Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment: Table 1

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 systematic review of workplace triggers of emotions in the healthcare environment, the emotions experienced, and the impact on patient safety

BACKGROUND

Healthcare staff deliver patient care in emotionally charged settings and experience a wide range of emotions as part of their work. These emotions and emotional contexts can impact the quality and safety of care. Despite the growing acknowledgement of the important role of emotion, we know very little about what triggers emotion within healthcare environments or the impact this has on patient safety.

OBJECTIVE

To systematically review studies to explore the workplace triggers of emotions within the healthcare environment, the emotions experienced in response to these triggers, and the impact of triggers and emotions on patient safety.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four electronic databases were searched (MEDLINE, PsychInfo, Scopus, and CINAHL) to identify relevant literature. Studies were then selected and data synthesized in two stages. A quality assessment of the included studies at stage 2 was undertaken.

RESULTS

In stage 1, 90 studies were included from which seven categories of triggers of emotions in the healthcare work environment were identified, namely: patient and family factors, patient safety events and their repercussions, workplace toxicity, traumatic events, work overload, team working and lack of supervisory support. Specific emotions experienced in response to these triggers (e.g., frustration, guilt, anxiety) were then categorised into four types: immediate, feeling states, reflective, and longer-term emotional sequelae. In stage 2, 13 studies that explored the impact of triggers or emotions on patient safety processes/outcomes were included.

CONCLUSION

The various triggers of emotion and the types of emotion experienced that have been identified in this review can be used as a framework for further work examining the role of emotion in patient safety. The findings from this review suggest that certain types of emotions (including fear, anger, and guilt) were more frequently experienced in response to particular categories of triggers and that healthcare staff's experiences of negative emotions can have negative effects on patient care, and ultimately, patient safety. This provides a basis for developing and tailoring strategies, interventions, and support mechanisms for dealing with and regulating emotions in the healthcare work environment.

Teaching medical students to apply deliberate reflection

PURPOSE

Deliberate reflection on initial diagnosis has been found to repair diagnostic errors. We investigated the effectiveness of teaching students to use deliberate reflection on future cases and whether their usage would depend on their perception of case difficulty.

METHOD

One-hundred-nineteen medical students solved cases either with deliberate-reflection or without instructions to reflect. One week later, all participants solved six cases, each with two equally likely diagnoses, but some symptoms in the case were associated with only one of the diagnoses (discriminating features). Participants provided one diagnosis and subsequently wrote down everything they remembered from it. After the first three cases, they were told that the next three would be difficult cases. Reflection was measured by the proportion of discriminating features recalled (overall; related to their provided diagnosis; related to alternative diagnosis).

RESULTS

The deliberate-reflection condition recalled more features for the alternative diagnosis than the control condition (p = .013) regardless of described difficulty. They also recalled more features related to their provided diagnosis on the first three cases (p = .004), but on the last three cases (described as difficult), there was no difference.

CONCLUSION

Learning deliberate reflection helped students engage in more reflective reasoning when solving future cases.

Diagnostic Reasoning Competency and Accuracy by Nurse Practitioner Students Following the Use of Structured Reflection in Simulation: A Mixed-Methods Experiment

AIM

The aim of this study was to examine the effect of structured reflection used during a simulated patient's diagnostic workup on diagnostic reasoning competency and accuracy and explore participants' cognitive bias experience and perceived utility of structured reflection.

BACKGROUND

Reasoning flaws may lead to diagnostic errors. Medical learners who used structured reflection demonstrated improved diagnosis accuracy.

METHOD

Embedded mixed-methods experiment examined diagnostic reasoning competency and accuracy of nurse practitioner students who did and did not use structured reflection. Cognitive bias experience and perceptions of structured reflection's utility were explored.

RESULTS

Diagnostic Reasoning Assessment mean competency scores and categories were not changed. Accuracy trended toward improvement with structured reflection. The theme, diagnostic verification, prompted diagnosis change by both structured reflection users and control participants.

CONCLUSION

Despite no changes in quantitative outcomes, explicit users of structured reflection believed that this strategy is helpful to their reasoning, and control participants used the strategy's components with the same noted benefits.

Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment

OBJECTIVES

Patients with mental illness are less likely to receive the same physical healthcare as those without mental illness and are less likely to be treated in accordance with established guidelines. This study employed a randomized experiment to investigate the influence of comorbid depression on diagnostic accuracy.

METHODS

Physicians were presented with an interactive vignette describing a patient with a complex presentation of pernicious anemia. They were randomized to diagnose either a patient with or without (control) comorbid depression and related behaviors. All other clinical information was identical. Physicians recorded a differential diagnosis, ordered tests, and rated patient likeability.

RESULTS

Fifty-nine physicians completed the study. The patient with comorbid depression was less likeable than the control patient (p=0.03, 95 % CI [0.09, 1.53]). Diagnostic accuracy was lower in the depression compared to control condition (59.4 % vs. 40.7 %), however this difference was not statistically significant χ2(1)=2.035, p=0.15. Exploratory analyses revealed that patient condition (depression vs. control) interacted with the number of diagnostic tests ordered to predict diagnostic accuracy (OR=2.401, p=0.038). Accuracy was lower in the depression condition (vs. control) when physicians ordered fewer tests (1 SD below mean; OR=0.103, p=0.028), but there was no difference for physicians who ordered more tests (1 SD above mean; OR=2.042, p=0.396).

CONCLUSIONS

Comorbid depression and related behaviors lowered diagnostic accuracy when physicians ordered fewer tests - a time when more possibilities should have been considered. These findings underscore the critical need to develop interventions to reduce diagnostic error when treating vulnerable populations such as those with depression.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study

BACKGROUND

Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult.

