Believing is seeing: the influence of a diagnostic hypothesis on the interpretation of clinical features

Effectiveness of a Web-Based Training Intervention in Teaching Emergency Physicians First-Trimester Point-of-Care Ultrasound Image Interpretation

STUDY OBJECTIVE

To examine the effectiveness of an education intervention on emergency physician accuracy in identifying pregnancy-related findings from first-trimester point-of-care ultrasound. Case features associated with the odds of a correct response were also determined.

METHODS

This was a multicenter prospective cross-sectional study in a convenience sample of emergency physicians in the United States and Canada. The unsupervised web-based education intervention included first-trimester point-of-care ultrasound cases acquired through the transabdominal (n=200 cases) or transvaginal (n=200 cases) approach. Physicians deliberately practiced identifying pregnancy-related imaging findings until they achieved a mastery standard.

RESULTS

In 204 participants, there were learning gains in accuracy (15.2%; 95% confidence interval [CI] 14.6 to 15.8), sensitivity (15.1%; 95% CI 14.3 to 15.9), and specificity (14.3%; 95% CI 13.7 to 15.0). Of these, 132 (64.7%) achieved the mastery standard in a median of 60 cases (interquartile range 58 to 83). Case features associated with an increased odds of a correct intrauterine pregnancy "present" diagnosis were transvaginal versus transabdominal-acquired images (odds ratio [OR]=1.5; 95% CI 1.3 to 1.8) and fetal heartbeat (OR=4.3; 95% CI 3.4 to 5.5). A decreased odds was associated with an eccentrically located intrauterine pregnancy (OR=0.2; 95% CI 0.1 to 0.2), subchorionic hemorrhage (OR=0.5; 95% CI 0.4 to 0.6), adnexal mass (OR=0.7; 95% CI 0.6 to 0.9), and endometrial collection (OR=0.1; 95% CI 0.09 to 0.2).

CONCLUSIONS

This study's intervention was effective in teaching first-trimester point-of-care ultrasound image interpretation and identified the specific variables that posed the greatest diagnostic challenges. The methods and results from this work can serve to expand learning opportunities for this critical skill in emergency medicine.

The effect of a provisional diagnosis on intern diagnostic reasoning: a mixed methods study

OBJECTIVES

Competency in diagnostic reasoning is integral to medical training and patient safety. Situativity theory highlights the importance of contextual factors on learning and performance, such as being informed of a provisional diagnosis prior to a patient encounter. This study aims to determine how being informed of a provisional diagnosis affects an intern's approach to diagnostic reasoning.

METHODS

This mixed methods study was conducted in a real-time workplace learning environment at a large teaching hospital. Interns were randomized to the Chief Complaint (CC) only or chief complaint with Provisional Diagnosis (PD) group. One blinded researcher assessed intern diagnostic reasoning using a validated tool. Mean group scores were compared using the two-sample t-test. The researcher was unblinded for think aloud interviews analyzed via thematic analysis.

RESULTS

There was no difference in performance between the CC and PD groups (mean ± SD): 47.8 ± 8.1 vs. 43.9 ± 10.9, p=0.24. Thematic analysis identified that interns aware of the provisional diagnosis 1) invested less effort in diagnostic reasoning, 2) formulated a differential through a narrowly focused frame, 3) accepted a provisional diagnosis as definitive, and 4) sought to confirm rather than refute the provisional diagnosis.

CONCLUSIONS

Our discordant results highlight the complex interplay between a provisional diagnosis and diagnostic reasoning performance in early learners. Though an accurate provisional diagnosis may enhance diagnostic reasoning outcomes, our qualitative results suggest that it may pose certain risks to the diagnostic reasoning process. Metacognitive strategies may be a ripe field for exploration to optimize this complex interplay.

The influence of context on diagnostic reasoning: A narrative synthesis of experimental findings

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.

A Targeted Clinical Reasoning Remediation Program for Residents and Fellows in Need

Background There is no standardized, widely accepted process for individualized clinical reasoning remediation. Objective We describe a novel, targeted assessment and coaching process that allows for individualized intervention for residents and fellows struggling with clinical reasoning. Methods Residents and fellows at the University of Virginia with performance concerns are referred to COACH (Committee on Achieving Competence Through Help) and assessed by a remediation expert. A subset is referred to a clinical reasoning remediation coach who performs an additional assessment and cocreates an individualized remediation plan. Following remediation, residents and fellows are reassessed by their respective programs. We report the frequency of struggle, remediation time invested, and academic outcomes. Results From 2017 to 2022, 114 residents and fellows referred to COACH met inclusion criteria, of which 38 (33%) had a deficiency in clinical reasoning. Targeted assessment revealed the following microskill deficits: hypothesis generation (16 of 38, 42%); data gathering (6 of 38, 16%); problem representation (7 of 38, 18%); hypothesis refinement (3 of 38, 8%); and management (6 of 38, 16%). Remediation required a mean of nearly 23 hours per trainee. Of the 38 trainees, 33 (87%) are in good standing at the time of writing. Conclusions Our unique program offers a feasible, targeted approach to clinical reasoning remediation based on our current understanding of the clinical reasoning process. Early hypothesis generation was the most common microskill deficit identified.

The effect of the auditory signal on videolaryngostroboscopy ratings and interpretation

OBJECTIVE

The primary aim of this study was to examine the effect of the videolaryngostroboscopic auditory signal on videolaryngostroboscopy (VLS) ratings and interpretation in normophonic and dysphonic speakers.

STUDY DESIGN

Prospective repeated measures design METHOD: Eight speech-language pathologists evaluated rigid VLS exams obtained from 12 dysphonic speakers with vocal fold pathology and 4 normophonic speakers with normal VLS exams. VLS exams were evaluated with the auditory signal present and absent with a washout period between rating sessions. VLS measures were obtained using the Voice-vibratory Assessment of Laryngeal Imaging (VALI) and a 100mm visual analog scale (VAS). The effects of the auditory signal and its interaction with voice quality severity on 9 VLS ratings, diagnostic billing codes, and treatment recommendations were examined.

RESULTS

There was no effect of auditory information on VLS measures or overall severity of laryngeal function evaluated using the VAS (ps > 0.05). There was a main effect of auditory information and a significant interaction with voice quality severity for only one VLS measure (non-vibrating portion-left) evaluated using the VALI (P = 0.05). Post-hoc analysis for this rating showed significant increases (t-test adjusted P < 0.05) when voice quality severity was moderate-severe (M = 4.8%; SD = 1.65%) and auditory information was present. Agreement in individual clinician's selection of diagnostic codes (73%) and treatment recommendations (65.6%) when auditory cues were present and absent was moderate to high.

CONCLUSION

The presence of the videolaryngostroboscopic auditory signal had a minimal effect on VLS ratings, treatment recommendations, or diagnostic billing codes.

