1
|
Norman G, Pelaccia T, Wyer P, Sherbino J. Dual process models of clinical reasoning: The central role of knowledge in diagnostic expertise. J Eval Clin Pract 2024. [PMID: 38825755 DOI: 10.1111/jep.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 04/09/2024] [Indexed: 06/04/2024]
Abstract
RATIONALE Research on diagnostic reasoning has been conducted for fifty years or more. There is growing consensus that there are two distinct processes involved in human diagnostic reasoning: System 1, a rapid retrieval of possible diagnostic hypotheses, largely automatic and based to a large part on experiential knowledge, and System 2, a slower, analytical, conscious application of formal knowledge to arrive at a diagnostic conclusion. However, within this broad framework, controversy and disagreement abound. In particular, many authors have suggested that the root cause of diagnostic errors is cognitive biases originating in System 1 and propose that educating learners about the types of cognitive biases and their impact on diagnosis would have a major influence on error reduction. AIMS AND OBJECTIVES In the present paper, we take issue with these claims. METHOD We reviewed the literature to examine the extent to which this theoretical model is supported by the evidence. RESULTS We show that evidence derived from fundamental research in human cognition and studies in clinical medicine challenges the basic assumptions of this theory-that errors arise in System 1 processing as a consequence of cognitive biases, and are corrected by slow, deliberative analytical processing. We claim that, to the contrary, errors derive from both System 1 and System 2 reasoning, that they arise from lack of access to the appropriate knowledge, not from errors of processing, and that the two processes are not essential to the process of diagnostic reasoning. CONCLUSIONS The two processing modes are better understood as a consequence of the nature of the knowledge retrieved, not as independent processes.
Collapse
Affiliation(s)
- Geoff Norman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Thierry Pelaccia
- Centre for Training and Research in Health Sciences Education (CFRPS), Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Peter Wyer
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jonathan Sherbino
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
2
|
Staal J, Waechter J, Allen J, Lee CH, Zwaan L. Deliberate practice of diagnostic clinical reasoning reveals low performance and improvement of diagnostic justification in pre-clerkship students. BMC MEDICAL EDUCATION 2023; 23:684. [PMID: 37735677 PMCID: PMC10515060 DOI: 10.1186/s12909-023-04541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/27/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE Diagnostic errors are a large burden on patient safety and improving clinical reasoning (CR) education could contribute to reducing these errors. To this end, calls have been made to implement CR training as early as the first year of medical school. However, much is still unknown about pre-clerkship students' reasoning processes. The current study aimed to observe how pre-clerkship students use clinical information during the diagnostic process. METHODS In a prospective observational study, pre-clerkship medical students completed 10-11 self-directed online simulated CR diagnostic cases. CR skills assessed included: creation of the differential diagnosis (Ddx), diagnostic justification (DxJ), ordering investigations, and identifying the most probable diagnosis. Student performances were compared to expert-created scorecards and students received detailed individualized formative feedback for every case. RESULTS 121 of 133 (91%) first- and second-year medical students consented to the research project. Students scored much lower for DxJ compared to scores obtained for creation of the Ddx, ordering tests, and identifying the correct diagnosis, (30-48% lower, p < 0.001). Specifically, students underutilized physical exam data (p < 0.001) and underutilized data that decreased the probability of incorrect diagnoses (p < 0.001). We observed that DxJ scores increased 40% after 10-11 practice cases (p < 0.001). CONCLUSIONS We implemented deliberate practice with formative feedback for CR starting in the first year of medical school. Students underperformed in DxJ, particularly with analyzing the physical exam data and pertinent negative data. We observed significant improvement in DxJ performance with increased practice.
Collapse
Affiliation(s)
- Justine Staal
- Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, the Netherlands
| | - Jason Waechter
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jon Allen
- Department of Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Chel Hee Lee
- Department of Mathematics, University of Calgary, Calgary, AB, Canada
| | - Laura Zwaan
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Institute of Medical Education Research, Erasmus Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands.
