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Abstract
PURPOSE The prevailing paradigms of clinical reasoning conceptualize context either as noise that masks, or as external factors that influence, the internal cognitive processes involved in reasoning. The authors reimagined clinical reasoning through the lens of ecological psychology to enable new ways of understanding context-specific manifestations of clinical performance and expertise, and the bidirectional ways in which individuals and their environments interact. METHOD The authors performed a critical review of foundational and current literature from the field of ecological psychology to explore the concepts of clinical reasoning and context as presented in the health professions education literature. RESULTS Ecological psychology offers several concepts to explore the relationship between an individual and their context, including affordance, effectivity, environment, and niche. Clinical reasoning may be framed as an emergent phenomenon of the interactions between a clinician's effectivities and the affordances in the clinical environment. Practice niches are the outcomes of historical efforts to optimize practice and are both specialty-specific and geographically diverse. CONCLUSIONS In this framework, context specificity may be understood as fundamental to clinical reasoning. This changes the authors' understanding of expertise, expert decision making, and definition of clinical error, as they depend on both the expert's actions and the context in which they acted. Training models incorporating effectivities and affordances might allow for antiableist formulations of competence that apply learners' abilities to solving problems in context. This could offer both new means of training and improve access to training for learners of varying abilities. Rural training programs and distance education can leverage technology to provide comparable experience to remote audiences but may benefit from additional efforts to integrate learners into local practice niches.
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Affiliation(s)
- Bjorn K Watsjold
- B.K. Watsjold is assistant professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4888-8857
| | - Jonathan S Ilgen
- J.S. Ilgen is professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4590-6570
| | - Glenn Regehr
- G. Regehr is professor, Department of Surgery, and senior scientist, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada; ORCID: https://orcid.org/0000-0002-3144-331X
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Ilgen JS, Eva KW, de Bruin A, Cook DA, Regehr G. Comfort with uncertainty: reframing our conceptions of how clinicians navigate complex clinical situations. Adv Health Sci Educ Theory Pract 2019; 24:797-809. [PMID: 30390181 DOI: 10.1007/s10459-018-9859-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/17/2018] [Indexed: 05/23/2023]
Abstract
Learning to take safe and effective action in complex settings rife with uncertainty is essential for patient safety and quality care. Doing so is not easy for trainees, as they often consider certainty to be a necessary precursor for action and subsequently struggle in these settings. Understanding how skillful clinicians work comfortably when uncertain, therefore, offers an important opportunity to facilitate trainees' clinical reasoning development. This critical review aims to define and elaborate the concept of 'comfort with uncertainty' in clinical settings by juxtaposing a variety of frameworks and theories in ways that generate more deliberate ways of thinking about, and researching, this phenomenon. We used Google Scholar to identify theoretical concepts and findings relevant to the topics of 'uncertainty,' 'ambiguity,' 'comfort,' and 'confidence,' and then used preliminary findings to pursue parallel searches within the social cognition, cognition, sociology, sociocultural, philosophy of medicine, and medical education literatures. We treat uncertainty as representing the lived experience of individuals, reflecting the lack of confidence one feels that he/she has an incomplete mental representation of a particular problem. Comfort, in contrast, references confidence in one's capabilities to act (or not act) in a safe and effective manner given the situation. Clinicians' 'comfort with uncertainty' is informed by a variety of perceptual, emotional, and situational cues, and is enabled through a combination of self-monitoring and forward planning. Potential implications of using 'comfort with uncertainty' as a framework for educational and research programs are explored.