OBJECTIVE

To investigate the association between physician empathy and difficult patient encounters (DPEs).

DESIGN

Cross-sectional study.

PARTICIPANTS

Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities.

MAIN MEASURES

Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering.

KEY RESULTS

The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01).

CONCLUSION

Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty.

The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases

BACKGROUND

Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted.

OBJECTIVE

To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs.

DESIGN

Experimental vignette research.

SETTING

Online experiment distributed via email between October and December 2020.

PARTICIPANTS

Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States.

METHODS

Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information.

RESULTS

Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis.

CONCLUSIONS

Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs.

TWEETABLE ABSTRACT

Experimental evidence links irritable patient behaviors to lower quality emergency department nurse handoffs, which may compromise patient safety @(lindamisbell) @(Nathan_Huff_1).

Learning deliberate reflection in medical diagnosis: does learning-by-teaching help?

Deliberate reflection has been found to foster diagnostic accuracy on complex cases or under circumstances that tend to induce cognitive bias. However, it is unclear whether the procedure can also be learned and thereby autonomously applied when diagnosing future cases without instructions to reflect. We investigated whether general practice residents would learn the deliberate reflection procedure through 'learning-by-teaching' and apply it to diagnose new cases. The study was a two-phase experiment. In the learning phase, 56 general-practice residents were randomly assigned to one of two conditions. They either (1) studied examples of deliberate reflection and then explained the procedure to a fictitious peer on video; or (2) solved cases without reflection (control). In the test phase, one to three weeks later, all participants diagnosed new cases while thinking aloud. The analysis of the test phase showed no significant differences between the conditions on any of the outcome measures (diagnostic accuracy, p = .263; time to diagnose, p = .598; mental effort ratings, p = .544; confidence ratings, p = .710; proportion of contradiction units (i.e. measure of deliberate reflection), p = .544). In contrast to findings on learning-by-teaching from other domains, teaching deliberate reflection to a fictitious peer, did not increase reflective reasoning when diagnosing future cases. Potential explanations that future research might address are that either residents in the experimental condition did not apply the learned deliberate reflection procedure in the test phase, or residents in the control condition also engaged in reflection.

Toward understanding nurses' decisions whether to miss care: A discrete choice experiment

BACKGROUND

Studies of missed nursing care suggest that it results from ward-level, patient-related, and task-type factors, while nurses' decision-making style was scarcely studied. Studying the effect of nurses' decision-preference structures, namely a pattern of joint ward and patient factors, on missed care may also contribute to understanding the phenomenon.

OBJECTIVES

To examine the relationships between decision-preference structures and missed care and the moderating effects of decision-making styles and task type in these links.

DESIGN

A discrete choice experiment with a between- and within-participants design.

PARTICIPANTS

A sample of 387 registered nurses working in acute medical surgical wards in Israel.

METHODS

Based on the protocol for discrete choice experiments, a survey was developed to assess the decision-preference structure, considering five factors: overload, presence of head nurse, clinical complexity, difficult patient, and presence of relatives. Participants were randomly assigned to four task-type conditions and completed a survey regarding their task. Decision-making style was assessed using a validated questionnaire.

RESULTS

Extensive workload (b = -0.46; p = 0.001), difficult patient (b = -0.20; p = 0.001), and patient clinical complexity (b = -0.10; p = 0.006) were negatively linked to the probability of missed care. The interaction between workload and task type (b = 0.252; p = 0.017) indicated that the probability of missed care under extensive compared with regular workload was lowest for developing a discharge plan and highest for providing emotional support. The interaction of patient complexity and task type (b = 0.230; p = 0.013) indicated that the probability of missed care in developing a discharge plan and medication administration was lower for patients having high compared with low clinical complexity. The interaction between difficult patient and task type (b = -0.219; p = 0.044) indicated that the probability of missed care in emotional support, developing a discharge plan, and patient's mobility was lower for difficult than for non-difficult patients. Finally, the interaction between workload and decision-making style (b = -0.48; p = 0.001) indicated that the probability of missed care under heavy compared with regular workloads was lower for the dual-preference or the dominantly intuitive styles.

CONCLUSIONS

This design enabled examining the prioritizing processes nurses use when deciding about whether to miss care. The likelihood of missing more in structured tasks is lower under a heavy overload and when patients appear difficult or clinically complex. Dual-preference styles or dominantly intuitive styles are more suitable for the routine high workload.

Frequency of Difficult Patient Encounters in a Japanese University Hospital and Community Hospitals: A Cross-sectional Study

Objective Difficult patient encounters (DPEs) are defined as encounters with patients causing strong negative feelings in physicians. In primary care settings, DPEs account for approximately 15% of visits among outpatients. To our knowledge, this is the first epidemiological study of DPEs in Japan. Methods We conducted a survey of 8 physicians (5.0±2 years of clinical experience) who examined first-visit patients ≥15 years old with clinical symptoms at the Department of General Medicine in Chiba University Hospital and 4 community hospitals over a 2-month period since December 2015. Materials We evaluated 10-Item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) scores (DPE ≥31 points; non-DPE ≤30 points) and patient age, sex, and presence of psychological or social problems. Results The valid response rate was 98.9% (94/95) and 98.4% (189/192) in the university and community hospitals, respectively. The percentage of DPEs was 39.8% (37/93) and 15.0% (26/173) in the university and community hospitals, respectively; the percentage of DPEs was significantly higher at the university hospital than at the community hospitals (p<0.001). The proportion of patients with psychosocial problems was significantly higher in the DPE group than in the non-DPE group (93.7% vs. 40.4%, p<0.001). Conclusion Our findings were similar to those reported in primary care settings in other countries in community hospital outpatient and general internal medicine departments, where patients are mostly non-referrals, although the values were higher in university hospital general medicine departments, where patients were mostly referrals. Patients involved in DPEs have a high rate of psychological and social problems.