| |
Collapse
|
3
|
Staal J, Zegers R, Caljouw-Vos J, Mamede S, Zwaan L. Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. Diagnosis (Berl) 2023; 10:121-129. [PMID: 36490202 DOI: 10.1515/dx-2022-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Checklists that aim to support clinicians' diagnostic reasoning processes are often recommended to prevent diagnostic errors. Evidence on checklist effectiveness is mixed and seems to depend on checklist type, case difficulty, and participants' expertise. Existing studies primarily use abnormal cases, leaving it unclear how the diagnosis of normal cases is affected by checklist use. We investigated how content-specific and debiasing checklists impacted performance for normal and abnormal cases in electrocardiogram (ECG) diagnosis. METHODS In this randomized experiment, 42 first year general practice residents interpreted normal, simple abnormal, and complex abnormal ECGs without a checklist. One week later, they were randomly assigned to diagnose the ECGs again with either a debiasing or content-specific checklist. We measured residents' diagnostic accuracy, confidence, patient management, and time taken to diagnose. Additionally, confidence-accuracy calibration was assessed. RESULTS Accuracy, confidence, and patient management were not significantly affected by checklist use. Time to diagnose decreased with a checklist (M=147s (77)) compared to without a checklist (M=189s (80), Z=-3.10, p=0.002). Additionally, residents' calibration improved when using a checklist (phase 1: R2=0.14, phase 2: R2=0.40). CONCLUSIONS In both normal and abnormal cases, checklist use improved confidence-accuracy calibration, though accuracy and confidence were not significantly affected. Time to diagnose was reduced. Future research should evaluate this effect in more experienced GPs. Checklists appear promising for reducing overconfidence without negatively impacting normal or simple ECGs. Reducing overconfidence has the potential to improve diagnostic performance in the long term.
Collapse
Affiliation(s)
- Justine Staal
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - Robert Zegers
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Sílvia Mamede
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Rotterdam, The Netherlands
| | - Laura Zwaan
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
4
|
Harendza S, Bacher HJ, Berberat PO, Kadmon M, Gärtner J. Implicit expression of uncertainty in medical students during different sequences of clinical reasoning in simulated patient handovers. GMS JOURNAL FOR MEDICAL EDUCATION 2023; 40:Doc7. [PMID: 36923315 PMCID: PMC10010770 DOI: 10.3205/zma001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 08/19/2022] [Accepted: 11/23/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Dealing with medical uncertainty is an essential competence of physicians. During handovers, communication of uncertainty is important for patient safety, but is often not explicitly expressed and can hamper medical decisions. This study examines medical students' implicit expression of uncertainty in different sequences of clinical reasoning during simulated patient handovers. METHODS In 2018, eighty-seven final-year medical students participated in handovers of three simulated patient cases, which were videotaped and transcribed verbatim. Sequences of clinical reasoning and language references to implicit uncertainty that attenuate and strengthen information based on a framework were identified, categorized, and analyzed with chi-square goodness-of-fit tests. RESULTS A total of 6358 sequences of clinical reasoning were associated with the four main categories "statement", "assessment", "consideration", and "implication", with statements occurring significantly (p<0.001) most frequently. Attenuated sequences of clinical reasoning occurred significantly (p<0.003) more frequently than strengthened sequences. Implications were significantly more often attenuated than strengthened (p<0.003). Statements regarding results occurred significantly more often plain or strengthened than statements regarding actions (p<0.0025). CONCLUSION Implicit expressions of uncertainty in simulated medical students' handovers occur in different degrees during clinical reasoning. These findings could contribute to courses on clinical case presentations by including linguistic terms and implicit expressions of uncertainty and making them explicit.
Collapse
Affiliation(s)
- Sigrid Harendza
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Hans Jakob Bacher
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Pascal O. Berberat
- Technische Universität München, Fakultät für Medizin, TUM Medical Education Center, München, Germany
| | - Martina Kadmon
- Universität Augsburg, Medizinische Fakultät, Dekanat, Augsburg, Germany
| | - Julia Gärtner
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| |
Collapse
|
5
|
Job C, Adenipekun B, Cleves A, Samuriwo R. Health professional's implicit bias of adult patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review protocol. BMJ Open 2022; 12:e059837. [PMID: 36523234 PMCID: PMC9748961 DOI: 10.1136/bmjopen-2021-059837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Despite efforts to improve population health and reduce health inequalities, higher morbidity and mortality rates for people with lower socioeconomic status (SES) persist. People with lower SES are said to receive worse care and have worse outcomes compared with those with higher SES, in part due to bias and prejudice. Implicit biases adversely affect professional patient relationships and influence healthcare-related decision-making. A better understanding of the relationship between SES and healthcare-related decision-making is therefore essential to address socioeconomic inequalities in health. AIM To scope the reported impact of health professionals bias about SES on clinical decision-making and its effect on the care of adults with lower SES in wider literature. METHODS This scoping review will use Joanna Briggs Institute methods and will report its findings in line with Preferred Items for Systematic Reviews and Meta-Analyses for Protocols and Scoping Reviews guidelines. Data analysis, interpretation and reporting will be underpinned by the PAGER (Patterns, Advances, Gaps, Evidence for Practice and Research recommendations) framework and input from a patient and public interest representative. A systematic search for literature will be conducted on various, pertinent databases to identify relevant literature such as peer-reviewed articles, editorials, discussion papers and empirical research papers. Additionally, other sources of relevant literature such as policies, guidelines, reports and conference abstracts, identified through key website searches will be considered for inclusion. ETHICS AND DISSEMINATION Ethical approval is not required for this scoping review. The results will be disseminated through an open access peer-reviewed international journal, conference presentations and a plain language summary that will be shared with the public and other relevant stakeholders.
