Dealing with cognitive dissonance: an approach

Types of therapeutic errors in the management of osteoporosis made by physicians and medical students

BACKGROUND

Clinical reasoning is of high importance in clinical practice and thus in medical education research. Regarding the clinical reasoning process, the focus has primarily been on diagnostic reasoning and diagnostic errors, but little research has been done on the subsequent management reasoning process, although the therapeutic decision-making process is at least equally important. The aim of this study was to investigate the frequency of therapeutic decision errors and the cognitive factors leading to these errors in the context of osteoporosis, as it is known to be frequently associated with inadequate treatment decisions in clinical practice worldwide.

METHODS

In 2019, 19 medical students and-for comparison-23 physicians worked on ten patient cases with the medical encounter of osteoporosis. A total of 254 cases were processed. The therapeutic decision errors were quantitatively measured, and the participants' cognitive contributions to therapeutic errors and their clinical consequences were qualitatively analysed.

RESULTS

In 26% of the cases, all treatment decisions were correct. In the remaining 74% cases, multiple errors occurred; on average, 3 errors occurred per case. These 644 errors were further classified regarding the cognitive contributions to the error. The most common cognitive contributions that led to errors were faulty context generation and interpretation (57% of students, 57% of physicians) and faulty knowledge (38% of students, 35% of physicians). Errors made due to faulty metacognition (5% of students, 8% of physicians) were less common. Consequences of these errors were false therapy (37% of cases), undertreatment (30% of cases) or overtreatment (2.5% of cases).

CONCLUSION

The study is the first to show that errors in therapy decisions can be distinguished and classified, similar to the already known classification for errors in diagnostic reasoning. Not only the correct diagnosis, but particularly the correct therapy, is critical for the outcome of a patient.

Medical student misconceptions in cardiovascular physiology

Students find cardiovascular physiology challenging. Misunderstandings can be due to the nature of the subject, the way it is taught, and prior knowledge, which impede learning of new concepts. Some misunderstood concepts can be corrected with teaching (i.e., preconceptions), whereas others are resistant to instruction (i.e., misconceptions). A set of questions, specifically created by a panel of physiology experts to probe difficult cardiovascular concepts, was used to identify preconceptions, misconceptions, and the effect of education level on question performance. The introductory cardiovascular lecture used in this study was created based on these questions. In-class polling of medical students' (n = 736) performance was performed using the Turning-Point clicker response system during lecture instruction. Results were compared with published data from undergraduates (n = 1,076) who completed the same questions but without prior instruction. To our knowledge, there have been no studies directly comparing performance using the same instrument and large numbers of undergraduate and medical students. A higher education level was associated with increased performance (preconceptions), whereas several concepts resistant to instruction (misconceptions) were identified. Findings suggest that prior knowledge interfered with the acquisition of medical knowledge. Based on these results, potential causes for these misconceptions and remedial teaching suggestions are discussed.