Influences of early diagnostic suggestions on clinical reasoning

Previous research has highlighted the importance of physicians' early hypotheses for their subsequent diagnostic decisions. It has also been shown that diagnostic accuracy improves when physicians are presented with a list of diagnostic suggestions to consider at the start of the clinical encounter. The psychological mechanisms underlying this improvement in accuracy are hypothesised. It is possible that the provision of diagnostic suggestions disrupts physicians' intuitive thinking and reduces their certainty in their initial diagnostic hypotheses. This may encourage them to seek more information before reaching a diagnostic conclusion, evaluate this information more objectively, and be more open to changing their initial hypotheses. Three online experiments explored the effects of early diagnostic suggestions, provided by a hypothetical decision aid, on different aspects of the diagnostic reasoning process. Family physicians assessed up to two patient scenarios with and without suggestions. We measured effects on certainty about the initial diagnosis, information search and evaluation, and frequency of diagnostic changes. We did not find a clear and consistent effect of suggestions and detected mainly non-significant trends, some in the expected direction. We also detected a potential biasing effect: when the most likely diagnosis was included in the list of suggestions (vs. not included), physicians who gave that diagnosis initially, tended to request less information, evaluate it as more supportive of their diagnosis, become more certain about it, and change it less frequently when encountering new but ambiguous information; in other words, they seemed to validate rather than question their initial hypothesis. We conclude that further research using different methodologies and more realistic experimental situations is required to uncover both the beneficial and biasing effects of early diagnostic suggestions.

Deduction, Induction and the Art of Clinical Reasoning in Medical Education: Systematic Review and Bayesian Proposal

BACKGROUND

Clinical reasoning is at the core of medical practice and entangled in a conceptual confusion. The duality theory in probability allows to evaluate its objective and subjective aspects.

OBJECTIVES

To conduct a systematic review of the literature about clinical reasoning in decision making in medical education and to propose a "reasoning based on the Bayesian rule" (RBBR).

METHODS

A systematic review on PubMed was conducted (until February 27, 2022), following a strict methodology, by a researcher experienced in systematic review. The RBBR, presented in the discussion section, was constructed in his undergraduate dissertation in Philosophy at Minas Gerais Federal University. Heart failure was used as example.

RESULTS

Of 3,340 articles retrieved, 154 were included: 24 discussing the uncertainty condition, 87 on vague concepts (case discussion, heuristics, list of cognitive biases, choosing wisely) subsumed under the term "art", and 43 discussing the general idea of inductive or deductive reasoning. RBBR provides coherence and reproducibility rules, inference under uncertainty, and learning rule, and can incorporate those vague terms classified as "art", arguments and evidence, from a subjective perspective about probability.

CONCLUSIONS

This systematic review shows that reasoning is grounded in uncertainty, predominantly probabilistic, and reviews possible errors of the hypothetico-deductive reasoning. RBBR is a two-step probabilistic reasoning that can be taught. The Bayes theorem is a linguistic tool, a general rule of reasoning, diagnosis, scientific communication and review of medical knowledge according to new evidence.

The Effect of Information Presentation Order on Residents' Diagnostic Accuracy of Online Simulated Patients With Chest Pain

BACKGROUND

Physicians may receive diagnostic information in different orders, and there is a lack of empirical evidence that the order of presentation may influence clinical reasoning.

OBJECTIVE

We investigated whether diagnostic accuracy of chest pain cases is influenced by the order of presentation of the history and electrocardiogram (EKG) to cardiology residents.

METHODS

We conducted an experimental study during a resident training in 2019. Twelve clinical cases were presented in 2 diagnostic rounds. Residents were randomly allocated to seeing the EKG first (EKGF) or the history first (HF). The mean diagnostic accuracy scores (range 0-1) and confidence level (0-100) in each diagnostic round and time needed to make the diagnosis were evaluated.

RESULTS

The final diagnostic accuracy was higher than the initial in both groups. After the first round, diagnostic accuracy was higher in HF (n=24) than in EKGF (n=28). Time taken to judge the history was comparable in both groups. Time taken to judge the EKG was shorter in HF (40±11 vs 64±13 seconds; P<.01). Time invested in the second round was significantly correlated with changing the initial diagnosis. A significant difference was observed in confidence ratings after the initial diagnosis, with EKGF reporting less confidence relative to HF.

CONCLUSIONS

The order in which history and EKG are presented influences the clinical reasoning process.

Relationship of Physical Examination Technique to Associated Clinical Skills: Results from a Direct Observation Assessment

BACKGROUND

The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy.

METHODS

The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents' self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected.

RESULTS

From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback.

CONCLUSIONS

Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.

Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study

BACKGROUND

Diagnostic errors are a major cause of preventable patient harm. Studies suggest that presenting inaccurate diagnostic suggestions can cause errors in physicians' diagnostic reasoning processes. It is common practice for general practitioners (GPs) to suggest a diagnosis when referring a patient to secondary care. However, it remains unclear via which underlying processes this practice can impact diagnostic performance. This study therefore examined the effect of a diagnostic suggestion in a GP's referral letter to the emergency department on the diagnostic performance of medical interns.

METHODS

Medical interns diagnosed six clinical cases formatted as GP referral letters in a randomized within-subjects experiment. They diagnosed two referral letters stating a main complaint without a diagnostic suggestion (control), two stating a correct suggestion, and two stating an incorrect suggestion. The referral question and case order were randomized. We analysed the effect of the referral question on interns' diagnostic accuracy, number of differential diagnoses, confidence, and time taken to diagnose.

RESULTS

Forty-four medical interns participated. Interns considered more diagnoses in their differential without a suggested diagnosis (M = 1.85, SD = 1.09) than with a suggested diagnosis, independent of whether this suggestion was correct (M = 1.52, SD = 0.96, d = 0.32) or incorrect ((M = 1.42, SD = 0.97, d = 0.41), χ2(2) =7.6, p = 0.022). The diagnostic suggestion did not influence diagnostic accuracy (χ2(2) = 1.446, p = 0.486), confidence, (χ2(2) = 0.058, p = 0.971) or time to diagnose (χ2(2) = 3.128, p = 0.209).

CONCLUSIONS

A diagnostic suggestion in a GPs referral letter did not influence subsequent diagnostic accuracy, confidence, or time to diagnose for medical interns. However, a correct or incorrect suggestion reduced the number of diagnoses considered. It is important for healthcare providers and teachers to be aware of this phenomenon, as fostering a broad differential could support learning. Future research is necessary to examine whether these findings generalize to other healthcare workers, such as more experienced specialists or triage nurses, whose decisions might affect the diagnostic process later on.

TRIAL REGISTRATION

The study protocol was preregistered and is available online at Open Science Framework ( https://osf.io/7de5g ).

Representation, interaction and interpretation. Making sense of the context in clinical reasoning

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.

Computerized history-taking improves data quality for clinical decision-making-Comparison of EHR and computer-acquired history data in patients with chest pain

Patients’ medical histories are the salient dataset for diagnosis. Prior work shows consistently, however, that medical history-taking by physicians generally is incomplete and not accurate. Such findings suggest that methods to improve the completeness and accuracy of medical history data could have clinical value. We address this issue with expert system software to enable automated history-taking by computers interacting directly with patients, i.e. computerized history-taking (CHT). Here we compare the completeness and accuracy of medical history data collected and recorded by physicians in electronic health records (EHR) with data collected by CHT for patients presenting to an emergency room with acute chest pain. Physician history-taking and CHT occurred at the same ED visit for all patients. CHT almost always preceded examination by a physician. Data fields analyzed were relevant to the differential diagnosis of chest pain and comprised information obtainable only by interviewing patients. Measures of data quality were completeness and consistency of negative and positive findings in EHR as compared with CHT datasets. Data significant for the differential of chest pain was missing randomly in all EHRs across all data items analyzed so that the dimensionality of EHR data was limited. CHT files were near complete for all data elements reviewed. Separate from the incompleteness of EHR data, there were frequent factual inconsistencies between EHR and CHT data across all data elements. EHR data did not contain representations of symptoms that were consistent with those reported by patients during CHT.

