used effectively. Dermatologist leadership in the development of these tools will further improve their clinical relevance and safety.

Cognitive mechanisms underlying interaction and contribution in online health communities: the perspectives of doctors and patients

Purpose

Active interaction and knowledge contribution are vital yet challenging elements of the sustainable development of online health communities (OHCs). To investigate the cognitive mechanisms underlying these behaviours in doctors' and patients' use of OHCs, this study develops a theoretical model to examine the relationships among cognitive modes, patterns of interaction, perceived usefulness, and contribution behaviour and the impact of user identity on these relationships.

Design/methodology/approach

To test the research hypotheses, structural equation modelling and multiple-group analysis were used to analyse survey data from 207 doctors and 213 patients.

Findings

The results indicate that dual processes and perceived usefulness are the key cognitive antecedents of interaction and knowledge contribution, respectively. However, the correlation of the rational mode and instrumental interaction is significantly stronger in the doctors' group than in the patients' group, while a stronger correlation between the experiential mode and instrumental interaction is observed in the patients' group.

Practical implications

These findings support the development of information and system strategies to support the operation of dual processes underlying doctors' and patients' instrumental and affective interactions, facilitate evaluation and sense-making of interaction activities, and motivate knowledge contribution.

Originality/value

This study uncovers the invariance and variability in the relationships between salient cognitive activities and behavioural responses in doctors' and patients' use of OHCs and the impact of user identity on variability.

Clinical Decision-making among Emergency Physicians: Experiential or Rational?

It has been postulated that everyone has an affinity for one of two cognitive approaches: experiential (intuitive) or rational (conscious). The aim of this study was to analyze the thinking processes of Saudi emergency physicians at nine hospitals in Riyadh. This was a cross-sectional study, which was undertaken in Riyadh using a psychometric tool called the Rational–Experiential Inventory-40. The survey, sent by e-mail to 202 emergency physicians, had a 53% response rate. Most respondents were male (86%). The total surveyed participants included consultants (36%), associate consultants (19%), registrars, fellow or staff physicians (7%), and residents (38%). The results found a mean (standard deviation) score of 3.73 (0.51) for rational approaches to decision-making and 3.09 (0.45) for experiential approaches among the emergency physicians surveyed. The difference of 0.46 between the two scores was not statistically significant (p = 0.23). Female emergency physicians tended toward slower logical thinking (rational). Consultant emergency physicians had a higher score for fast intuitive automatic thinking (experiential) than nonconsultant physicians. This was statistically significant, t₁₀₅ = 2.1, p = 0.4. Our results suggest that although both thinking styles are used in clinical decision-making, consultant emergency physicians prefer rational approaches to decision-making.

Preference of cognitive approaches for decision making among anesthesiologists' in Saudi Arabia

Aims:

The aim of this study was to analyze the thinking processes of anesthesia physicians at in Riyadh, Jeddah, and Dammam cities in Saudi Arabia.

Subjects and Methods:

This cross-sectional study was undertaken in the cities of Riyadh, Jeddah, and Dammam in Saudi Arabia. Using a previously published psychometric tool (the Rational and Experiential Inventory, REI-40), the survey was sent through email and social networks to anesthesia physicians working in the targeted hospitals. An initial survey was sent out, followed by a reminder and a second survey to nonrespondents. Analysis included descriptive statistics and Student's t-tests.

Results:

Most of the participants (69.2%) were males. At the time of the study, 35% of participants were consultants; 9.6% were associate consultants; 19.2% were registrars, fellows, or staff physicians; and 35.8% were senior residents. Anesthesia physicians’ mean “rational” score was 3.22 [standard deviation (SD) =0.49)] and their mean “experiential” score was 3.01 (SD = 0.31). According to Pearson's correlation, the difference of 0.21 between these two scores was not statistically significant (P = 0.35). Male anesthesia physicians tended more toward faster, logical thinking. Consultant anesthesia physicians had faster rational thinking than nonconsultant physicians (P = 0.01). Anesthesia physicians with more than 10 years in practice had faster rational thinking than physicians who had worked for fewer than 10 years (P = 0.001).

Conclusions:

This study evaluated anesthesia physicians’ general decision-making approaches. Despite the fact that both rational and experiential techniques are used in clinical decision-making, male consultants and physicians with more than 10 years’ experience and certified non-Saudi board anesthesiologists prefer rational decision-making style.