Improving diagnostic decision support through deliberate reflection: a proposal

Digital decision support (DDS) is expected to play an important role in improving a physician's diagnostic performance and reducing the burden of diagnostic error. Studies with currently available DDS systems indicate that they lead to modest gains in diagnostic accuracy, and these systems are expected to evolve to become more effective and user-friendly in the future. In this position paper, we propose that a way towards this future is to rethink DDS systems based on deliberate reflection, a strategy by which physicians systematically review the clinical findings observed in a patient in the light of an initial diagnosis. Deliberate reflection has been demonstrated to improve diagnostic accuracy in several contexts. In this paper, we first describe the deliberate reflection strategy, including the crucial element that would make it useful in the interaction with a DDS system. We examine the nature of conventional DDS systems and their shortcomings. Finally, we propose what DDS based on deliberate reflection might look like, and consider why it would overcome downsides of conventional DDS.

Deliberate reflection and clinical reasoning: Founding ideas and empirical findings

CONTEXT

The idea that reflection improves reasoning and learning, since long present in other fields, emerged in the 90s in the medical education literature. Since then, the number of publications on reflection as a means to improve diagnostic learning and clinical problem-solving has increased steeply. Recently, concerns with diagnostic errors have raised further interest in reflection. Several approaches based on reflection have been proposed to reduce clinicians' errors during diagnostic reasoning. What reflection entails varies substantially, and most approaches still require empirical examination.

PURPOSE

The present essay aims to help clarify the role of deliberate reflection in diagnostic reasoning. Deliberate reflection is an approach whose effects on diagnostic reasoning and learning have been empirically studied over the past 15 years. The philosophical roots of the approach will be briefly examined, and the theory and practice of deliberate reflection, particularly its effectiveness, will be reviewed. Lessons learned and unresolved issues will be discussed.

DISCUSSION

The deliberate reflection approach originated from a conceptualization of the nature of reflection practice in medicine informed by Dewey's and Schön's work. The approach guides physicians through systematically reviewing the grounds of their initial diagnosis and considering alternatives. Experimental evidence has supported the effectiveness of deliberate reflection in increasing physicians' diagnostic performance, particularly in nonstraightforward diagnostic tasks. Deliberate reflection has also proved helpful to improve students' diagnostic learning and to facilitate learning of new information. The mechanisms behind the effects of deliberate reflection remain unclear. Tentative explanations focus on the activation/reorganisation of prior knowledge induced by deliberate reflection. Its usefulness depends therefore on the difficulty of the problem relative to the clinician's knowledge. Further research should examine variations in instructions on how to reflect upon a case, the value of further guidance while learning from deliberate reflection, and its benefits in real practice.

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit?

Objective

To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit.

Methods

A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales.

Results

Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration.

Conclusion

Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration.

Innovation

Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness.

Level of evidence

N/a.

Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis

Background

Preventable diagnostic errors are a large burden on healthcare. Cognitive reasoning tools, that is, tools that aim to improve clinical reasoning, are commonly suggested interventions. However, quantitative estimates of tool effectiveness have been aggregated over both workplace-oriented and educational-oriented tools, leaving the impact of workplace-oriented cognitive reasoning tools alone unclear. This systematic review and meta-analysis aims to estimate the effect of cognitive reasoning tools on improving diagnostic performance among medical professionals and students, and to identify factors associated with larger improvements.

Methods

Controlled experimental studies that assessed whether cognitive reasoning tools improved the diagnostic accuracy of individual medical students or professionals in a workplace setting were included. Embase.com, Medline ALL via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar were searched from inception to 15 October 2021, supplemented with handsearching. Meta-analysis was performed using a random-effects model.

Results

The literature search resulted in 4546 articles of which 29 studies with data from 2732 participants were included for meta-analysis. The pooled estimate showed considerable heterogeneity (I2=70%). This was reduced to I2=38% by removing three studies that offered training with the tool before the intervention effect was measured. After removing these studies, the pooled estimate indicated that cognitive reasoning tools led to a small improvement in diagnostic accuracy (Hedges’ g=0.20, 95% CI 0.10 to 0.29, p<0.001). There were no significant subgroup differences.

Conclusion

Cognitive reasoning tools resulted in small but clinically important improvements in diagnostic accuracy in medical students and professionals, although no factors could be distinguished that resulted in larger improvements. Cognitive reasoning tools could be routinely implemented to improve diagnosis in practice, but going forward, more large-scale studies and evaluations of these tools in practice are needed to determine how these tools can be effectively implemented.

PROSPERO registration number

CRD42020186994.

“Difficult” dental patients: a grounded theory study of dental staff’s experiences

Introduction

The “difficult” patient is a well-known and potentially negative character in various care contexts.

Objectives

This study aimed to generate a conceptual framework explaining the main concerns about “difficult” dental patients, and obtain a deeper understanding of their characteristics, how they affect the dental staff and how the staff think and act in order to manage these patients.

Methods

Ten interviews were conducted with professional dental caregivers, including dentists, dental hygienists, and dental nurses. The audio-recorded interviews were transcribed and analyzed in accordance with the principles of grounded theory.

Results

The main concern regarding “difficult” dental patients generated a framework of seven descriptive interrelated lower-level categories grounded in the data, subsumed in the core category “balancing subjective difficulties”. The informants perceived the possession of “showing interaction difficulties” and “having bio-psycho-social complexity”, as characteristic features of “difficult” patients, who could further adversely affect the dental staff by “evoking negative emotions and behaviors”, “hampering self-esteem and job satisfaction”, and “impairing life and health in general”. To manage the dental care of these patients, the staff used strategies aimed at “activating internal and external resources” and “creating adaptive treatment relations” with patients.

