A situated cognition model for clinical reasoning performance assessment: a narrative review

Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Exploring Embodied and Bioenergetic Approaches in Trauma Therapy: Observing Somatic Experience and Olfactory Memory

Recent studies highlight how body psychotherapy is becoming highly cited, especially in connection with studies on trauma-related disorders. This review highlights the theoretical assumptions and recent points in common with embodied simulation and new sensory theories by integrating bioenergetic analysis, embodiment, and olfactory memory in trauma and post-traumatic stress disorder (PTSD) therapy. Embodied memory, rooted in sensorimotor experiences, shapes cognitive functions and emotional responses. Trauma, embodied in somatic experiences, disrupts these processes, leading to symptoms such as chronic pain and dissociation. The literature discussed highlights the impact of burning odors on individuals with PTSD and those who have experienced childhood maltreatment. Burning odors can increase stress and heart rate in war veterans, with sensitivity to these odors intensifying over time since the trauma. Additionally, adults who experienced childhood maltreatment exhibit faster processing of unpleasant odors and increased symptom severity. Grounding techniques, such as adopting a balanced posture, enhance breathing and sensory capabilities, potentially aiding in managing symptoms associated with trauma-related disorders such as PTSD.

Cognitive perspectives on maintaining physicians' medical expertise: I. Reimagining Maintenance of Certification to promote lifelong learning

Until recently, physicians in the USA who were board-certified in a specialty needed to take a summative test every 6-10 years. However, the 24 Member Boards of the American Board of Medical Specialties are in the process of switching toward much more frequent assessments, which we refer to as longitudinal assessment. The goal of longitudinal assessments is to provide formative feedback to physicians to help them learn content they do not know as well as serve an evaluation for board certification. We present five articles collectively covering the science behind this change, the likely outcomes, and some open questions. This initial article introduces the context behind this change. This article also discusses various forms of lifelong learning opportunities that can help physicians stay current, including longitudinal assessment, and the pros and cons of each.

Clinical Reasoning in Occupational Therapy Practice: A Scoping Review of Qualitative and Conceptual Peer-Reviewed Literature

IMPORTANCE

The occupational therapy clinical reasoning literature includes a large proportion of peer-reviewed qualitative and conceptual articles. Although these articles can contribute to the understanding of how clinical reasoning has been conceptualized in occupational therapy, they have not yet received in-depth analytic attention. To address this gap, we conducted a scoping review.

OBJECTIVE

To examine how qualitative and conceptual literature has addressed clinical reasoning in occupational therapy.

DATA SOURCES

Database searches were conducted in Scopus, Web of Science, PsycINFO, Embase, and MEDLINE.

STUDY SELECTION AND DATA COLLECTION

Included articles were published between 2010 and 2019, were peer reviewed, addressed clinical reasoning in occupational therapy, were qualitative or conceptual articles, focused on practitioners, and were in English. Twenty-six articles met the inclusion criteria. Data were extracted according to relevant categories and were analyzed numerically and thematically.

FINDINGS

Four themes were identified: clinical reasoning processes, factors influencing clinical reasoning, new models or frameworks to guide clinical reasoning, and emergent perspectives on clinical reasoning.

CONCLUSIONS AND RELEVANCE

This review advances knowledge about how clinical reasoning has been conceptualized in occupational therapy and has been applied in a range of practice contexts. The review highlights discussions about types of reasoning, the dynamic and iterative nature of reasoning, contextual dimensions of reasoning, client-centered and occupation-based approaches, new frameworks and models, and emergent and innovative perspectives on clinical reasoning in occupational therapy. What This Article Adds: This scoping review represents an important contribution to knowledge about how clinical reasoning has been conceptualized in occupational therapy by mapping key themes and illuminating scholarly conversations in the qualitative and conceptual clinical reasoning literature.

Failure to demonstrate effects of interruptions on diagnostic reasoning: three experiments

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.

Real Workload-Situated Training in COVID-19 Prevention of General Practice Residents in China: A Situated Cognition Study

Objective: The participation of general practice (GP) residents in COVID-19 prevention and control tasks touched workload participation in public health and disease prevention and control and was also a rare, valuable training experience for the residents and research material for medical education. This experience contributed to the understanding of three key points: First, was the content of the COVID-19 prevention task suited to them, or did it overload them in the present? Second, their competence in the COVID-19 prevention task reflected whether the early medical school training was sufficient or not. Third, what can be drawn from this study to promote public health training in the future? This study aimed to explore these issues by conducting a real epidemic situated training (REST) program.

Methods: A situated cognition study was designed that included situational context design, legitimate peripheral participation, and the construction of a community of practice. The Task Cognitive Load Scale (NASA-TLX Scale) and self-developed questionnaires were adopted to conduct a questionnaire survey of resident doctors in a GP training program from West China Hospital of Sichuan University, and 183 questionnaires were collected. SPSS 23.0 statistical software was used for the statistical analysis of data.

Results: The NASA scale showed that the intensity of field epidemic prevention and control (training) was tolerable. In particular, there was statistical difference in the cognitive load intensity of training before and after the epidemic occurred at different time points (P < 0.05). This shows that they were early trained and well-prepared before sudden outbreak of the COVID-19. Before the outbreak of the epidemic, the public health knowledge and training received came from undergraduate education (83.16%), early residents program training (69.47%), online self-study (49.16%), and continuing education (20.53%).

Conclusion: Former medical school education and training at the regulatory training stage have a good effect and enable residents to master the skills required for epidemic prevention and control and to physically and mentally prepare for the task. After this stage, epidemic prevention and control training in real situations will make important contributions to the self-assessment and performance improvement of public health training.

Sociocultural learning in emergency medicine: a holistic examination of competence

Objectives

In the medical community of practice, the resident is situated in systems of professional and cultural activities. How diagnostic competence manifests in their sociocultural context is examined through situativity and systems theories. A holistic model is proposed that could examine diagnostic competence across micro (individual), meso (activity), and macro (cultural) systems.

Methods

Two short scenarios are presented resulting from observations of emergency medicine residents and their supervising physicians. These scenarios are analyzed using a trans-theoretical model of situativity and systems theories to understand how diagnostic competence manifests in practice (activity system).

Results

Assessment of diagnostic competence in a sociocultural context may require assessment of responses to contextual factors that seem immaterial to clinical reasoning. This information may signal that the resident also has the skills to identify appropriate information channels within an activity system and can accurately collect and prioritize clinical information within those channels. Therefore, the formal assessment of competent clinical reasoning performance, as a situated practice, may benefit from delineating how much of the context of an activity system is required to be competently managed and synthesized across the competency milestones.

Conclusions

The examination of diagnostic competence as a sociocultural practice can provide a unique and holistic examination of clinical reasoning performance and assessment.