Trial registration: This study is registered at https://www.clinicaltrials.gov (unique identifier: NCT03439449).

Image interpretation: Learning analytics-informed education opportunities

OBJECTIVES

Using a sample of pediatric chest radiographs (pCXR) taken to rule out pneumonia, we obtained diagnostic interpretations from physicians and used learning analytics to determine the radiographic variables and participant review processes that predicted for an incorrect diagnostic interpretation.

METHODS

This was a prospective cross-sectional study. A convenience sample of frontline physicians with a range of experience levels interpreted 200 pCXR presented using a customized online radiograph presentation platform. Participants were asked to determine absence or presence (with respective location) of pneumonia. The pCXR were categorized for specific image-based variables potentially associated with interpretation difficulty. We also generated heat maps displaying the locations of diagnostic error among normal pCXR. Finally, we compared image review processes in participants with higher versus lower levels of clinical experience.

RESULTS

We enrolled 83 participants (20 medical students, 40 postgraduate trainees, and 23 faculty) and obtained 12,178 case interpretations. Variables that predicted for increased pCXR interpretation difficulty were pneumonia versus no pneumonia (β = 8.7, 95% confidence interval [CI] = 7.4 to 10.0), low versus higher visibility of pneumonia (β = -2.2, 95% CI = -2.7 to -1.7), nonspecific lung pathology (β = 0.9, 95% CI = 0.40 to 1.5), localized versus multifocal pneumonia (β = -0.5, 95% CI = -0.8 to -0.1), and one versus two views (β = 0.9, 95% CI = 0.01 to 1.9). A review of diagnostic errors identified that bony structures, vessels in the perihilar region, peribronchial thickening, and thymus were often mistaken for pneumonia. Participants with lower experience were less accurate when they reviewed one of two available views (p < 0.0001), and accuracy of those with higher experience increased with increased confidence in their response (p < 0.0001).

CONCLUSIONS

Using learning analytics, we identified actionable learning opportunities for pCXR interpretation, which can be used to allow for a customized weighting of which cases to practice. Furthermore, experienced-novice comparisons revealed image review processes that were associated with greater diagnostic accuracy, providing additional insight into skill development of image interpretation.

Child Abuse Recognition Training for Prehospital Providers Using Deliberate Practice

BACKGROUND

In most states, prehospital professionals (PHPs) are mandated reporters of suspected abuse but cite a lack of training as a challenge to recognizing and reporting physical abuse. We developed a learning platform for the visual diagnosis of pediatric abusive versus non-abusive burn and bruise injuries and examined the amount and rate of skill acquisition.

METHODS

This was a prospective cross-sectional study of PHPs participating in an online educational intervention containing 114 case vignettes. PHPs indicated whether they believed a case was concerning for abuse and would report a case to child protection services. Participants received feedback after submitting a response, permitting deliberate practice of the cases. We describe learning curves, overall accuracy, sensitivity (diagnosis of abusive injuries) and specificity (diagnosis of non-abusive injuries) to determine the amount of learning. We performed multivariable regression analysis to identify specific demographic and case variables associated with a correct case interpretation. After completing the educational intervention, PHPs completed a self-efficacy survey on perceived gains in their ability to recognize cutaneous signs of abuse and report to social services.

RESULTS

We enrolled 253 PHPs who completed all the cases; 158 (63.6%) emergency medical technicians (EMT), 95 (36.4%) advanced EMT and paramedics. Learning curves demonstrated that, with one exception, there was an increase in learning for participants throughout the educational intervention. Mean diagnostic accuracy increased by 4.9% (95% CI 3.2, 6.7), and the mean final diagnostic accuracy, sensitivity, and specificity were 82.1%, 75.4%, and 85.2%, respectively. There was an increased odds of getting a case correct for bruise versus burn cases (OR = 1.4; 95% CI 1.3, 1.5); if the PHP was an Advanced EMT/Paramedic (OR = 1.3; 95% CI 1.1, 1.4) ; and, if the learner indicated prior training in child abuse (OR = 1.2; 95% CI 1.0, 1.3). Learners indicated increased comfort in knowing which cases should be reported and interpreting exams in children with cutaneous injuries with a median Likert score of 5 out of 6 (IQR 5, 6).

CONCLUSION

An online module utilizing deliberate practice led to measurable skill improvement among PHPs for differentiating abusive from non-abusive burn and bruise injuries.

Understanding context specificity: the effect of contextual factors on clinical reasoning

Background Situated cognition theory argues that thinking is inextricably situated in a context. In clinical reasoning, this can lead to context specificity: a physician arriving at two different diagnoses for two patients with the same symptoms, findings, and diagnosis but different contextual factors (something beyond case content potentially influencing reasoning). This paper experimentally investigates the presence of and mechanisms behind context specificity by measuring differences in clinical reasoning performance in cases with and without contextual factors. Methods An experimental study was conducted in 2018-2019 with 39 resident and attending physicians in internal medicine. Participants viewed two outpatient clinic video cases (unstable angina and diabetes mellitus), one with distracting contextual factors and one without. After viewing each case, participants responded to six open-ended diagnostic items (e.g. problem list, leading diagnosis) and rated their cognitive load. Results Multivariate analysis of covariance (MANCOVA) results revealed significant differences in angina case performance with and without contextual factors [Pillai's trace = 0.72, F = 12.4, df =(6, 29), p < 0.001, η p 2 = 0.72 $\eta _{\rm p}^2 = 0.72$ ], with follow-up univariate analyses indicating that participants performed statistically significantly worse in cases with contextual factors on five of six items. There were no significant differences in diabetes cases between conditions. There was no statistically significant difference in cognitive load between conditions. Conclusions Using typical presentations of common diagnoses, and contextual factors typical for clinical practice, we provide ecologically valid evidence for the theoretically predicted negative effects of context specificity (i.e. for the angina case), with large effect sizes, offering insight into the persistence of diagnostic error.

[Effect of the use of heuristics on diagnostic error in Primary Care: Scoping review]

OBJECTIVE

To assess the use of representativeness, availability, overconfidence, anchoring and adjustment heuristics in clinical practice, specifically in Primary Care setting.

DESIGN

Panoramic review (scope review).

DATA SOURCES

OvidMedline, Scopus, PsycoINFO, Cochrane Library and PubMed databases. Each one of the selected studies was reviewed applying TIDIER criteria (Template for Description of the Intervention and Replication) to facilitate their understanding and replicability.

SELECTION OF STUDIES

A total of 48 studies were selected that analyzed availability heuristics (26), anchoring and adjustment (9), overconfidence (9) and representativeness (8).

RESULTS

From the 48 studies selected, 26 analyzed availability heuristics, 9 anchoring and adjustment, 9 overconfidence; and 8 representativeness. The study population included physicians (35.4%), patients (27%), trainees (20.8%), nurses (14.5%) and students (14.5%). The studies conducted in clinical practice setting were 17 (35.4%). In 33 of the 48 studies (68,7%) it was observed heuristic use in the population studied. Heuristics use on diagnostic process was found in 27 studies (54.1%); 5 of them (18%) were carried out in clinical practice setting. Of the 48 studies, 6 (12,5%) were performed in Primary Care, 3 of which studied diagnostic process: only one of them analyzed the use of heuristics in clinical practice setting, without demonstrating bias as consequence of the use of heuristic.

