Do malpractice claim clinical case vignettes enhance diagnostic accuracy and acceptance in clinical reasoning education during GP training?

BACKGROUND

Using malpractice claims cases as vignettes is a promising approach for improving clinical reasoning education (CRE), as malpractice claims can provide a variety of content- and context-rich examples. However, the effect on learning of adding information about a malpractice claim, which may evoke a deeper emotional response, is not yet clear. This study examined whether knowing that a diagnostic error resulted in a malpractice claim affects diagnostic accuracy and self-reported confidence in the diagnosis of future cases. Moreover, suitability of using erroneous cases with and without a malpractice claim for CRE, as judged by participants, was evaluated.

METHODS

In the first session of this two-phased, within-subjects experiment, 81 first-year residents of general practice (GP) were exposed to both erroneous cases with (M) and erroneous cases without (NM) malpractice claim information, derived from a malpractice claims database. Participants rated suitability of the cases for CRE on a five-point Likert scale. In the second session, one week later, participants solved four different cases with the same diagnoses. Diagnostic accuracy was measured with three questions, scored on a 0-1 scale: (1) What is your next step? (2) What is your differential diagnosis? (3) What is your most probable diagnosis and what is your level of certainty on this? Both subjective suitability and diagnostic accuracy scores were compared between the versions (M and NM) using repeated measures ANOVA.

RESULTS

There were no differences in diagnostic accuracy parameters (M vs. NM next step: 0.79 vs. 0.77, p = 0.505; differential diagnosis 0.68 vs. 0.75, p = 0.072; most probable diagnosis 0.52 vs. 0.57, p = 0.216) and self-reported confidence (53.7% vs. 55.8% p = 0.390) of diagnoses previously seen with or without malpractice claim information. Subjective suitability- and complexity scores for the two versions were similar (suitability: 3.68 vs. 3.84, p = 0.568; complexity 3.71 vs. 3.88, p = 0.218) and significantly increased for higher education levels for both versions.

CONCLUSION

The similar diagnostic accuracy rates between cases studied with or without malpractice claim information suggests both versions are equally effective for CRE in GP training. Residents judged both case versions to be similarly suitable for CRE; both were considered more suitable for advanced than for novice learners.

Twelve tips for physicians’ mastering expertise in diagnostic excellence

Diagnostic errors, which account for a large proportion of medical errors, are a global medical challenge. The slogan of reducing diagnostic errors has recently shifted to a new strategy of diagnostic excellence, the core of which is the importance of improving the multidisciplinary diagnostic process. Many of the elements and strategies necessary for diagnostic excellence have been presented. In the context of this diagnostic improvement, some reports have been structured to improve the quality of performance of individual physicians as players. Still, surprisingly, only a few reports have focused on specific day-to-day training strategies for the diagnostic thinking process as expertise. This paper focuses on this point and proposes strategies for refining the diagnostic thinking expertise of frontline physicians in the new era, based on the following four elements: knowledge and experience, diagnostic thinking strategies, information management skills, and calibration and reflection.

An Ecological Account of Clinical Reasoning

PURPOSE

The prevailing paradigms of clinical reasoning conceptualize context either as noise that masks, or as external factors that influence, the internal cognitive processes involved in reasoning. The authors reimagined clinical reasoning through the lens of ecological psychology to enable new ways of understanding context-specific manifestations of clinical performance and expertise, and the bidirectional ways in which individuals and their environments interact.

METHOD

The authors performed a critical review of foundational and current literature from the field of ecological psychology to explore the concepts of clinical reasoning and context as presented in the health professions education literature.

RESULTS

Ecological psychology offers several concepts to explore the relationship between an individual and their context, including affordance, effectivity, environment, and niche. Clinical reasoning may be framed as an emergent phenomenon of the interactions between a clinician's effectivities and the affordances in the clinical environment. Practice niches are the outcomes of historical efforts to optimize practice and are both specialty-specific and geographically diverse.

CONCLUSIONS

In this framework, context specificity may be understood as fundamental to clinical reasoning. This changes the authors' understanding of expertise, expert decision making, and definition of clinical error, as they depend on both the expert's actions and the context in which they acted. Training models incorporating effectivities and affordances might allow for antiableist formulations of competence that apply learners' abilities to solving problems in context. This could offer both new means of training and improve access to training for learners of varying abilities. Rural training programs and distance education can leverage technology to provide comparable experience to remote audiences but may benefit from additional efforts to integrate learners into local practice niches.

Multilevel Evaluation of Rapid Weight Loss in Wrestling and Taekwondo

The practice of strategies for rapid weight loss (RWL) involve diverse factors, such as individual expectations, social interactions, structural elements, etc., conforming to a "culture" of RWL, which must be evaluated and understood in a broad sense. Based on the need of a comprehensive evaluation of the use of RWL in practitioners of combat sports, an ad hoc questionnaire designed for this study, which includes the types and detailed descriptions of RWL strategies, that athletes currently use, the prevalence and frequency of use, the physiological and psychological consequences, the perception of the effect of RWL on their own performance and finally, the individuals who influence the adoption of this practice. One hundred and sixty combat athletes from wrestling and taekwondo disciplines, from Mexico, filled out this questionnaire. Data collected for their statistical analyses. Results revealed a RWL strategies prevalence of 96% across the participants. Our results revealed that 57% of those athletes using RWL lose more than 5% of their body mass. Across the athletes, the most commonly used RWL strategies and with higher intensity were increased exercise and training with plastic or thick clothes. The greater the relative weight loss, the greater the presence of physiological symptoms in athletes, such as rapid breathing and blood pressure. Athletes also mentioned mood states such as tiredness, sadness, confusion, fatigue and vigor, these last two positive and negative mood states are associated with the relative weight loss, respectively. Finally, the people who most influenced the adoption of RWL strategies were the coaches, parents and nutritionists. In conclusion, the questionnaire prepared for this study allowed us to obtain valuable information about the several factors, and their interactions, involved in the practice of RWL in combat athletes. This type of practice could increase health risks and decrease their performance. Therefore, here we state the importance of a comprehensive evaluation of RWL strategies that allows the development of psycho-educational and social-based interventions and programs for the promotion of proper weight maintenance, and prevention against RWL strategies, involving the individuals who influence the adoption of these practices and supporting it with the help of communication technologies.

Re-visioning clinical reasoning, or stepping out from the skull

THE PROBLEM

Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts.

A SOLUTION

Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, 'extended' cognition is configured as an outside-in process of 'sensemaking' or 'adaptive expertise'.

THE FUTURE

Current 'predictive processing' cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an 'ecological perception' or 'externalistic' model provides a counter to the current dominant paradigm of 'ego-logical' cognitive reasoning - the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.