Collapse
Affiliation(s)
- Claire Job
- Cardiff University College of Biomedical and Life Sciences, Cardiff, UK
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Bami Adenipekun
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Anne Cleves
- Velindre University NHS Trust Library, Cardiff University Information Services, Cardiff, UK
| | - Ray Samuriwo
- School of Nursing and Healthcare Leadership, University of Bradford, Bradford, UK
| |
Collapse
|
6
|
Watsjold BK, Ilgen JS, Regehr G. An Ecological Account of Clinical Reasoning. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:S80-S86. [PMID: 35947479 DOI: 10.1097/acm.0000000000004899] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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.
Collapse
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
| |
Collapse
|
7
|
Anatomy of diagnosis in a clinical encounter: how clinicians discuss uncertainty with patients. BMC PRIMARY CARE 2022; 23:153. [PMID: 35715733 PMCID: PMC9205543 DOI: 10.1186/s12875-022-01767-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 06/12/2022] [Indexed: 12/27/2022]
Abstract
Background Studies consider the clinical encounter as linear, comprising six phases (opening, problem presentation, history-taking, physical examination, diagnosis, treatment and closing). This study utilizes formal conversation analysis to explore patient-physician interactions and understanding diagnostic utterances during these phases. Methods This study is a qualitative sub-analysis that explores how the diagnosis process, along with diagnostic uncertainty, are addressed during 28 urgent care visits. We analyzed physicians’ hypothesis-generation process by focusing on: location of diagnostic utterances during the encounter; whether certain/uncertain diagnostic utterances were revised throughout the encounter; and how physicians tested their hypothesis-generation and managed uncertainty. We recruited 7 primary care physicians (PCPs) and their 28 patients from Brigham and Women’s Hospital (BWH) in 3 urgent care settings. Encounters were audiotaped, transcribed, and coded using NVivo12 qualitative data analysis software. Data were analyzed inductively and deductively, using formal content and conversation analysis. Results We identified 62 diagnostic communication utterances in 12 different clinical situations. In most (24/28, 86%) encounters, the diagnosis process was initiated before the diagnosis phase (57% during history taking and 64% during physical examination). In 17 encounters (61%), a distinct diagnosis phase was not observed. Findings show that the diagnosis process is nonlinear in two ways. First, nonlinearity was observed when diagnostic utterances occurred throughout the encounter, with the six encounter phases overlapping, integrating elements of one phase with another. Second, nonlinearity was noted with respect to the resolution of diagnostic uncertainty, with physicians acknowledging uncertainty when explaining their diagnostic reasoning, even during brief encounters. Conclusions Diagnosis is often more interactive and nonlinear, and expressions of diagnostic assessments can occur at any point during an encounter, allowing more flexible and potentially more patient-centered communication. These findings are relevant for physicians’ training programs and helping clinicians improve their communication skills in managing uncertain diagnoses.