CONCLUSION

The evidence about heuristic use in diagnostic process on clinical practice setting is limited, especially in Primary Care.

Deliberate practice as an educational method for learning to interpret the prepubescent female genital examination

BACKGROUND

Correct interpretation of the prepubescent female genital examination is a critical skill; however, physician skill in this area is limited.

OBJECTIVE

To complement the bedside learning of this examination, we developed a learning platform for the visual diagnosis of the prepubescent female genital examination and examined the amount and rate of skill acquisition.

PARTICIPANTS AND SETTING

Medical students, residents, and fellows and attendings participated in an on-line learning platform.

METHODS

This was a multicenter prospective cross-sectional study. Study participants deliberately practiced 158 prepubescent female genital examination cases hosted on a computer-based learning and assessment platform. Participants assigned the case normal or abnormal; if abnormal, they identified the location of the abnormality and the specific diagnosis. Participants received feedback after every case.

RESULTS

We enrolled 107 participants (26 students, 31 residents, 24 fellows and 26 attendings). Accuracy (95 % CI) increased by 10.3 % (7.8, 12.8), Cohen's d-effect size of 1.17 (1.14, 1.19). The change in specificity was +16.8 (14.1, 19.5) and sensitivity +2.4 (-0.9, 5.6). It took a mean (SD) 46.3 (32.2) minutes to complete cases. There was no difference between learner types with respect to initial (p = 0.2) or final accuracy (p = 0.4) scores.

CONCLUSIONS

This study's learning intervention led to effective and feasible skill improvement. However, while participants improved significantly with normal cases, which has relevance in reducing unnecessary referrals to child protection teams, learning gains were not as evident in abnormal cases. All levels of learners demonstrated a similar performance, emphasizing the need for this education even among experienced clinicians.

The information distortion bias: implications for medical decisions

CONTEXT

Every diagnosis involves an act of decision making, which requires proper evaluation of information. However, even seemingly objective information can require interpretation, often without our conscious awareness. In this cross-cutting edge article we describe the phenomenon of leader-driven information distortion (ID) and its implications for medical education.

INFORMATION DISTORTION

Recent research indicates that one threat to good decisions is a biased interpretation of information to favour one alternative course of action over another. Once an alternative emerges as a leader during a decision there is a strong tendency to evaluate subsequent information as supporting that option. This can occur when deciding between two competing diagnoses. It is particularly a concern if diagnostic tests provide potentially ambiguous results. This leader-driven ID is pre-decisional in nature, in that it develops during a decision and involves the interpretation of information available prior to the final decision or diagnosis, with different interpretations possible depending on whichever alternative is the leader. Studies reveal that the distortion bias is pervasive in decisions, and that awareness of the act of distortion is low in decision makers.

APPLICATION TO MEDICAL EDUCATION

Empirical research has confirmed the presence of leader-driven ID in hypothetical diagnoses made by physicians. ID creates two threats to medical decisions: First, it can make a diagnosis sticky in that it is resistant to being overturned by contradictory information. Second, it can promote unwarranted certainty in a diagnosis. The outcome may be premature closure, unnecessary testing or incorrect treatment, resulting in delayed or missed diagnoses.

METHODS

This paper summarises research related to leader-driven ID in medical and professional decisions and discusses various approaches directed towards reducing ID. A framework and language are provided for thinking about and discussing ID in medical decisions and medical education. Courses of action for mitigating the effects of ID are suggested.

Theories of truth and teaching clinical reasoning and problem solving

In this paper, we will first discuss two current meta-theories dealing with different, aspects of "truth". The first metatheory conceives of truth in terms of coherence (rationality, consistency): a body of knowledge is true when it contains no inconsistencies and has at least some credibility. The second metatheory conceives of truth as correspondence, i.e., empirical accuracy. The two metatheories supplement each other, but are also incommensurable, i.e., they cannot be expressed in each other's terms, for they employ completely different criteria to establish truth (Englebretsen in Bare facts and naked truths: a new correspondence theory of truth, Routledge, London, 2005). We will discuss both the role of both metatheories in medicine, in particular in medical education in a clinical context. In line with Hammond's view (Med Decis Mak 16(3):281-287, 1996a; Human judgment and social policy: irreducible uncertainty, inevitable error, unavoidable injustice, Oxford University Press, New York, 1996b), we will extend the two metatheories to two forms of competence: coherence competence and correspondence competence, and demonstrate that distinguishing these two forms of competence increases our insights as to the best way to teach undergraduate students clinical problem solving.

Does the accuracy of case history affect interpretation of videolaryngostroboscopic exams?

OBJECTIVE

To determine the effect of initial diagnostic hypotheses on clinicians' 1) detection and perceived severity of abnormalities, and 2) clinical impressions and treatment recommendations for individuals with and without voice disorders following interpretation of videolaryngostroboscopy (VLS).

METHODS

Thirty-two experienced speech-language pathologists and otolaryngologists specializing in voice disorders read case histories prior to interpreting exams. Case histories suggested specific accurate or inaccurate laryngeal diagnoses, or a control scenario that suggested a normal larynx. The effects of the accuracy of case histories on perceived severity of associated visual-perceptual parameters, clinical impressions, and treatment recommendations were examined.

RESULTS

Significant increases in perceived severity of posterior laryngeal appearance (P < 0.05) and mucosal wave (P < 0.02) were observed when these abnormalities were suggested by case histories. Overall agreement with clinical impressions improved from 49% to 72% when the case history was consistent with the examination. Case histories (accurate and inaccurate) indicating voice symptoms predicted recommendations for treatment above and beyond that of VLS presentation alone, P < 0.001.

CONCLUSION

Case histories suggesting specific abnormalities significantly affected severity ratings for two of three associated visual-perceptual parameters selected as primary outcome measures. Accurate case histories suggesting specific abnormalities increased the probability of detection and perceived severity. Inaccurate case histories led to false-positive findings and failures to detect abnormalities or to interpret them as less severe. Case histories affected visual-perceptual judgments and contributed to decisions about clinical impressions and treatment.

LEVEL OF EVIDENCE

2b Laryngoscope, 130:718-725, 2020.

Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?

Background Clinical medicine has long recognized the potential for cognitive bias in the development of new treatments, and in response developed a tradition of blinding both clinicians and patients to address this specific concern. Although cognitive biases have been shown to exist which impact the accuracy of clinical diagnosis, blinding the diagnostician to potentially misleading information has received little attention as a possible solution. Recently, within the forensic sciences, the control of contextual information (i.e. information apart from the objective test results) has been studied as a technique to reduce errors. We consider the applicability of this technique to clinical medicine. Content This article briefly describes the empirical research examining cognitive biases arising from context which impact clinical diagnosis. We then review the recent awakening of forensic sciences to the serious effects of misleading information. Comparing the approaches, we discuss whether blinding to contextual information might (and in what circumstances) reduce clinical errors. Summary and outlook Substantial research indicates contextual information plays a significant role in diagnostic error and conclusions across several medical specialties. The forensic sciences may provide a useful model for the control of potentially misleading information in diagnosis. A conceptual analog of the forensic blinding process (the "agnostic" first reading) may be applicable to diagnostic investigations such as imaging, microscopic tissue examinations and waveform recognition. An "agnostic" approach, where the first reading occurs with minimal clinical referral information, but is followed by incorporation of the clinical history and reinterpretation, has the potential to reduce errors.