Conclusions

The dental staff’s meaning of the phenomenon of “difficult” dental patients points to specific characteristics, effects, and handling strategies. The core category captures the contradictory dynamics of characteristics and affects as these concepts seem interrelated to the caregivers’ handling capacity. The dental staff’s possibility of handling the main concern through balancing subjective difficulties depends on contextual conditions regarding time, to bring the patient and/or oneself at the center of attention. This indicates a need for further research regarding dental interactions and studies generalizing the outlook on “difficult” dental patients.

Using conversation analysis to appraise how novel educational videos impact patient medical education

OBJECTIVE

To determine in what ways, if any, do patients, caregivers, and nurses make videos relevant during in-person education.

METHODS

We applied conversation analysis to analyze interaction in 12 nurse-led education visits (1011 min of audio) in which speakers referred to a supplemental education video.

RESULTS

Patients initiated talk about the video in about half of the clinic visits analyzed, while nurses initiated talk about the video across all clinic visits analyzed. Interactions showed that patients demonstrated knowledge of video content and clarified information concerning their treatment plans by asking questions of nurses. Nurses referenced the video prior to repeating information that they recognized patients had viewed. In all instances analyzed, nurses made references to the videos in ways that re-oriented conversations back toward the content of the informal scripts that they used to deliver patient education.

CONCLUSION

Patients referenced the video in ways that demonstrated that they had viewed it and had gained knowledge concerning treatment plans, and to ask specific questions about these. Nurses referred to the videos by acknowledging patients' prior knowledge of upcoming information.

PRACTICE IMPLICATIONS

Understanding how pre-delivered supplemental videos impact patient involvement in in-person education contributes understanding to how video-based instruction supports patient-centered care.

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.

Even a little sleepiness influences neural activation and clinical reasoning in novices

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.

Workplace violence on healthcare professionals and underreporting: Characterization and knowledge gaps for prevention

Work-related violence against healthcare workers inflicted by healthcare users is a rising multidimensional phenomenon, a cause of concern among those who ensure the safety and health of these professionals. Although different studies indicate high percentages of attacks against healthcare workers, statistics from reports reveal much lower data. Underreporting of occupational violence against healthcare workers is a well-known fact reported in many studies. It is presented as a major obstacle when it comes to proposing adequate preventive measures, because the data on which to base these measures do not correspond to the true incidence of all the assaults that take place. Underreporting also makes it difficult to correctly assess the usefulness of preventive measures implemented. The following article looks at the latest studies carried out on the subject, presenting an overview of the factors accompanying these assaults, as well as the main reasons for this underreporting. It also highlights the lack in the literature of instruments designed to measure underreporting that have undergone a validation process. For all these reasons, this problem requires further study with validated tools to determine the reasons and circumstances that accompany and promote the underreporting of violence against healthcare workers. Knowing these reasons is a preliminary step in the fight against workplace violence and to measure the true magnitude of the problem, to provide the occupational health services with precise data and develop and assess the preventive measures implemented.

Somatic health care professionals' stigmatization of patients with mental disorder: a scoping review

BACKGROUND

Patients with mental disorders have an increased risk of developing somatic disorders, just as they have a higher risk of dying from them. These patients often report feeling devaluated and rejected by health professionals in the somatic health care system, and increasing evidence shows that disparities in health care provision contribute to poor health outcomes. The aim of this review was to map and synthesize literature on somatic health professionals' stigmatization toward patients with mental disorders.

METHODS

We conducted a scoping review using Arksey and O'Malley's framework and carried out a systematic search in three databases: Cinahl, MEDLINE, and PsycINFO in May-June 2019. Peer-reviewed articles published in English or Scandinavian languages during 2008-2019 were reviewed according to title, abstract and full-text reading. We organized and analyzed data using NVivo.

RESULTS

A total of 137 articles meeting the eligibility criteria were reviewed and categorized as observational studies (n = 73) and intervention studies (n = 64). A majority of studies (N = 85) focused on patients with an unspecified number of mental disorders, while 52 studies focused on specific diagnoses, primarily schizophrenia (n = 13), self-harm (n = 13), and eating disorders (n = 9). Half of the studies focused on health students (n = 64), primarily nursing students (n = 26) and medical students (n = 25), while (n = 66) focused on health care professionals, primarily emergency staff (n = 16) and general practitioners (n = 13). Additionally, seven studies focused on both health professionals and students. A detailed characterization of the identified intervention studies was conducted, resulting in eight main types of interventions.

CONCLUSIONS

The large number of studies identified in this review suggests that stigmatizing attitudes and behaviors toward patients with mental disorders is a worldwide challenge within a somatic health care setting. For more targeted interventions, there is a need for further research on underexposed mental diagnoses and knowledge on whether specific health professionals have a more stigmatizing attitude or behavior toward specific mental disorders.

Clinician-family relationships may impact neonatal intensive care: clinicians' perspectives

OBJECTIVE

Collaborative clinician-family relationships are necessary for the delivery of successful patient- and family-centered care (PFCC) in the NICU. Challenging clinician-family relationships may undermine such collaboration and the potential impacts on patient care are unknown.

STUDY DESIGN

Consistent caregivers were surveyed to describe their relationships and collaboration with families of infants hospitalized ≥ 28 days. Medical record review collected infant and family characteristics hypothesized to impact relationships. Mixed methods analysis was performed.

RESULTS

Clinicians completed 243 surveys representing 77 families. Clinicians reported low collaboration with families who were not at the bedside and/or did not speak English. Clinicians perceived most clinician-family relationships impact the infant's hospital course. Negative impacts included communication challenges, mistrust or frustration with the team and disruptions to patient care.