Collapse
|
8
|
Cleland J, Gates LJ, Waiter GD, Ho VB, Schuwirth L, Durning S. Even a little sleepiness influences neural activation and clinical reasoning in novices. Health Sci Rep 2021; 4:e406. [PMID: 34761123 PMCID: PMC8566838 DOI: 10.1002/hsr2.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND AIMS Sleepiness influences alertness and cognitive functioning and impacts many aspects of medical care, including clinical reasoning. However, dual processing theory suggests that sleepiness will impact clinical reasoning differently in different individual, depending on their level of experience with the given condition. Our aim, therefore, was to examine the association between clinical reasoning, neuroanatomical activation, and sleepiness in senior medical students. METHODS Our methodology replicated an earlier study but with novices rather than board-certified physicians. Eighteen final-year medical students answered validated multiple-choice questions (MCQs) during an fMRI scan. Each MCQ was projected in three phases: reading, answering, and reflection (modified think aloud). Echo-planar imaging (EPI) scans gave a time series that reflected blood oxygenation level dependent (BOLD) signal in each location (voxel) within the brain. Sleep data were collected via self-report (Epworth Sleepiness Scale) and actigraphy. These data were correlated with answer accuracy using Pearson correlation. RESULTS Analysis revealed an increased BOLD signal in the right dorsomedial prefrontal cortex (P < .05) during reflection (Phase 3) associated with increased self-reported sleepiness (ESS) immediately before scanning. Covariate analysis also revealed that increased BOLD signal in the right supramarginal gyrus (P < .05) when reflecting (Phase 3) was associated with increased correct answer response time. Both patterns indicate effortful analytic (System 2) reasoning. CONCLUSION Our findings that novices use System 2 thinking for clinical reasoning and even a little (perceived) sleepiness influences their clinical reasoning ability to suggest that the parameters for safe working may be different for novices (eg, junior doctors) and experienced physicians.
Collapse
Affiliation(s)
- Jennifer Cleland
- Lee Kong Chian School of Medicine, Nanyang Technological UniversitySingaporeSingapore
| | - Laura J. Gates
- Institute of Education for Medical and Dental Sciences, University of AberdeenAberdeenUK
| | - Gordon D. Waiter
- Aberdeen Biomedical Imaging Centre, University of AberdeenAberdeenUK
| | - Vincent B. Ho
- Department of Radiology and Radiological SciencesUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Lambert Schuwirth
- College of Medicine and Public Health, Flinders UniversityAdelaideAustralia
| | - Steven Durning
- Department of MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| |
Collapse
|
9
|
Feller L, Lemmer J, Nemutandani MS, Ballyram R, Khammissa RAG. Judgment and decision-making in clinical dentistry. J Int Med Res 2021; 48:300060520972877. [PMID: 33249958 PMCID: PMC7708710 DOI: 10.1177/0300060520972877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The development of clinical judgment and decision-making skills is complex, requiring clinicians—whether students, novices, or experienced practitioners—to correlate information from their own experience; from discussions with colleagues; from attending professional meetings, conferences and congresses; and from studying the current literature. Feedback from treated cases will consolidate retention in memory of the complexities and management of past cases, and the conversion of this knowledge base into daily clinical practice. The purpose of this narrative review is to discuss factors related to clinical judgment and decision-making in clinical dentistry and how both narrative, intuitive, evidence-based data-driven information and statistical approaches contribute to the global process of gaining clinical expertise.
Collapse
Affiliation(s)
- Liviu Feller
- Office of the Chair of School, School of Oral Health Sciences. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Johan Lemmer
- Department of Oral Medicine and Periodontology, School of Oral Health Sciences. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mbulaheni Simon Nemutandani
- Chair of School of Oral Health Sciences. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raoul Ballyram
- Department of Periodontology and Oral Medicine, 37715Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Razia Abdool Gafaar Khammissa
- Department of Periodontics and Oral Medicine, School of Oral Health Sciences, Faculty of Health Sciences. 56410University of Pretoria, Pretoria, South Africa
| |
Collapse
|
10
|
Staal J, Alsma J, Mamede S, Olson APJ, Prins-van Gilst G, Geerlings SE, Plesac M, Sundberg MA, Frens MA, Schmidt HG, Van den Broek WW, Zwaan L. The relationship between time to diagnose and diagnostic accuracy among internal medicine residents: a randomized experiment. BMC MEDICAL EDUCATION 2021; 21:227. [PMID: 33882919 PMCID: PMC8061054 DOI: 10.1186/s12909-021-02671-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/08/2021] [Indexed: 05/02/2023]
Abstract
BACKGROUND Diagnostic errors have been attributed to cognitive biases (reasoning shortcuts), which are thought to result from fast reasoning. Suggested solutions include slowing down the reasoning process. However, slower reasoning is not necessarily more accurate than faster reasoning. In this study, we studied the relationship between time to diagnose and diagnostic accuracy. METHODS We conducted a multi-center within-subjects experiment where we prospectively induced availability bias (using Mamede et al.'s methodology) in 117 internal medicine residents. Subsequently, residents diagnosed cases that resembled those bias cases but had another correct diagnosis. We determined whether residents were correct, incorrect due to bias (i.e. they provided the diagnosis induced by availability bias) or due to other causes (i.e. they provided another incorrect diagnosis) and compared time to diagnose. RESULTS We did not successfully induce bias: no significant effect of availability bias was found. Therefore, we compared correct diagnoses to all incorrect diagnoses. Residents reached correct diagnoses faster than incorrect diagnoses (115 s vs. 129 s, p < .001). Exploratory analyses of cases where bias was induced showed a trend of time to diagnose for bias diagnoses to be more similar to correct diagnoses (115 s vs 115 s, p = .971) than to other errors (115 s vs 136 s, p = .082). CONCLUSIONS We showed that correct diagnoses were made faster than incorrect diagnoses, even within subjects. Errors due to availability bias may be different: exploratory analyses suggest a trend that biased cases were diagnosed faster than incorrect diagnoses. The hypothesis that fast reasoning leads to diagnostic errors should be revisited, but more research into the characteristics of cognitive biases is important because they may be different from other causes of diagnostic errors.