Exploring the sources and mechanisms of cognitive errors in medical diagnosis with associative memory models

BACKGROUND

One of the central challenges of third millennium medicine is the abatement of medical errors. Among the most frequent and hardiest causes of misdiagnosis are cognitive errors produced by faulty medical reasoning. These errors have been analyzed from the perspectives of cognitive psychology and empirical medical studies. We introduce a neurocognitive model of medical diagnosis to address this issue.

METHODS

We construct a connectionist model based on the associative nature of human memory to explore the non-analytical, pattern-recognition mode of diagnosis. A context-dependent matrix memory associates signs and symptoms with their corresponding diseases. The weights of these associations depend on the frequencies of occurrence of each disease and on the different combinations of signs and symptoms of each presentation of that disease. The system receives signs and symptoms and by a second input, the degree of diagnostic uncertainty. Its output is a probabilistic map on the set of possible diseases.

RESULTS

The model reproduces different kinds of well-known cognitive errors in diagnosis. Errors in the model come from two sources. One, dependent on the knowledge stored in memory, varies with the accumulated experience of the physician and explains age-dependent errors and effects such as epidemiological masking. The other is independent of experience and explains contextual effects such as anchoring.

CONCLUSIONS

Our results strongly suggest that cognitive biases are inevitable consequences of associative storage and recall. We found that this model provides valuable insight into the mechanisms of cognitive error and we hope it will prove useful in medical education.

Quantifying Heuristic Bias: Anchoring, Availability, and Representativeness

Construct: Authors examined whether a new vignette-based instrument could isolate and quantify heuristic bias.

BACKGROUND

Heuristics are cognitive shortcuts that may introduce bias and contribute to error. There is no standardized instrument available to quantify heuristic bias in clinical decision making, limiting future study of educational interventions designed to improve calibration of medical decisions. This study presents validity data to support a vignette-based instrument quantifying bias due to the anchoring, availability, and representativeness heuristics.

APPROACH

Participants completed questionnaires requiring assignment of probabilities to potential outcomes of medical and nonmedical scenarios. The instrument randomly presented scenarios in one of two versions: Version A, encouraging heuristic bias, and Version B, worded neutrally. The primary outcome was the difference in probability judgments for Version A versus Version B scenario options.

RESULTS

Of 167 participants recruited, 139 enrolled. Participants assigned significantly higher mean probability values to Version A scenario options (M = 9.56, SD = 3.75) than Version B (M = 8.98, SD = 3.76), t(1801) = 3.27, p = .001. This result remained significant analyzing medical scenarios alone (Version A, M = 9.41, SD = 3.92; Version B, M = 8.86, SD = 4.09), t(1204) = 2.36, p = .02. Analyzing medical scenarios by heuristic revealed a significant difference between Version A and B for availability (Version A, M = 6.52, SD = 3.32; Version B, M = 5.52, SD = 3.05), t(404) = 3.04, p = .003, and representativeness (Version A, M = 11.45, SD = 3.12; Version B, M = 10.67, SD = 3.71), t(396) = 2.28, p = .02, but not anchoring. Stratifying by training level, students maintained a significant difference between Version A and B medical scenarios (Version A, M = 9.83, SD = 3.75; Version B, M = 9.00, SD = 3.98), t(465) = 2.29, p = .02, but not residents or attendings. Stratifying by heuristic and training level, availability maintained significance for students (Version A, M = 7.28, SD = 3.46; Version B, M = 5.82, SD = 3.22), t(153) = 2.67, p = .008, and residents (Version A, M = 7.19, SD = 3.24; Version B, M = 5.56, SD = 2.72), t(77) = 2.32, p = .02, but not attendings.

CONCLUSIONS

Authors developed an instrument to isolate and quantify bias produced by the availability and representativeness heuristics, and illustrated the utility of their instrument by demonstrating decreased heuristic bias within medical contexts at higher training levels.

Measuring Up to Expectation: Cognitive Bias in Wrist Range-of-Motion Measurement

Study Design Controlled laboratory study, cross-sectional design. Background The role of cognitive biases and their effect on a wide range of aspects relevant to clinical medicine has become the focus of a growing body of research, yet their effect in physical therapy is not well established. Objectives To test whether anchoring information provided to physical therapists prior to assessment of wrist range of motion (ROM) may induce bias in the measurement. Methods A total of 120 physical therapists participated in the study. Participants were asked to measure passive wrist extension ROM of a 65-year-old woman with no history of injury to the upper limb using a universal goniometer. Before initiating the measurement, some participants received a clinical description, which included sham information about the patient's health history. Three groups were differentiated according to the provided clinical content: no bias (n = 38), moderate bias (n = 41), and substantial bias (n = 41). An analysis of covariance was applied to test for differences between the 3 groups while controlling for any potential sex and experience effects. Results The analysis of covariance yielded a significant group effect (P = .009), with no significant effect for sex and experience. The adjusted mean wrist ROM was 80.2° for the no-bias group, 74.5° for the moderate-bias group, and 72.4° for the substantial-bias group. Post hoc tests demonstrated significant difference only between the group with no bias and the substantial-bias group (mean difference, 7.7°; P = .009). Conclusion Anchoring information was associated with differential results of an objective test. Physical therapists should increase their awareness of biases and consider employing debiasing strategies. J Orthop Sports Phys Ther 2016;46(12):1037-1041. Epub 30 Oct 2016. doi:10.2519/jospt.2016.6845.

Assessing musculoskeletal examination skills and diagnostic reasoning of 4th year medical students using a novel objective structured clinical exam

BACKGROUND

Medical students have difficulty performing and interpreting musculoskeletal physical examinations and interpreting the findings. Research has focused on students' knowledge deficits, but there are few direct assessments of students' ability to perform a hypothesis-driven physical examination (HDPE). We developed a novel musculoskeletal Objective Structured Clinical Exam (OSCE) focusing on HDPE skills for disorders of the shoulder, back and knee, and used it to explore medical student diagnostic reasoning.

METHODS

A multidisciplinary group of musculoskeletal specialists developed and gathered validity evidence for a three station OSCE focusing on the HDPE of the shoulder, back and knee, emphasizing the ability to anticipate (identify pre-encounter) expected physical exam findings, and subsequently perform discriminatory physical examination maneuvers. The OSCE was administered to 45 final year medical students. Trained faculty observed and scored students' ability to anticipate exam findings and perform diagnostic examination maneuvers on simulated patients. Encounters were digitally recorded and scored again by another trained faculty member. Inter-rater reliability for each maneuver was estimated using type-2 intra-class correlations (ICC). Percentages of perfect scores for anticipation and performance were calculated. Pearson's correlation between anticipation and performance scores was computed for each maneuver and their relationship to diagnostic accuracy was tested with logistic regression.

RESULTS

Inter-rater reliability was good (ICC between .69 and .87) for six exam maneuvers. Maneuver performance was overall poor, with no discriminatory maneuver performed correctly by more than two thirds of students, and one maneuver only performed correctly by 4 % of students. For the shoulder and knee stations, students were able to anticipate necessary discriminatory exam findings better than they could actually perform relevant exam maneuvers. The ability to anticipate a discriminatory finding correlated with the ability to perform the associated maneuver correctly, with the exception of the ability to perform maneuvers needed to diagnose a torn anterior cruciate ligament of the knee. Neither the ability to anticipate or perform was predictive of identifying correct diagnoses for the different cases.