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Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine and Center for Leadership and Innovation in Medical Education, University of Washington School of Medicine, Seattle, WA, USA.
| | - Kevin W Eva
- Department of Medicine and Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
| | - Anique de Bruin
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - David A Cook
- Department of Medicine and Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Glenn Regehr
- Department of Surgery and Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
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Yokoyama H. Introducing off-the-job training to cardiovascular surgical residency training: a new era of developing competent cardiovascular surgeons. Surg Today 2019; 49:300-10. [DOI: 10.1007/s00595-018-1747-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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Vaporciyan AA, Fikfak V, Lineberry MC, Park YS, Tekian A. Consensus-Derived Coronary Anastomotic Checklist Reveals Significant Variability Among Experts. Ann Thorac Surg 2017; 104:2087-2092. [PMID: 29074155 DOI: 10.1016/j.athoracsur.2017.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/11/2017] [Accepted: 07/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Surgical skill assessment tools frequently reflect the opinions of small groups of surgeons. That raises concerns over their generalizability as well as their utilization when applied broadly. A Delphi approach could engage a broad group of experts to identify key elements for a checklist assessing coronary anastomotic skill, improving generalizability. METHODS Expert surgeons in North America (10 or more years in practice, actively teaching coronary artery surgery) were contacted randomly to participate. Consenting surgeons first provided items they believed were mandatory when performing a coronary artery bypass. These were then entered into a three-round Delphi. Positive consensus was reached when 75% or more of participants ranked an item mandatory. RESULTS Sixteen faculty consented to participate. Each participant provided 25 ± 10 items. The 407 items provided were condensed, resulting in 146 items in the final list, divided into six sections based on the conduct of the operation. Twenty-three items reached consensus in the first round, 14 in the second, and 3 in the third. These 40 items represented only 27% of the initial 146 items. Agreement within sections varied widely, from 0% for "management of assistants" to 47% for "testing and final steps." CONCLUSIONS A randomly selected group of experts using a Delphi approach can generate a checklist to assess construction of a coronary artery bypass. Considerable disagreement among experts regarding what steps are mandatory calls into question the generalizability of any locally developed checklist.
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Affiliation(s)
- Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas.
| | - Vid Fikfak
- Department of General Surgery, Houston Methodist Hospital, Houston, Texas
| | - Matthew C Lineberry
- Department of Health Policy and Management, Zamierowksi Institute for Experiential Learning, University of Kansas Medical Center, Kansas City, Kansas
| | - Yoon Soo Park
- Department of Medical Education, College of Medicine, University of Chicago, Chicago, Illinois
| | - Ara Tekian
- Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
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Cong L, Yan Q, Sun C, Zhu Y, Tu G. Effect of problem and scripting-based learning on spine surgical trainees' learning outcomes. Eur Spine J 2017; 26:3068-74. [PMID: 28526918 DOI: 10.1007/s00586-017-5135-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/20/2017] [Accepted: 05/10/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess the impact of problem and scripting-based learning (PSBL) on spine surgical trainees' learning outcomes. METHODS 30 spine surgery postgraduate-year-1 residents (PGY-1s) from the First Hospital of China Medical University were randomly divided into two groups. The first group studied spine surgical skills and developed individual judgment under a conventional didactic model, whereas the PSBL group used PBL and Scripted model. A feedback questionnaire and the satisfaction of residents were evaluated by the first assistant surgeon immediately following each procedure. At the end of the study, residents filled out questionnaires focused on identifying the strengths of each teaching method and took a multiple-choice theoretical examination. The results were analyzed by t tests. RESULTS Significant difference was found between the two groups in total mean score of preparedness and performance feedback statement (P = 0.01) and the questionnaire by PGY-1's opinion on the effectiveness of the two teaching methods (P = 0.004). Compared with the non-PSBL group, the PSBL group had significantly higher mean score of pre-operative preparedness (P = 0.01), but there was no significant difference between the two groups in theoretical examination, intra-operative performance, and overall satisfaction with the PGY-1s. The residents found that PSBL could develop their judgment (P = 0.03) and provide greater satisfaction (P = 0.02), and would like to repeat the experience (P = 0.03). CONCLUSIONS The PSBL method can activate spine residents' prior knowledge and building on existing cognitive frameworks, which is an important tool for improving pre-operative preparedness. We believe that PSBL is an important first step in training spine residents to become confident and safe spine surgeons.