Collapse
Affiliation(s)
- J Staal
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands.
| | - J Alsma
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S Mamede
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - A P J Olson
- Division of General Internal Medicine, University of Minnesota, Section of Hospital Medicine, Minneapolis, USA
| | - G Prins-van Gilst
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S E Geerlings
- Department of Internal Medicine and Department of Infectious Diseases, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M Plesac
- Division of General Internal Medicine, University of Minnesota, Section of Hospital Medicine, Minneapolis, USA
| | - M A Sundberg
- Division of General Internal Medicine, University of Minnesota, Section of Hospital Medicine, Minneapolis, USA
| | - M A Frens
- Department of Neuroscience, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - H G Schmidt
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - W W Van den Broek
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - L Zwaan
- Erasmus Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
11
|
Mays SA. A dual process model for paleopathological diagnosis. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2020; 31:89-96. [PMID: 33132164 DOI: 10.1016/j.ijpp.2020.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/25/2020] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This paper aims to provide an explicit theoretical model for the cognitive processes involved in paleopathological diagnosis. METHODS The approach adopted is a dual process model (DPM). DPMs recognize that cognition is a result of both Type 1 (intuitive) and Type 2 (analytical) processes. DPMs have been influential for understanding decision-making in a range of fields, including diagnosis in clinical medicine. Analogies are drawn between diagnosis in a clinical and a paleopathological setting. RESULTS In clinical medicine, both Type 1 and Type 2 processes play a part in diagnosis. In paleopathology the role of Type 1 processes has been unacknowledged. However, like clinical diagnosis, paleopathological diagnosis is inherently a result of a combination of both Type 1 and Type 2 processes. A model is presented by which Type 1 processes can be explicitly incorporated into a scientific approach to diagnosis from skeletal remains, and in which diagnosis is formalized as a process of hypothesis testing. SIGNIFICANCE Accurately modelling our diagnostic processes allows us to understand the biases and limitations in our work and potentially helps us to improve our procedures, including how we impart diagnostic skills in pedagogical settings. LIMITATIONS This work provides a theoretical model for paleopathological diagnosis. However, such models are by their nature dynamic and developing rather than static entities; it is hoped that this work stimulates further debate and discussion in this important area.
Collapse
Affiliation(s)
- S A Mays
- Investigative Science, Historic England, UK; Department of Archaeology, University of Southampton, UK; School of History, Classics and Archaeology, University of Edinburgh, UK.
| |
Collapse
|
12
|
Hartigan S, Brooks M, Hartley S, Miller RE, Santen SA, Hemphill RR. Review of the Basics of Cognitive Error in Emergency Medicine: Still No Easy Answers. West J Emerg Med 2020; 21:125-131. [PMID: 33207157 PMCID: PMC7673867 DOI: 10.5811/westjem.2020.7.47832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022] Open
Abstract
Emergency physicians (EP) make clinical decisions multiple times daily. In some instances, medical errors occur due to flaws in the complex process of clinical reasoning and decision-making. Cognitive error can be difficult to identify and is equally difficult to prevent. To reduce the risk of patient harm resulting from errors in critical thinking, it has been proposed that we train physicians to understand and maintain awareness of their thought process, to identify error-prone clinical situations, to recognize predictable vulnerabilities in thinking, and to employ strategies to avert cognitive errors. The first step to this approach is to gain an understanding of how physicians make decisions and what conditions may predispose to faulty decision-making. We review the dual-process theory, which offers a framework to understand both intuitive and analytical reasoning, and to identify the necessary conditions to support optimal cognitive processing. We also discuss systematic deviations from normative reasoning known as cognitive biases, which were first described in cognitive psychology and have been identified as a contributing factor to errors in medicine. Training physicians in common biases and strategies to mitigate their effect is known as debiasing. A variety of debiasing techniques have been proposed for use by clinicians. We sought to review the current evidence supporting the effectiveness of these strategies in the clinical setting. This discussion of improving clinical reasoning is relevant to medical educators as well as practicing EPs engaged in continuing medical education.