CONCLUSIONS

A novel musculoskeletal OSCE, based on principles of the hypothesis-driven physical examination, was able to identify significant deficiencies in examination skills needed to diagnose common disorders of the shoulder, back and knee amongst graduating medical students. In addition, the OSCE demonstrated that accurate anticipation of discriminatory examination findings correlates with ability to perform the associated maneuver; however, the ability to anticipate exceeds the ability to perform. Students do not appear to be using the physical exam to inform their diagnostic reasoning. The findings of this study have implications for both assessment and teaching of the musculoskeletal exam.

Adversarial allegiance: The devil is in the evidence details, not just on the witness stand

This study examined the potential influence of adversarial allegiance on expert testimony in a simulated child sexual abuse case. A national sample of 100 witness suggestibility experts reviewed a police interview of an alleged 5-year-old female victim. Retaining party (prosecution, defense) and interview suggestibility (low, high) varied across experts. Experts were very willing to testify, but more so for the prosecution than the defense when interview suggestibility was low and vice versa when interview suggestibility was high. Experts' anticipated testimony focused more on prodefense aspects of the police interview and child's memory overall (negativity bias), but favored retaining party only when interview suggestibility was low. Prosecution-retained experts shifted their focus from prodefense aspects of the case in the high suggestibility interview to proprosecution aspects in the low suggestibility interview; defense experts did not. Blind raters' perceptions of expert focus mirrored those findings. Despite an initial bias toward retaining party, experts' evaluations of child victim accuracy and police interview quality were lower in the high versus low interview suggestibility condition only. Our data suggest that adversarial allegiance exists, that it can (but not always) influence how experts process evidence, and that it may be more likely in cases involving evidence that is not blatantly flawed. Defense experts may evaluate this type of evidence more negatively than prosecution experts because of negativity bias and positive testing strategies associated with confirmation bias. (PsycINFO Database Record

The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study

Aims and objectives

The aim of this study was to explore the consequences of the nurse's use of advanced assessment skills on medical and surgical wards.

Background

Appropriate, accurate, and timely assessment by nurses is the cornerstone of maintaining patient safety in hospitals. The inclusion of “advanced” physical assessment skills such as auscultation, palpation, and percussion is thought to better prepare nurses for complex patient presentations within a wide range of clinical situations.

Design

This qualitative study used a hermeneutic pragmatic approach.

Method

Unstructured interviews were conducted with five experienced medical and surgical nurses to obtain 13 detailed narratives of assessment practice. Narratives were analyzed using Van Manen's six-step approach to identify the consequences of the nurse's use of advanced assessment skills.

Results

The consequences of using advanced assessment skills include looking for more, challenging interpretations, and perseverance. The use of advanced assessment skills directs what the nurse looks for, what she sees, interpretation of the findings, and her response. It is the interpretation of what is seen, heard, or felt within the full context of the patient situation, which is the advanced skill.

Conclusion

Advanced assessment skill is the means to an accurate interpretation of the clinical situation and contributes to appropriate diagnosis and medical management in complex patient situations.

Relevance to clinical practice

The nurse's use of advanced assessment skills enables her to contribute to diagnostic reasoning within the acute medical and surgical setting.

The validity and reliability of the clinical assessment of increased work of breathing in acutely ill patients

BACKGROUND

Mechanical ventilation is frequently indicated to reduce the work of breathing. Because it cannot be measured easily at the bedside, physicians rely on surrogate measurements such as patient appearance of distress and increased breathing effort.

OBJECTIVE

We determined the validity and reliability of subjectively rating the appearance of respiratory distress and the reliability of 11 signs of increased breathing effort.

SUBJECTS

The study included consecutive, acutely ill patients requiring various levels of respiratory support.

METHODS

Blinded to each other's observations, a fellow and a critical care consultant rated the severity of distress (absent, slight, moderate, severe) after observing subjects for 10 seconds and then determined the presence of the signs of increased breathing effort.

RESULTS

A total of 149 paired examinations occurred 6±6 minutes apart. The rating of respiratory distress correlated with oxygenation, respiratory rate, and 9 signs of increased work of breathing. It had the highest intraclass correlation coefficient (0.69; 95% confidence interval, 0.59-0.78). Rating distress as moderate to severe had a sensitivity of 70%, specificity of 92%, and positive likelihood ratio of 8 for the presence of 3 or more of hypoxia, tachypnea, and any sign of increased breathing effort. Agreement was moderate (κ = 0.53-0.47) for rating of distress, nasal flaring, scalene contraction, gasping, and abdominal muscle contraction, and fair (κ = 0.36-0.23) for sternomastoid contraction, tracheal tug, and thoracoabdominal paradox.

CONCLUSION

Assessing the increased work of breathing by rating the severity of respiratory distress based on subject appearance is a valid and moderately reliable sign that predicts the presence of serious respiratory dysfunction. The reliability of the individual signs of increased breathing effort is moderate at best.

Effect of Extrinsic and Intrinsic Stressors on Clinical Skills Performance in Third-Year Medical Students

BACKGROUND

Both enhancements and impairments of clinical performance due to acute stress have been reported, often as a function of the intensity of an individual's response. According to the broader stress literature, peripheral or extrinsic stressors (ES) and task-contingent or intrinsic stressors (IS) can be distinguished within a stressful situation. The objective of this study was to assess the impact of IS and ES on clinical performance.

METHOD

A prospective randomized crossover study was undertaken with third-year medical students conducting two medical experiences with simulated patients. The effects of severity of the disease (IS) and the patient's aggressiveness (ES) were studied. A total of 109 students were assigned to four groups according to the presence of ES and IS. Subjective stress and anxiety responses were assessed before and after each experience. The students' clinical skills, diagnostic accuracy and argumentation were assessed as clinical performance measures. Sex and student-perceived cognitive difficulty of the task were considered as adjustment variables.

RESULTS

Both types of stressors improved clinical performance. IS improved diagnostic accuracy (regression parameter β = 9.7, p = 0.004) and differential argumentation (β = 5.9, p = 0.02), whereas ES improved clinical examination (β = 12.3, p < 0.001) and communication skills (β = 15.4, p < 0.001). The student-perceived cognitive difficulty of the task was a strong deleterious factor on both stress and performance.

CONCLUSION

In simulated consultation, extrinsic and intrinsic stressors both have a positive but different effect on clinical performance.

Errors in multidetector row computed tomography

Multidetector row computed tomography (MDCT) represents the technique of choice for the majority of pathologies today and is responsible for the majority of diagnoses. However, despite the low number of studies dedicated to errors in MDCT, CT reporting seems especially prone to generating errors and errors are an inevitable part of MDCT practice. Most of these arise during image interpretation but, differently from other radiological techniques, the awareness of radiologists regarding technical CT aspects and pathologies substantially contribute in generating errors, in particular because CT technology expands rapidly and radiologists do not routinely receive specific and appropriate training for its use and because CT examinations are not the same for each patient and each pathology and the choice of the most appropriate CT examination (including the dose exposure to the patient) presumes a very large awareness from radiologists. This review is aimed at increasing awareness regarding the type of errors in MDCT and in particular to also highlight technical and procedural errors.

Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy

BACKGROUND

The role of cognitive biases and heuristics in medical decision making is of growing interest. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to categorize the types of cognitive biases and heuristics found and whether they are found in patients or in medical personnel; and to critically review the studies based on standard methodological quality criteria.

METHOD

Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and the CINAHL databases published in 1980-2013. Predefined exclusion criteria were used to identify 213 studies. During data extraction, information was collected on type of bias or heuristic studied, respondent population, decision type, study type (actual or hypothetical), study method, and study conclusion.

RESULTS

Of the 213 studies analyzed, 164 (77%) were based on hypothetical vignettes, and 175 (82%) were conducted with representative populations. Nineteen types of cognitive biases and heuristics were found. Only 34% of studies (n = 73) investigated medical personnel, and 68% (n = 145) confirmed the presence of a bias or heuristic. Each methodological quality criterion was satisfied by more than 50% of the studies, except for sample size and validated instruments/questions. Limitations are that existing terms were used to inform search terms, and study inclusion criteria focused strictly on decision making.

CONCLUSIONS

Most of the studies on biases and heuristics in medical decision making are based on hypothetical vignettes, raising concerns about applicability of these findings to actual decision making. Biases and heuristics have been underinvestigated in medical personnel compared with patients.

The twin traps of overtreatment and therapeutic nihilism in clinical practice

CONTEXT

The modern version of the Hippocratic Oath requires doctors to swear that they will apply, for the benefit of the sick, all measures that are required, avoiding the twin traps of overtreatment and therapeutic nihilism. This paper explores the magnitude of the problem of overtreatment and undertreatment and the potential sources of these treatment errors.

METHODS

We undertook a narrative review of the literature on errors in treatment associated with flaws in doctors' judgements and present evidence from research into clinical reasoning and from psychological research into decision making. Based on evidence from these two research fields, we explored the possible reasons why doctors erroneously withhold or unnecessarily administer treatments.

RESULTS

Variation in treatment has been documented, even with similar clinical presentations under a variety of conditions, suggesting that overtreatment and undertreatment actually occur, with adverse effects for patients. Both types of error have been demonstrated, even when the doctor arrived at the correct diagnosis. They may be associated with the influence exerted on doctors' treatment judgements by factors that are unrelated to the specific problem, such as patients' socio-demographic characteristics and the doctor's practice culture. Doctors are also subject to commission bias and to omission bias, which have been demonstrated to occur in several domains. Such biases lead doctors to administer unnecessary treatments or to withhold required treatments due to anticipated regret. Little is known about cognitive processes underlying doctors' treatment decisions, but mental representations of diseases that provide the basis for diagnostic reasoning are also probably used for treatment judgements.

CONCLUSIONS

Doctors are at risk of falling into the twin traps of overtreatment and therapeutic nihilism. Further research should explore how to avoid these traps, but it may require deliberate reflection on problems to be solved to counteract the influence of factors that are beyond the patient's problem.

Cognitive Processes in Anesthesiology Decision Making

The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.

Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.

Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.

Effect of diagnostic predictions combined with clinical information on avoiding perceptual errors of computed tomography

PURPOSE

We hypothesized that even with appropriate clinical information, abnormal CT findings can still be missed if correct diagnostic predictions are not made.

MATERIALS AND METHODS

Of 388 total students (97 5th-year medical students × 4), students who detected abnormalities without clinical information were eliminated. The remaining students (hereafter, subjects) obtained clinical information, made diagnostic predictions, and reevaluated images. The proportion of failures in detecting abnormalities was compared between the correct prediction group and the incorrect prediction group. In the correct prediction group, the relationship between failures of detection and the ranking of the correct diagnosis was also examined.

RESULTS

A total of 341 subjects were assessed. The proportion of subjects who failed to detect abnormalities in the correct prediction group (47.7 %, 93/195) was significantly lower (P < 0.001) than in the incorrect prediction group (85.6 %, 125/146). In the correct prediction group, the proportion of subjects who failed to detect abnormalities was significantly lower (P = 0.004) when the correct diagnosis was ranked first (38.5 %, 42/109) compared with lower rankings (59.3 %, 51/86).

CONCLUSION

Making appropriate diagnostic predictions and estimating the possibility of them based on clinical information is important to avoid missing abnormal CT findings.

Cognitive diagnostic error in internal medicine

Medical error poses an important healthcare burden and a challenge for physicians and policy makers worldwide. Diagnostic error accounts for a substantial fraction of all medical mistakes. Most diagnostic errors have been associated with flaws in clinical reasoning. Empirical evidence on the cognitive mechanisms underlying such flaws and effectiveness of strategies to counteract them is scarce. Recent experimental studies, reviewed in this article, have increased our understanding of the relationship between cognitive factors and diagnostic mistakes. These studies have explored the role of cognitive biases, such as confirmation and availability bias, in diagnostic mistakes. They have suggested that confirmation bias and availability bias may indeed cause diagnostic errors. The latter bias seems to be associated with non-analytical reasoning, and was neutralized by analytical, or reflective, reasoning. Although non-analytical reasoning is a hallmark of clinical expertise, reflective reasoning was shown to improve diagnoses when cases are complex. Research on cognitive diagnostic mistakes remains a quite novel line of investigation. Follow-up studies that shine more light on the cognitive roots of, and cure for, diagnostic errors are needed.

Effect of stress on clinical reasoning during simulated ambulatory consultations

BACKGROUND

The goal of this study was to examine the impact of subjective and physiological stress responses on medical students' diagnostic reasoning and communication skills.

METHOD

A prospective randomized quantitative study was undertaken, looking at ambulatory consultations in internal medicine. On the first day (baseline day), volunteer year 6 students (n = 41) participated in a simulated ambulatory consultation with standardized patients (SPs). On the second day (study day), one week later, they were randomly assigned to two groups: a low stress (n = 20) and a high stress (n = 21) simulated ambulatory consultation. Stress was measured using validated questionnaires and salivary cortisol. The SPs assessed the students' reasoning and communication. The students completed assessments of their clinical reasoning after the consultations.

RESULTS

Although stress measures were all significantly higher in the high-stress condition (all p < 0.05), no differences were found in diagnostic accuracy and justification scores. However, correlational analyses revealed a negative correlation between multiple-stress measures and the students' ability to generate arguments for differential diagnoses.

CONCLUSION

Stress was associated with impairments in clinical reasoning, of a nature typically suggestive of premature closure.

Diagnostic reasoning: where we've been, where we're going

Recently, clinical diagnostic reasoning has been characterized by "dual processing" models, which postulate a fast, unconscious (System 1) component and a slow, logical, analytical (System 2) component. However, there are a number of variants of this basic model, which may lead to conflicting claims. This paper critically reviews current theories and evidence about the nature of clinical diagnostic reasoning. We begin by briefly discussing the history of research in clinical reasoning. We then focus more specifically on the evidence to support dual-processing models. We conclude by identifying knowledge gaps about clinical reasoning and provide suggestions for future research. In contrast to work on analytical and nonanalytical knowledge as a basis for reasoning, these theories focus on the thinking process, not the nature of the knowledge retrieved. Ironically, this appears to be a revival of an outdated concept. Rather than defining diagnostic performance by problem-solving skills, it is now being defined by processing strategy. The version of dual processing that has received most attention in the literature in medical diagnosis might be labeled a "default/interventionist" model,(17) which suggests that a default system of cognitive processes (System 1) is responsible for cognitive biases that lead to diagnostic errors and that System 2 intervenes to correct these errors. Consequently, from this model, the best strategy for reducing errors is to make students aware of the biases and to encourage them to rely more on System 2. However, an accumulation of evidence suggests that (a) strategies directed at increasing analytical (System 2) processing, by slowing down, reducing distractions, paying conscious attention, and (b) strategies directed at making students aware of the effect of cognitive biases, have no impact on error rates. Conversely, strategies based on increasing application of relevant knowledge appear to have some success and are consistent with basic research on concept formation.