CONCLUSION

This study identifies features of clinician-family relationships that may negatively impact an infant's NICU stay. Targeting supports for these families is necessary to achieve effective PFCC.

Unravelling the polyphony in clinical reasoning research in medical education

RATIONALE

Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion.

AIMS AND OBJECTIVES

We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses.

METHODS

A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review.

RESULTS

A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described.

CONCLUSIONS

Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.

Characteristics and Burden of Diagnostic Error-Related Malpractice Claims in Neurosurgery

BACKGROUND

Neurosurgery is a specialty associated with high risk of malpractice claims, which can be influenced by quality and safety of care. Diagnostic errors have gained increasing attention as a potentially preventable problem. Despite the burden of diagnostic errors, few studies have analyzed diagnostic errors in neurosurgery. We aimed to delineate the effect of diagnostic errors on malpractice claims involving a neurosurgeon.

METHODS

This retrospective study used the national Japanese malpractice claims database and included cases closed between 1961 and 2017. To examine the effect of diagnostic errors in neurosurgery, we compared diagnostic error-related claims (DERCs) with non-DERCs in indemnity, clinical outcomes, and factors relating to neurosurgeons.

RESULTS

There were 95 closed malpractice claims involving neurosurgeons during the study period. Of these claims, 36 (37.9%, 95% confidence interval [CI] 28.7%-47.9%) were DERCs. Patient death was the most common outcome associated with DERCs. Wrong, delayed, and missed diagnosis occurred in 25 (69.4%, 95% CI 53.1%-82.0%), 4 (11.1%, 95% CI 4.4%-25.3%), and 7 (19.4%, 95% CI 9.8%-35.0%) cases, respectively. The most common presenting medical condition in DERCs was stroke. Subarachnoid hemorrhage, accounting for 85.7% of stroke cases, led to 27.8% of the total indemnity paid in DERCs.

CONCLUSIONS

DERCs are associated with higher numbers of accepted claims and worse outcomes. Identifying diagnostic errors is important in neurosurgery, and countermeasures are required to reduce the burden on neurosurgeons and improve quality. This is the first study to focus on diagnostic errors in malpractice claims arising from neurosurgery.

Emotionally salient patient information enhances the educational value of surgical videos

Medical students' motivations for choosing a medical career are likely based on and remain tethered to the affectively-laden caring component of doctor-patient interactions. However, this component is rarely presented in educational surgical videos. It is unknown whether affectively engaging students by including patient-related emotionally salient information potentiates or draws focus away from learning a surgical procedure and whether such information affects motivation and attitudes toward the video. Therefore, we investigate whether presenting a patient's emotional state before video surgery enhances or weakens the educational value of that video. In a within-subjects crossover design, second-year medical students (n = 130) viewed video clips of surgeries. These videos, from online medical education platforms, were preceded by the patient's information from the original video or by information about the patient's preoperative emotional preparation. After each video, participants completed a multiple-choice test about the video's content to measure learning, answered a question about their motivation to re-watch the video, and completed an attitude scale regarding the video. Incorporating patient's information into surgical videos significantly enhanced students' acquisition of the technical aspects of surgery procedures (p < 0.0001), motivation to re-watch the video (p < 0.001), and favorable attitudes toward the video (p = 0.02). These findings show that incorporating information about patients' emotional states may enhance students' positive attitudes and motivations toward educational videos and may improve their learning of surgical techniques. They also suggest that the role of this factor should be considered when developing guidelines for medical educational video release.

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: A scoping review

BACKGROUND

The high prevalence of diagnostic errors by health care providers has prompted medical educators to examine cognitive biases and debiasing strategies in an effort to prevent these errors. The National Academy of Medicine hypothesized that explicit diagnostic reasoning education of all health care professionals can improve diagnostic accuracy.

OBJECTIVES

The purpose of this scoping review is to identify, analyze, and summarize the existing literature on student health care providers' use of cognitive debiasing strategies to reduce diagnostic error.

DATA SOURCES

The review was guided by the Joanna Briggs Institute methodology for scoping reviews. A systematic search of PubMed, CINAHL, PsychINFO, and Scopus databases for debiasing strategies in student provider education yielded 33 studies.

CONCLUSIONS

The 33 studies included in this review represent four categories of debiasing strategies: increased medical knowledge or experience (seven studies), guided reflection (eight studies), self-explanation of reasoning (nine studies), and checklists to expand diagnosis considerations (seven studies). The studies were inclusive of medical students and residents; no studies included nurse practitioner (NP) students. Guided reflection, the most clearly defined and implemented strategy, showed the most promise for improvement of diagnostic accuracy. Educational interventions were wide ranging in content and delivery but did yield a path for future research.

IMPLICATIONS FOR PRACTICE

There are myriad debiasing strategies student providers may use to mitigate cognitive bias. Structured reflection and education initiatives demonstrated the most consistent improvements in diagnostic accuracy. Future studies on debiasing strategies must include NP students to understand their response to these initiatives.

"You're wrong!": The impact of accuracy feedback on the bat-and-ball problem

The popular bat-and-ball problem is a relatively simple math riddle on which people are easily biased by intuitive or heuristic thinking. In two studies we tested the impact of a simple but somewhat neglected manipulation - the impact of minimal accuracy feedback - on bat-and-ball performance. Participants solved a total of 15 standard and 15 control versions of the bat-and-ball problem in three consecutive blocks. Half of the participants received accuracy feedback in the intermediate block. Results of both studies indicated that the feedback had, on average, no significant effect on bat-and-ball accuracy over and above mere repeated presentation. We did observe a consistent improvement for a small number of individual participants. Explorative analyses indicated that this improved group showed a more pronounced conflict detection effect (i.e., latency increase) at the pretest and took more deliberation time after receiving the negative feedback compared to the unimproved group.

Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety

BACKGROUND

Emergency department (ED) physicians and nurses frequently interact with emotionally evocative patients, which can impact clinical decision-making and behaviour. This study introduces well-established methods from social psychology to investigate ED providers' reported emotional experiences and engagement in their own recent patient encounters, as well as perceived effects of emotion on patient care.

METHODS

Ninety-four experienced ED providers (50 physicians and 44 nurses) vividly recalled and wrote about three recent patient encounters (qualitative data): one that elicited anger/frustration/irritation (angry encounter), one that elicited happiness/satisfaction/appreciation (positive encounter), and one with a patient with a mental health condition (mental health encounter). Providers rated their emotions and engagement in each encounter (quantitative data), and reported their perception of whether and how their emotions impacted their clinical decision-making and behaviour (qualitative data).

RESULTS

Providers generated 282 encounter descriptions. Emotions reported in angry and mental health encounters were remarkably similar, highly negative, and associated with reports of low provider engagement compared with positive encounters. Providers reported their emotions influenced their clinical decision-making and behaviour most frequently in angry encounters, followed by mental health and then positive encounters. Emotions in angry and mental health encounters were associated with increased perceptions of patient safety risks; emotions in positive encounters were associated with perceptions of higher quality care.

CONCLUSIONS

Positive and negative emotions can influence clinical decision-making and impact patient safety. Findings underscore the need for (1) education and training initiatives to promote awareness of emotional influences and to consider strategies for managing these influences, and (2) a comprehensive research agenda to facilitate discovery of evidence-based interventions to mitigate emotion-induced patient safety risks. The current work lays the foundation for testing novel interventions.

Influence of psychiatric or social backgrounds on clinical decision making: a randomized, controlled multi-centre study

BACKGROUND

Frequent and repeated visits from patients with mental illness or free medical care recipients may elicit physicians' negative emotions and influence their clinical decision making. This study investigated the impact of the psychiatric or social background of such patients on physicians' decision making about whether to offer recommendations for further examinations and whether they expressed an appropriate disposition toward the patient.

METHODS

A randomized, controlled multi-centre study of residents in transitional, internal medicine, or emergency medicine was conducted in five hospitals. Upon randomization, participants were stratified by gender and postgraduate year, and they were allocated to scenario set 1 or 2. They answered questions pertaining to decision-making based on eight clinical vignettes. Half of the eight vignettes presented to scenario set 1 included additional patient information, such as that the patient had a past medical history of schizophrenia or that the patient was a recipient of free care who made frequent visits to the doctor (biased vignettes). The other half included no additional information (neutral vignettes). For scenario set 2, the four biased vignettes presented to scenario set 1 were neutralized, and the four neutral vignettes were rendered biased by providing additional information. After reading, participants answered decision-making questions regarding diagnostic examination, interventions, or patient disposition. The primary analysis was a repeated-measures ANOVA on the mean management accuracy score, with patient background information as a within-subject factor (no bias, free care recipients, or history of schizophrenia).

RESULTS

A total of 207 questionnaires were collected. Repeated-measures ANOVA showed that additional background information had influence on mean accuracy score (F(7, 206) = 13.84, p <  0.001 partial η2 = 0.063). Post hoc pairwise multiple comparison test, Sidak test, showed a significant difference between schizophrenia and no bias condition (p <  0.05). The ratings for patient likability were lower in the biased vignettes compared to the neutral vignettes, which was associated with the lower utilization of medical resources by the physicians.

CONCLUSIONS

Additional background information on past medical history of schizophrenia increased physicians' mistakes in decision making. Patients' psychiatric backgrounds should not bias physicians' decision-making. Based on these findings, physicians are recommended to avoid being influenced by medically unrelated information.

Do poor patients suffer from inaccurate diagnoses more than well-to-do patients? A randomized control trial

BACKGROUND

Poor patients have greater morbidity and die up to 10 years earlier than patients who have higher socio-economic status. These findings are often attributed to differences in life-style between groups. The present study aimed at investigating the extent to which physicians contribute to the effect by providing relative poorer care, resulting in relative neglect in terms of time spent with a poor patient and more inaccurate diagnoses.

METHODS

A randomised experiment with 45 internal medicine residents. Doctors diagnosed 12 written clinical vignettes that were exactly the same except for the description of the patients' socio-economic status. Each participant diagnosed four of the vignettes in a poor-patient version, four in a rich-patient version, and four in a version that did not contain socio-economic markers, in a balanced within-subjects incomplete block design. Main measurements were: diagnostic accuracy scores and time spent on diagnosis.

RESULTS

Mean diagnostic accuracy scores (range 0-1) did not significantly differ among the conditions of the experiment (for poor patients: 0.48; for rich patients: 0.52; for patients without socio-economic markers: 0.54; p > 0.05). While confronted with patients not presenting with socio-economic background information, the participants spent significantly less time-to-diagnosis ((for poor patients: 168 s; for rich patients: 176 s; for patients without socio-economic markers: 151 s; p < 0.01), however due to the fact that the former vignettes were shorter.

CONCLUSION

There is no reason to believe that physicians are prejudiced against poor patients and therefore treat them differently from rich patients or patients without discernible socio-economic background.

Resource consumption of multi-substance users in the emergency room: A neglected patient group

Background

Multi-substance use is accompanied by increased morbidity and mortality and responsible for a large number of emergency department (ED) consultations. To improve the treatment for this vulnerable group of patients, it is important to quantify and break down in detail the ED resources used during the ED treatment of multi-substance users.