Collapse
Affiliation(s)
- Sarah Hartigan
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Internal Medicine, Richmond, Virginia
| | - Michelle Brooks
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Internal Medicine, Richmond, Virginia
| | - Sarah Hartley
- University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan
| | - Rebecca E Miller
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Internal Medicine, Richmond, Virginia
| | - Sally A Santen
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Emergency Medicine, Richmond, Virginia
| | - Robin R Hemphill
- Virginia Commonwealth University School of Medicine/VCU Health, Department of Emergency Medicine, Richmond, Virginia
| |
Collapse
|
13
|
Richmond A, Cooper N, Gay S, Atiomo W, Patel R. The student is key: A realist review of educational interventions to develop analytical and non-analytical clinical reasoning ability. MEDICAL EDUCATION 2020; 54:709-719. [PMID: 32083744 DOI: 10.1111/medu.14137] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/19/2020] [Accepted: 02/06/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Clinical reasoning refers to the cognitive processes used by individuals as they formulate a diagnosis or treatment plan. Clinical reasoning is dependent on formal and experiential knowledge. Developing the ability to acquire and recall knowledge effectively for both analytical and non-analytical cognitive processing has patient safety implications. This realist review examines the way educational interventions develop analytical and non-analytical reasoning ability in undergraduate education. A realist review is theory-driven, seeking not only to identify if an intervention works, but also understand the reasons why, for whom, and in what circumstances. The aim of this study is to develop understanding about the way educational interventions develop effective analytical and non-analytical clinical reasoning ability, when they do, for whom and in what circumstances. METHODS Literature from a scoping search, combined with expert opinion and researcher experience was synthesised to generate an initial programme theory (IPT). Four databases were searched and articles relevant to the developing theory were selected as appropriate. Factors affecting educational outcomes at the individual student, teacher and wider organisational levels were investigated in order to further refine the IPT. RESULTS A total of 28 papers contributed to the overall programme theory. The review predominantly identified evidence of mechanisms for interventions at the individual student level. Key student level factors influencing the effectiveness of interventions included an individual's self-confidence, self-efficacy and pre-existing level of knowledge. These contexts influenced a variety of educational interventions, impacting both positively and negatively on educational outcomes. CONCLUSIONS Development of analytical and non-analytical clinical reasoning ability requires activities that enhance knowledge acquisition and recall alongside the accumulation of clinical experience and opportunities to practise reasoning in real or simulated clinical environments. However, factors such as pre-existing knowledge and self-confidence influence their effectiveness, especially amongst individuals with 'low knowledge.' Promoting non-analytical reasoning once novices acquire more clinical knowledge is important for the development of clinical reasoning in undergraduate education.
Collapse
Affiliation(s)
- Anna Richmond
- Education Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola Cooper
- Department of Acute Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Simon Gay
- School of Medicine, University of Leicester, Leicester, UK
| | - William Atiomo
- Education Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rakesh Patel
- Education Centre, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
14
|
Olson AP, Graber ML. Improving Diagnosis Through Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1162-1165. [PMID: 31977340 PMCID: PMC7382536 DOI: 10.1097/acm.0000000000003172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Diagnosis is the cornerstone of providing safe and effective medical care. Still, diagnostic errors are all too common. A key to improving diagnosis in practice is improving diagnosis education, yet formal education about diagnosis is often lacking, idiosyncratic, and not evidence based. In this Invited Commentary, the authors describe the outcomes of a national consensus project to identify key competencies for diagnosis and the themes that emerged as part of this work. The 12 competencies the authors describe span 3 categories-individual, teamwork, and system related-and address ideal diagnostic practice for all health professionals. In addition, the authors identify strategies for improving diagnosis education, including the use of theory-based pedagogy and interprofessional approaches, the recognition of the role of the health care system to enhance or inhibit the diagnostic process, and the need to focus on the individual attributes necessary for high-quality diagnosis, such as humility and curiosity. The authors conclude by advocating for increasing and improving the assessment of individual and team-based diagnostic performance in health professions education programs.