Relationship between Student Pharmacist Decision Making Preferences and Experiential Learning

Objective. To determine if student pharmacists' preferences towards experiential and rational thinking are associated with performance on advanced pharmacy practice experiences (APPEs) and whether thinking style preference changes following APPEs. Methods. The Rational Experiential Inventory (REI), a validated survey of thinking style, was administered to student pharmacists before starting APPEs and re-administered after completing APPEs. APPE grades were compared to initial REI scores. Results. Rational Experiential Inventory scores remained consistent before and after APPEs. Overall, APPE grades were independent of REI scores. In a regression model, the REI experiential score was a significant negative predictor of hospital APPE grades. Conclusion. These findings suggest that overall APPE performance is independent of decision-making preference, and decision-making style does not change following immersion into APPEs. Instead of targeting teaching strategies towards a specific decision-making style, preceptors may use pedagogical approaches that promote sound clinical decision-making skills through critical thinking and reflection.

Practice what you preach? An exploratory multilevel study on rheumatoid arthritis guideline adherence by rheumatologists

Objectives

To assess variation in and determinants of rheumatologist guideline adherence in patients with rheumatoid arthritis (RA), in daily practice.

Methods

In this retrospective observational study, guideline adherence in the first year of treatment was assessed for 7 predefined parameters on diagnostics, treatment and follow-up in all adult patients with RA with a first outpatient clinic visit at the study centre, from September 2009 to March 2011. Variation in guideline adherence was assessed on parameter and rheumatologist level. Determinants for guideline adherence were assessed in patients (demographic characteristics, rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide antibody (aCCP) positivity, erythrocyte sedimentation rate, erosive disease, comorbidity and the number of available disease modifying anti-rheumatic drug (DMARD) treatment options) and rheumatologists (demographic and practice characteristics, guideline knowledge and agreement, outcome expectancy, cognitive bias, thinking style, numeracy and personality).

Results

A total of 994 visits in 137 patients with RA were reviewed. Variation in guideline adherence among parameters was present (adherence between 21% and 72%), with referral to the physician assistant as lowest scoring and referral to a specialised nurse as highest scoring parameter. Variation in guideline adherence among rheumatologists was also present (adherence between 22% and 100%). Patient sex, the number of DMARD options, presence of erosions, comorbidity, RF/aCCP positivity, type of patient and the rheumatologists' scientific education status were associated with adherence to 1 or more guideline parameters.

Conclusions

Guideline adherence varied considerably among the guideline parameters and rheumatologists, showing that there is room for improvement. Guideline adherence in our sample was related to several patient and rheumatologist determinants.

A Survey to Determine Decision-Making Styles of Working Paramedics and Student Paramedics

OBJECTIVE

Two major processes underlie human decision-making: experiential (intuitive) and rational (conscious) thinking. The predominant thinking process used by working paramedics and student paramedics to make clinical decisions is unknown.

METHODS

A survey was administered to ground ambulance paramedics and to primary care paramedic students. The survey included demographic questions and the Rational Experiential Inventory-40, a validated psychometric tool involving 40 questions. Twenty questions evaluated each thinking style: 10 assessed preference and 10 assessed ability to use that style. Responses were provided on a five-point Likert scale, with higher scores indicating higher affinity for the style in question. Analysis included both descriptive statistics and t tests to evaluate differences in thinking style.

RESULTS

The response rate was 88.4% (1172/1326). Paramedics (n=904) had a median age of 36 years (IQR 29-42) and most were male (69.5%) and primary or advanced care paramedics (PCP=55.5%; ACP=32.5%). Paramedic students (n=268) had a median age of 23 years (IQR 21-26), most were male (63.1%) and had completed high school (31.7%) or an undergraduate degree (25.4%) prior to paramedic training. Both groups scored their ability to use and favourability toward rational thinking significantly higher than experiential thinking. The mean score for rational thinking was 3.86/5 among paramedics and 3.97/5 among paramedic students (p<0.001). The mean score for experiential thinking was 3.41/5 among paramedics and 3.35/5 among paramedic students (p=0.06).

CONCLUSION

Working paramedics and student paramedics prefer and perceive that they have the ability to use rational over experiential thinking. This information adds to our current knowledge on paramedic decision-making and is potentially important for developing continuing education and clinical support tools.

Rational and experiential decision-making preferences of third-year student pharmacists

OBJECTIVE

To examine the rational (systematic and rule-based) and experiential (fast and intuitive) decision-making preferences of student pharmacists, and to compare these preferences to the preferences of other health professionals and student populations.