Methods

This retrospective single centre case-control study included all ED consultations of multi-substance users over a three-year study period at a university hospital in Switzerland. Resource consumption of these patients was compared to an age-matched control group of non-multi-substance users.

Results

The analysis includes 867 ED consultations of multi-substance users compared to 4,335 age-matched controls (5:1). Multi-substance users needed more total resources (median tax points [medical currency] (IQR): 762 (459–1226) vs. 462 (196–833), p<0.001), especially physician, radiology, and laboratory resources. This difference persisted in multivariable analysis (geometric mean ratio (GMR) 1.2, 95% CI: 1.1–1.3, p = 0.001) adjusted for sociodemographic parameters, consultation characteristics, and patient comorbidity; the GMR was highest in ED laboratory and radiology resource consumption. Among multi-substance user, indirect and non-drug-related consultations had higher ED resource consumption compared to drug-related consultations. Furthermore, leading discipline as well as urgency were predictors of ED resource consumption. Moreover, multi-substance users had more revisits (55.2% vs. 24.9%, p<0.001) as well as longer ED and in-hospital stays (both: GMR 1.2, 95% CI: 1.1–1.3, p<0.001).

Conclusion

ED consultations of multi-substance users are expensive and resource intensive. Multi-substance users visited the ED more often and stayed longer at the ED and in-hospital. The findings of our study underline the importance of this patient group. Additional efforts should be made to improve their ED care. Special interventions should target this patient group in order to decrease the high frequency and costs of emergency consultations caused by multi-substance users.

Patient-physician relationship and use of gut feeling in cancer diagnosis in primary care: a cross-sectional survey of patients and their general practitioners

OBJECTIVES

To examine whether the quality of the patient-physician relationship, assessed by the general practitioner (GP) and the patient, associates with GPs' use of gut feeling (GF) in cancer diagnosis.

DESIGN

Cross-sectional questionnaire survey of cancer patients and their GPs.

SETTING

Danish primary care.

PARTICIPANTS

Newly diagnosed cancer patients and their GPs. Patients completed a questionnaire and provided the name of the GP to whom they have presented their symptoms. The named GP subsequently received a questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

GPs' use of GF in the diagnostic process for the particular patient. GPs who answered that they used their GF 'to a high degree' or 'to a very high degree' were categorised as 'used their GF to a great extent'. GPs who answered that they used their GF 'to some degree', 'to a limited degree' or 'not at all' were categorised as 'limited or no use of GF'.

RESULTS

GPs were less likely to use GF when they assessed relational aspects of the patient encounter as difficult compared with less difficult (OR=0.67; 95% CI 0.46 to 0.97). The physician-reported level of empathy was positively associated with use of GF (OR=2.60; 95% CI 1.60 to 4.22). The lower use of GF in difficult encounters was not modified by level of empathy.

CONCLUSIONS

Experiencing relational aspects of patient encounter as difficult acted as a barrier for the use of GF in cancer diagnosis. Although physician-rated empathy increased use of GF, high empathy did not dissolve the low use of GF in difficult encounters. As diagnosis of cancer is a key challenge in primary care, it is important that GPs are aware that the sensitivity of cancer-related GF is compromised by a difficult patient-physician relationship.

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Background

Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them.

Methods

Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy.

Results

755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included.

The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009).

Conclusions

Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context.

Trial registration

https://bmjopen.bmj.com/content/6/5/e011585

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0629-z) contains supplementary material, which is available to authorized users.

Taking patient virtue seriously

Virtue theory in philosophical bioethics has influenced clinical ethics with depictions of the virtuous doctor or nurse. Comparatively little has been done with the concept of the virtuous patient, however. Bioethicists should correct the asymmetry in virtue theory between physician virtues and patient virtues in a way that provides a practical theory for the new patient-centered medicine-something clinicians and administrators can take seriously.

Training for Failure: A Simulation Program for Emergency Medicine Residents to Improve Communication Skills in Service Recovery

OBJECTIVES

Service failures such as long waits, testing delays, and medical errors are daily occurrences in every emergency department (ED). Service recovery refers to the immediate response of an organization or individual to resolve these failures. Effective service recovery can improve the experience of both the patient and the physician. This study investigated a simulation-based program to improve service recovery skills in postgraduate year 1 emergency medicine (PGY-1 EM) residents.

METHODS

Eighteen PGY-1 EM residents participated in six cases that simulated common ED service failures. The patient instructors (PIs) participating in each case and two independent emergency medicine (EM) faculty observers used the modified Master Interview Rating Scale to assess the communication skills of each resident in three simulation cases before and three simulation cases after a service recovery debriefing. For each resident, the mean scores of the first three cases and those of the last three cases were termed pre- and postintervention scores, respectively. The means and standard deviations of the pre- and postintervention scores were calculated by the type of rater and compared using paired t-tests. Additionally, the mean scores of each case were summarized. In the framework of the linear mixed-effects model, the variance in scores from the PIs and faculty observers was decomposed into variance contributed by PIs/cases, the program effect on individual residents, and the unexplained variance. In reliability analyses, the intraclass correlation coefficient between rater types and the 95% confidence interval were reported before and after the intervention.

RESULTS

When rated by the PIs, the pre- and postintervention scores showed no difference (p = 0.852). In contrast, when scored by the faculty observers, the postintervention score was significantly improved compared to the preintervention score (p < 0.001). In addition, for the faculty observers, the program effect was a significant contributor to the variation in scores. Low intraclass correlation was observed between rater groups.

CONCLUSIONS

This innovative simulation-based program was effective at teaching service recovery communication skills to residents as evaluated by EM faculty, but not PIs. This study supports further exploration into programs to teach and evaluate service recovery communication skills in EM residents.