Collapse
Affiliation(s)
- Andrew P.J. Olson
- A.P.J. Olson is associate professor, Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mark L. Graber
- M.L. Graber is chief medical officer, Society to Improve Diagnosis in Medicine, New York, New York
| |
Collapse
|
15
|
Elston DM. Confirmation bias in medical decision-making. J Am Acad Dermatol 2020; 82:572. [DOI: 10.1016/j.jaad.2019.06.1286] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 11/26/2022]
|
16
|
Abstract
After more than two decades of enthusiasm surrounding the concept of evidence based medicine, wide variation in its implementation is still present. Some have suggested that evidence based medicine may be a failed model. We propose that the highly formulaic approach of evidence based medicine has evolved toward a more personalized, integrated and contextualized method, consistent with the principle of shared decision making advanced by the Institute of Medicine. Evidence based medicine remains an essential prerequisite but ultimately, only the practitioner's clinical expertise, knowledge and practical wisdom will provide the ability to apply general rules of evidence to particular clinical situations.
Collapse
Affiliation(s)
- Alex C Vidaeff
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Mark A Turrentine
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
17
|
Burger A, Huenges B, Köster U, Thomas M, Woestmann B, Lieverscheidt H, Rusche HH, Schäfer T. 15 years of the model study course in medicine at the Ruhr University Bochum. GMS JOURNAL FOR MEDICAL EDUCATION 2019; 36:Doc59. [PMID: 31815169 PMCID: PMC6883250 DOI: 10.3205/zma001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 07/09/2019] [Accepted: 07/25/2019] [Indexed: 06/10/2023]
Abstract
The Faculty of Medicine of the Ruhr University Bochum (RUB) introduced a model study course in medicine (MSM) in the winter semester 2003. For 9 consecutive years, 42 out of 280 first year students at the Ruhr University Bochum had the opportunity to begin their studies in the model study course in medicine. The places were allocated amongst the applicants internally through a raffle. The MSM was consistently problem-, practice- and patient-oriented and largely did away with lectures, broke with the distinction between a pre-clinical and clinical phase and tested basic knowledge in equivalent integrated exams focusing on clinical application. Following a comparative evaluation of the standard degree course (RSM) and the MSM, the faculty merged the two degree courses into the Integrated Reformed Medical Curriculum (IRMC), which has been on offer since 2013 and is characterized by a topic-oriented hybrid curriculum. This article examines experiences relating to the origins, conception and introduction of the MSM.
Collapse
Affiliation(s)
- A. Burger
- Ruhr University Bochum, Zentrum für Medizinische Lehre, Bochum, Germany
| | - B. Huenges
- Ruhr University Bochum, Abteilung für Allgemeinmedizin, Bochum, Germany
| | - U. Köster
- Ruhr University Bochum, Zentrum für Medizinische Lehre, Bochum, Germany
| | - M. Thomas
- Ruhr University Bochum, Zentrum für Medizinische Lehre, Bochum, Germany
| | - B. Woestmann
- Ruhr University Bochum, Abteilung für Allgemeinmedizin, Bochum, Germany
| | - H. Lieverscheidt
- Ruhr University Bochum, Zentrum für Medizinische Lehre, Bochum, Germany
| | - H. H. Rusche
- Ruhr University Bochum, Zentrum für Medizinische Lehre, Bochum, Germany
- Ruhr University Bochum, Abteilung für Allgemeinmedizin, Bochum, Germany
| | - T. Schäfer
- Ruhr University Bochum, Zentrum für Medizinische Lehre, Bochum, Germany
| |
Collapse
|
18
|
Van den Brink N, Holbrechts B, Brand PLP, Stolper ECF, Van Royen P. Role of intuitive knowledge in the diagnostic reasoning of hospital specialists: a focus group study. BMJ Open 2019; 9:e022724. [PMID: 30696671 PMCID: PMC6352845 DOI: 10.1136/bmjopen-2018-022724] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Intuition is an important part of human decision-making and can be explained by the dual-process theory where analytical and non-analytical reasoning processes continually interact. These processes can also be identified in physicians' diagnostic reasoning. The valuable role of intuition, including gut feelings, has been shown among general practitioners and nurses, but less is known about its role among hospital specialists. This study focused on the diagnostic reasoning of hospital specialists, how they value, experience and use intuition. DESIGN AND PARTICIPANTS Twenty-eight hospital specialists in the Netherlands and Belgium participated in six focus groups. The discussions were recorded, transcribed verbatim and thematically coded. A circular and iterative analysis was applied until data saturation was achieved. RESULTS Despite initial reservations regarding the term intuition, all participants agreed that intuition plays an important role in their diagnostic reasoning process. Many agreed that intuition could guide them, but were cautious not to be misguided. They were especially cautious since intuition does not have probative force, for example, in medicolegal situations. 'On-the-job experience' was regarded as a precondition to relying on intuition. Some participants viewed intuition as non-rational and invalid. All participants said that intuitive hunches must be followed by analytical reasoning. Cultural differences were not found. Both the doctor as a person and his/her specialty were seen as important determinants for using intuition. CONCLUSIONS Hospital specialists use intuitive elements in their diagnostic reasoning, in line with general human decision-making models. Nevertheless, they appear to disagree more on its role and value than previous research has shown among general practitioners. A better understanding of how to take advantage of intuition, while avoiding pitfalls, and how to develop 'skilled' intuition may improve the quality of hospital specialists' diagnostic reasoning.