METHODS

The Rational-Experiential Inventory (REI-40), a validated psychometric tool, was administered electronically to 114 third-year (P3) student pharmacists. Student demographics and preadmission data were collected. The REI-40 results were compared with student demographics and admissions data to identify possible correlations between these factors.

RESULTS

Mean REI-40 rational scores were higher than experiential scores. Rational scores for younger students were significantly higher than students aged 30 years and older (p<0.05). No significant differences were found based on gender, race, or the presence of a prior degree. All correlations between REI-40 scores and incoming grade point average (GPA) and Pharmacy College Admission Test (PCAT) scores were weak.

CONCLUSION

Student pharmacists favored rational decision making over experiential decision making, which was similar to results of studies done of other health professions.

Clinician-led improvement in cancer care (CLICC)--testing a multifaceted implementation strategy to increase evidence-based prostate cancer care: phased randomised controlled trial--study protocol

BACKGROUND

Clinical practice guidelines have been widely developed and disseminated with the aim of improving healthcare processes and patient outcomes but the uptake of evidence-based practice remains haphazard. There is a need to develop effective implementation methods to achieve large-scale adoption of proven innovations and recommended care. Clinical networks are increasingly being viewed as a vehicle through which evidence-based care can be embedded into healthcare systems using a collegial approach to agree on and implement a range of strategies within hospitals. In Australia, the provision of evidence-based care for men with prostate cancer has been identified as a high priority. Clinical audits have shown that fewer than 10% of patients in New South Wales (NSW) Australia at high risk of recurrence after radical prostatectomy receive guideline recommended radiation treatment following surgery. This trial will test a clinical network-based intervention to improve uptake of guideline recommended care for men with high-risk prostate cancer.

METHODS/DESIGN

In Phase I, a phased randomised cluster trial will test a multifaceted intervention that harnesses the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network to increase evidence-based care for men with high-risk prostate cancer following surgery. The intervention will be introduced in nine NSW hospitals over 10 months using a stepped wedge design. Outcome data (referral to radiation oncology for discussion of adjuvant radiotherapy in line with guideline recommended care or referral to a clinical trial of adjuvant versus salvage radiotherapy) will be collected through review of patient medical records. In Phase II, mixed methods will be used to identify mechanisms of provider and organisational change. Clinicians' knowledge and attitudes will be assessed through surveys. Process outcome measures will be assessed through document review. Semi-structured interviews will be conducted to elucidate mechanisms of change.

DISCUSSION

The study will be one of the first randomised controlled trials to test the effectiveness of clinical networks to lead changes in clinical practice in hospitals treating patients with high-risk cancer. It will additionally provide direction regarding implementation strategies that can be effectively employed to encourage widespread adoption of clinical practice guidelines.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910.

Evaluation of Physicians’ Cognitive Styles

Background. Patient outcomes critically depend on accuracy of physicians’ judgment, yet little is known about individual differences in cognitive styles that underlie physicians’ judgments. The objective of this study was to assess physicians’ individual differences in cognitive styles relative to age, experience, and degree and type of training. Methods. Physicians at different levels of training and career completed a web-based survey of 6 scales measuring individual differences in cognitive styles (maximizing v. satisficing, analytical v. intuitive reasoning, need for cognition, intolerance toward ambiguity, objectivism, and cognitive reflection). We measured psychometric properties (Cronbach’s α) of scales; relationship of age, experience, degree, and type of training; responses to scales; and accuracy on conditional inference task. Results. The study included 165 trainees and 56 attending physicians (median age 31 years; range 25–69 years). All 6 constructs showed acceptable psychometric properties. Surprisingly, we found significant negative correlation between age and satisficing ( r = −0.239; P = 0.017). Maximizing (willingness to engage in alternative search strategy) also decreased with age ( r = −0.220; P = 0.047). Number of incorrect inferences negatively correlated with satisficing ( r = −0.246; P = 0.014). Disposition to suppress intuitive responses was associated with correct responses on 3 of 4 inferential tasks. Trainees showed a tendency to engage in analytical thinking ( r = 0.265; P = 0.025), while attendings displayed inclination toward intuitive-experiential thinking ( r = 0.427; P = 0.046). However, trainees performed worse on conditional inference task. Conclusion. Physicians capable of suppressing an immediate intuitive response to questions and those scoring higher on rational thinking made fewer inferential mistakes. We found a negative correlation between age and maximizing: Physicians who were more advanced in their careers were less willing to spend time and effort in an exhaustive search for solutions. However, they appeared to have maintained their “mindware” for effective problem solving.

Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures

BACKGROUND

Two of the current methodological barriers to implementation science efforts are the lack of agreement regarding constructs hypothesized to affect implementation success and identifiable measures of these constructs. In order to address these gaps, the main goals of this paper were to identify a multi-level framework that captures the predominant factors that impact implementation outcomes, conduct a systematic review of available measures assessing constructs subsumed within these primary factors, and determine the criterion validity of these measures in the search articles.

METHOD

We conducted a systematic literature review to identify articles reporting the use or development of measures designed to assess constructs that predict the implementation of evidence-based health innovations. Articles published through 12 August 2012 were identified through MEDLINE, CINAHL, PsycINFO and the journal Implementation Science. We then utilized a modified five-factor framework in order to code whether each measure contained items that assess constructs representing structural, organizational, provider, patient, and innovation level factors. Further, we coded the criterion validity of each measure within the search articles obtained.

RESULTS

Our review identified 62 measures. Results indicate that organization, provider, and innovation-level constructs have the greatest number of measures available for use, whereas structural and patient-level constructs have the least. Additionally, relatively few measures demonstrated criterion validity, or reliable association with an implementation outcome (e.g., fidelity).

DISCUSSION

In light of these findings, our discussion centers on strategies that researchers can utilize in order to identify, adapt, and improve extant measures for use in their own implementation research. In total, our literature review and resulting measures compendium increases the capacity of researchers to conceptualize and measure implementation-related constructs in their ongoing and future research.

Screening for hepatitis B surface antigen before chemotherapy: current practice and opportunities for improvement

INTRODUCTION

Hepatitis B virus (hbv) reactivation is a recognized complication of chemotherapy. The U.S. Centers for Disease Control and Prevention recommend that all patients be screened for the hbv surface antigen (hbsag) before chemotherapy. We sought to determine the frequency of hbsag testing before chemotherapy at our hospital and to increase the frequency of testing to more than 90% of patients starting chemotherapy.

METHODS

Using a retrospective electronic chart review, we identified the frequency of hbsag testing for patients initiated on intravenous chemotherapy at out institution between March 2006 and March 2007. The frequency of left ventricular function testing in the subgroup of patients receiving potentially cardiotoxic chemotherapy was identified as a comparator. An educational intervention was developed and delivered to the multidisciplinary oncology team. The frequency of hbsag testing was determined post intervention. Qualitative interviews were conducted with the members of the oncology team to identify risk perception and barriers to testing.

RESULTS

Of 208 patients started on intravenous chemotherapy between March 2006 and March 2007, only 28 (14%) were tested for hbsag. All 138 patients scheduled for cardiotoxic chemotherapy (100%) underwent left ventricular function testing. In the post-intervention phase, of 74 patients started on intravenous chemotherapy, 24 (31%) underwent hbsag testing, with 1 patient testing positive.

CONCLUSIONS

The frequency of testing for hbsag before chemotherapy was very low at our institution. An educational intervention resulted in only a modest improvement. Potential barriers to routine screening include lack of awareness about existing guidelines, controversy about the evidence that supports hbsag testing guidelines, and a perception by physicians that hbv reactivation does not occur with solid tumours.

Measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM)

Background

Understanding how doctors think may inform both undergraduate and postgraduate medical education. Developing such an understanding requires valid and reliable measurement tools. We examined the measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM), designed to tap this domain with specific reference to medicine, but with previously questionable measurement properties.

Methods

First year postgraduate entry medical students at Flinders University, and trainees (postgraduate doctors in any specialty) and consultants (N = 348) based at two teaching hospitals in Adelaide, Australia, completed the ICBM and a questionnaire measuring thinking styles (Rational Experiential Inventory).

Results

Questions with the lowest item-total correlation were deleted from the original 22 item ICBM, although the resultant 17 item scale only marginally improved internal consistency (Cronbach's α = 0.61 compared with 0.57). A factor analysis identified two scales, both achieving only α = 0.58. Construct validity was assessed by correlating Rational Experiential Inventory scores with the ICBM, with some positive correlations noted for students only, suggesting that those who are naïve to the knowledge base required to "successfully" respond to the ICBM may profit by a thinking style in tune with logical reasoning.

Conclusion

The ICBM failed to demonstrate adequate content validity, internal consistency and construct validity. It is unlikely that improvements can be achieved without considered attention to both the audience for which it is designed and its item content. The latter may need to involve both removal of some items deemed to measure multiple biases and the addition of new items in the attempt to survey the range of biases that may compromise medical decision making.