The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments

OBJECTIVE

To investigate whether bias in clinical history affects accuracy of electrocardiograph (ECG) interpretation among doctors working in emergency departments.

DESIGN AND SETTING

Observational study conducted at four teaching hospitals in Sydney from May to September 2011.

PARTICIPANTS

Participants interpreted 30 ECGs representing 10 diagnoses. ECGs were provided with positively biased history (suggestive of the correct diagnosis), negatively biased history (suggestive of an alternative diagnosis) or no history.

MAIN OUTCOME MEASURES

Accuracy of ECG interpretation, measured as a score out of 10 (for each category of clinical history) and as a percentage of correctly interpreted ECGs.

RESULTS

Of 307 doctors who were sent a recruitment email for the study, 132 participated (43%). The overall mean accuracy of ECG interpretation was 52% (95% CI, 50%-53%). For junior doctors, mean accuracy was 42% (95% CI, 40%-44%); for senior doctors, it was 65% (95% CI, 62%-67%). In adjusted models, the mean predicted score for senior doctors provided with no history was 6.25 (95% CI, 5.90-6.62) with junior doctors obtaining mean scores 34% lower than senior doctors (95% CI, 29%-40%; P < 0.001). Compared with no history, positively biased history was associated with 42% higher mean scores (95% CI, 35%-49%; P < 0.001) and negatively biased history was associated with 34% lower mean scores (95% CI, 29%-39%; P < 0.001).

CONCLUSION

Bias in clinical history significantly influenced the accuracy of ECG interpretation. Strategies that reduce the detrimental impact of cognitive bias and improved ECG training for doctors are recommended.

Judging whether a patient is actually improving: more pitfalls from the science of human perception

Fallible human judgment may lead clinicians to make mistakes when assessing whether a patient is improving following treatment. This article provides a narrative review of selected studies in psychology that describe errors that potentially apply when a physician assesses a patient's response to treatment. Comprehension may be distorted by subjective preconceptions (lack of double blinding). Recall may fail through memory lapses (unwanted forgetfulness) and tacit assumptions (automatic imputation). Evaluations may be further compromised due to the effects of random chance (regression to the mean). Expression may be swayed by unjustified overconfidence following conformist groupthink (group polarization). An awareness of these five pitfalls may help clinicians avoid some errors in medical care when determining whether a patient is improving.

Accepting diagnostic suggestions by residents: a potential cause of diagnostic error in medicine

BACKGROUND

Psychological research has shown that people tend toward accepting rather than refuting hypotheses. Diagnostic suggestions may evoke such confirmatory tendencies in physicians, which may lead to diagnostic errors.

PURPOSE

This study investigated the influence of a suggested diagnosis on physicians' diagnostic decisions on written clinical cases. It was hypothesized that physicians would tend to go along with the suggestions and therefore would have more difficulty rejecting incorrect suggestions than accepting correct suggestions.

METHODS

Residents (N = 24) had to accept or reject suggested diagnoses on 6 cases. Three of those suggested diagnoses were correct, and 3 were incorrect.

RESULTS

Results showed the mean correct evaluation score on cases with a correct suggested diagnosis (M = 2.21, SD = 0.88) was significantly higher than the score on cases with an incorrect suggested diagnosis (M = 1.42, SD = 0.97), meaning physicians indeed found it easier to accept correct diagnoses than to reject incorrect diagnoses, t(23) = 2.74, p < .05, d = .85, despite equal experience with the diagnoses.

CONCLUSION

These findings indicate that suggested diagnoses may evoke confirmatory tendencies and consequently may lead to diagnostic errors.

The biasing effect of clinical history on physical examination diagnostic accuracy

CONTEXT

Literature on diagnostic test interpretation has shown that access to clinical history can both enhance diagnostic accuracy and increase diagnostic error. Knowledge of clinical history has also been shown to enhance the more complex cognitive task of physical examination diagnosis, possibly by enabling early hypothesis generation. However, it is unclear whether clinicians adhere to these early hypotheses in the face of unexpected physical findings, thus resulting in diagnostic error.

METHODS

A sample of 180 internal medicine residents received a short clinical history and conducted a cardiac physical examination on a high-fidelity simulator. Resident Doctors (Residents) were randomised to three groups based on the physical findings in the simulator. The concordant group received physical examination findings consistent with the diagnosis that was most probable based on the clinical history. Discordant groups received findings associated with plausible alternative diagnoses which either lacked expected findings (indistinct discordant) or contained unexpected findings (distinct discordant). Physical examination diagnostic accuracy and physical examination findings were analysed.

RESULTS

Physical examination diagnostic accuracy varied significantly among groups (75 ± 44%, 2 ± 13% and 31 ± 47% in the concordant, indistinct discordant and distinct discordant groups, respectively (F(2,177)  = 53, p < 0.0001). Of the 115 Residents who were diagnostically unsuccessful, 33% adhered to their original incorrect hypotheses. Residents verbalised an average of 12 findings (interquartile range: 10-14); 58 ± 17% were correct and the percentage of correct findings was similar in all three groups (p = 0.44).

CONCLUSIONS

Residents showed substantially decreased diagnostic accuracy when faced with discordant physical findings. The majority of trainees given discordant physical findings rejected their initial hypotheses, but were still diagnostically unsuccessful. These results suggest that overcoming the bias induced by a misleading clinical history may involve two independent steps: rejection of the incorrect initial hypothesis, and selection of the correct diagnosis. Educational strategies focused solely on prompting clinicians to re-examine their hypotheses may be insufficient to reduce diagnostic error.

Role of clinical context in residents' physical examination diagnostic accuracy

CONTEXT

Clinical context may act as both an aid to decision making and a source of bias contributing to medical error. The effect of clinical history, a form of clinical context, on the diagnostic accuracy of the physical examination is unknown.

METHODS

We randomised internal medicine residents to receive either no history or a short stem suggestive of one of six cardiac valvular diagnoses prior to a 10-minute objective structured clinical examination station assessing cardiac examination skills using a high-fidelity simulator. Clinical performance and diagnostic accuracy were compared using a standardised checklist.

RESULTS

A total of 159 internal medicine residents were enrolled after providing informed consent. Of these, 80% arrived at the correct diagnosis, with diagnostic accuracy varying significantly by valve lesion (49-100%; p < 0.0001). Clinical context was associated with improved diagnostic accuracy compared with no history (90% versus 74%; likelihood ratio= 6.6, p < 0.0001), but was not associated with trainees' ability to identify and characterise physical findings. Among residents given clinical context, higher diagnostic accuracy was only achieved by those able to correctly predict the diagnosis from the history.

CONCLUSIONS

Clinical context is associated with enhanced diagnostic accuracy of common valvular lesions. However, this effect seems linked to heuristic hypothesis generation and may predispose to premature diagnostic closure, anchoring and confirmation bias.