Collapse
Affiliation(s)
- Nydia Van den Brink
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Birgit Holbrechts
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Paul L P Brand
- Department of Pediatrics, Isala Hospitals, Zwolle, The Netherlands
| | - Erik C F Stolper
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
- CAPHRI School for Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands
| | - Paul Van Royen
- CAPHRI School for Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands
| |
Collapse
|
19
|
Zeidan AJ, Khatri UG, Aysola J, Shofer FS, Mamtani M, Scott KR, Conlon LW, Lopez BL. Implicit Bias Education and Emergency Medicine Training: Step One? Awareness. AEM EDUCATION AND TRAINING 2019; 3:81-85. [PMID: 30680351 PMCID: PMC6339553 DOI: 10.1002/aet2.10124] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Prior research suggests that health care providers are susceptible to implicit biases, specifically prowhite biases, and that these may contribute to health care disparities by influencing physician behavior. Despite these findings, implicit bias training is not currently embedded into emergency medicine (EM) residency training and few studies exist that evaluate the effectiveness of implicit bias training on awareness during residency conference. We sought to conduct a mixed-methods program evaluation of a formalized educational intervention targeted on the topic of implicit bias. METHODS We used a design thinking framework to develop a curricular intervention. The intervention consisted of taking the Harvard Implicit Association Test (IAT) on race to introduce the concept of implicit bias, followed by a facilitated discussion to explore participant's perceptions on whether implicit bias may lead to variations in care. The facilitated discussion was audio recorded, transcribed, and coded for emerging themes. An online survey assessed participant awareness of these topics before and after the intervention and was analyzed using paired t-tests. RESULTS After the intervention, participant's awareness of their individual implicit biases increased by 33.3% (p = 0.003) and their awareness of how their IAT results influences how they deliver care to patients increased by 9.1% (p = 0.03). Emerging themes included skepticism of the implicit bias test results with the desire to have "neutral" results, acknowledgment that pattern recognition may lead to "blind spots" in care, recognition that bias exists on a personal and systemic level, and interest in regular educational interventions to address implicit bias. CONCLUSIONS This novel educational intervention on implicit bias resulted in improvement in participants' awareness of their implicit biases and how it may affect their patient care. Our intervention can serve as a model for other residency programs to develop and implement an intervention to create awareness of implicit bias and its potential impact on patient care.
Collapse
Affiliation(s)
- Amy J. Zeidan
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Utsha G. Khatri
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Jaya Aysola
- Division of General Internal MedicineDepartment of MedicinePerelman School of MedicineLeonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Frances S. Shofer
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Mira Mamtani
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Kevin R. Scott
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Lauren W. Conlon
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Bernard L. Lopez
- Department of Emergency MedicineSidney Kimmel Medical College, of Thomas Jefferson UniversityPhiladelphiaPA
| |
Collapse
|
20
|
Phelan PS. The value of Bayes' theorem for pure likelihood clinical reasoning. J Eval Clin Pract 2018; 24:782-783. [PMID: 29761592 DOI: 10.1111/jep.12952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Patrick S Phelan
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| |
Collapse
|
21
|
Chin-Yee B, Fuller J. Clinical judgement: Multidisciplinary perspectives. J Eval Clin Pract 2018; 24:635-637. [PMID: 29691965 DOI: 10.1111/jep.12931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Jonathan Fuller
- Toronto Philosophy of Medicine and Healthcare Network, University of Toronto, Toronto, Canada
| |
Collapse
|