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Abstract
UNLABELLED Construct: Clinical reasoning assessment is a growing area of interest in the medical education literature. Script concordance testing (SCT) evaluates clinical reasoning in conditions of uncertainty and has emerged as an innovative tool in the domain of clinical reasoning assessment. SCT quantifies the degree of concordance between a learner and an experienced clinician and attempts to capture the breadth of responses of expert clinicians, acknowledging the significant yet acceptable variation in practice under situations of uncertainty. BACKGROUND SCT has been shown to be a valid and reliable clinical reasoning assessment tool. However, as SCT provides only quantitative information, it may not provide a complete assessment of clinical reasoning. APPROACH Think aloud (TA) is a qualitative research tool used in clinical reasoning assessment in which learners verbalize their thought process around an assigned task. This study explores the use of TA, in the form of written reflection, in SCT to assess resident clinical reasoning, hypothesizing that the information obtained from the written TA would enrich the quantitative data obtained through SCT. Ninety-one pediatric postgraduate trainees and 21 pediatricians from 4 Canadian training centers completed an online test consisting of 24 SCT cases immediately followed by retrospective written TA. Six of 24 cases were selected to gather TA data. These cases were chosen to allow all phases of clinical decision making (diagnosis, investigation, and treatment) to be represented in the TA data. Inductive thematic analysis was employed when systematically reviewing TA responses. RESULTS Three main benefits of adding written TA to SCT were identified: (a) uncovering instances of incorrect clinical reasoning despite a correct SCT response, (b) revealing sound clinical reasoning in the context of a suboptimal SCT response, and (c) detecting question misinterpretation. CONCLUSIONS Written TA can optimize SCT by demonstrating when correct examinee responses are based on guessing or uncertainty rather than robust clinical rationale. TA can also enhance SCT by allowing examinees to provide justification for responses that otherwise would have been considered incorrect and by identifying questions that are frequently misinterpreted to avoid including them in future examinations. TA also has significant value in differentiating between acceptable variations in expert clinician responses and deviance associated with faulty rationale or question misinterpretation; this could improve SCT reliability. A written TA protocol appears to be a valuable tool to assess trainees' clinical reasoning and can strengthen the quantitative assessment provided by SCT.
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Affiliation(s)
- Alyssa Power
- a Department of Pediatrics , Alberta Children's Hospital , Calgary , Alberta , Canada
| | - Jean-Francois Lemay
- a Department of Pediatrics , Alberta Children's Hospital , Calgary , Alberta , Canada
| | - Suzette Cooke
- a Department of Pediatrics , Alberta Children's Hospital , Calgary , Alberta , Canada
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Gas BL, Mohan M, Jyot A, Buckarma EH, Farley DR. Does scripting operative plans in advance lead to better preparedness of trainees? A pilot study. Am J Surg 2016; 213:526-529. [PMID: 27839687 DOI: 10.1016/j.amjsurg.2016.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/05/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND We pondered if preoperative scripting might better prepare residents for the operating room (OR). METHODS Interns rotating on a general surgeon's service were instructed to script randomized cases prior to entering the OR. Scripts contained up to 20 points highlighting patient information perceived important for surgical management. The attending was blinded to the scripting process and completed a feedback sheet (Likert scale) following each procedure. Feedback questions were categorized into "preparedness" (aware of patient specific details, etc.) and "performance" (provided better assistance, etc.). RESULTS Eight surgical interns completed 55 scripted and 61 non-scripted cases. Total scores were higher in scripted cases (p = 0.02). Performance scores were higher for scripted cases (3.31 versus 3.13, p = 0.007), while preparedness did not differ (3.65 and 3.62, p = 0.51). CONCLUSIONS This pilot study suggests scripting cases may be a useful preoperative planning tool to increase interns' operative and patient care performance but may not affect perceived preparedness.
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Affiliation(s)
- Becca L Gas
- Department of Surgery, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | - Monali Mohan
- Department of Surgery, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | - Apram Jyot
- Department of Surgery, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | - EeeLN H Buckarma
- Department of Surgery, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | - David R Farley
- Department of Surgery, Mayo Clinic, College of Medicine, Rochester, MN, USA.
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