[The Physical Examination of an 'Uncooperative' Elderly Patient]

The Physical Examination of an 'Uncooperative' Elderly Patient Abstract. The physical examination of uncooperative elderly patients regularly presents physicians in the private practice, in the hospital or nursing home with great challenges. The lack of cooperation itself can be an important indication of an underlying medical problem. Important elements to improve the patient's cooperation include ensuring basic needs, sufficient time and patience, adequate communication and good cooperation with relatives and other healthcare professionals. Targeted clinical observation as well as thinking in geriatric syndromes and unmet needs can help to raise physical findings despite limited cooperation. Pathological findings are indicators of impaired organ and functional systems and must be supplemented by a detailed examination.

The erratic pathway to regaining a professional self-image after an obstetric work-related trauma: A grounded theory study

BACKGROUND

It is known that healthcare providers might be affected by severe medical events in which patients are badly hurt. In birth care, escalating situations can result in death or injury to a mother or new-born child.

OBJECTIVE

To explore the process that Swedish midwives and obstetricians go through after a severe event in the maternity unit.

DESIGN

A modified Constructivist Grounded Theory analysis, based on fourteen in-depth interviews with birth care professionals.

PARTICIPANTS

Seven midwives and seven obstetricians.

RESULTS

A core category, 'regaining of a professional self-image', was constructed and interpreted as being constituted of six main categories illustrating a frequently erratic pathway to the regaining of a professional self-image. The process included a search for external acceptance for the re-establishment of belongingness by obtaining corroboration from the woman, work colleagues and manager, and the medico-legal system. Media exposure was invariably seen as something negative. Internal processes involved coping with emotions of guilt and shame and the vulnerability that the work entails, as well as contemplating future work. The possibility to fully regain one's professional self-image depended on having a sense of confidence and an urge to support others in similar situations by sharing gained insights. However, the process could also result in reconsidering one's professional self-image by setting up boundaries, creating a better work-life balance, or creating mental back-up plans in case of similar recurrences. For others, the process led to a change of professional identity and a search for roles away from emergency obstetrics or the specialty as such.

CONCLUSIONS

Many midwives and obstetricians will experience severe obstetric events that might affect them, sometimes severely. The vulnerability that healthcare professionals are exposed to should not be underestimated and preparedness in terms of collegial support, as well as an awareness in the workplace of how badly affected employees might be, is important. Growth as well as leaving birth care can be the results of the process following a severe event.

How to tell a patient's story? Influence of the case narrative design on the clinical reasoning process in virtual patients

BACKGROUND

Virtual patients (VPs) are narrative-based educational activities to train clinical reasoning in a safe environment. Our aim was to explore the influence of the design of the narrative and level of difficulty on the clinical reasoning process, diagnostic accuracy and time-on-task.

METHODS

In a randomized controlled trial, we analyzed the clinical reasoning process of 46 medical students with six VPs in three different variations: (1) patients showing a friendly behavior, (2) patients showing a disruptive behavior and (3) a version without a patient story.

RESULTS

For easy VPs, we did not see a significant difference in diagnostic accuracy. For difficult VPs, the diagnostic accuracy was significantly higher for participants who worked on the friendly VPs compared to the other two groups. Independent from VP difficulty, participants identified significantly more problems and tests for disruptive than for friendly VPs; time on task was comparable for these two groups. The extrinsic motivation of participants working on the VPs without a patient story was significantly lower than for the students working on the friendly VPs.

CONCLUSIONS

Our results indicate that the measured VP difficulty has a higher influence on the clinical reasoning process and diagnostic accuracy than the variations in the narratives.

Teaching clinical reasoning through hypothetico-deduction is (slightly) better than self-explanation in tutorial groups: An experimental study

BACKGROUND

Self-explanation while individually diagnosing clinical cases has proved to be an effective instructional approach for teaching clinical reasoning. The present study compared the effects on diagnostic performance of self-explanation in small groups with the more commonly used hypothetico-deductive approach.

METHODS

Second-year students from a six-year medical school in Saudi Arabia (39 males; 49 females) worked in small groups on seven clinical vignettes (four criterion cases representing cardiovascular diseases and three 'fillers', i.e. cases of other unrelated diagnoses). The students followed different approaches to work on each case depending on the experimental condition to which they had been randomly assigned. Under the self-explanation condition, students provided a diagnosis and a suitable pathophysiological explanation for the clinical findings whereas in the hypothetico-deduction condition students hypothesized about plausible diagnoses for signs and symptoms that were presented sequentially. One week later, all students diagnosed eight vignettes, four of which represented cardiovascular diseases. A mean diagnostic accuracy score (range: 0-1) was computed for the criterion cases. One-way ANOVA with experimental condition as between-subjects factor was performed on the mean diagnostic accuracy scores.

RESULTS

Students in the hypothetico-deduction condition outperformed those in the self-explanation condition (mean = 0.22, standard deviation = 0.14, mean = 0.17; standard deviation = 0.12; F(1, 88) = 4.90, p = 0.03, partial η² = 0.06, respectively).

CONCLUSIONS

Students in the hypothetico-deduction condition performed slightly better on a follow-up test involving similar cases, possibly because they were allowed to formulate more than one hypothesis per case during the learning phase.

A study to explore specific stressors and coping strategies in primary dental care practice

Background and aims It is widely acknowledged that dentists experience occupational stress. This qualitative study aimed to explore previously identified specific stressors in more detail in order to inform the development of a future stress management programme.Method Two focus groups of dentists (N: 7 &6) were conducted to explore, in more detail, nine specific stressors and concepts; being out of one's comfort zone, zoning out from the patient, celebrating the positive aspects of work, thinking aloud, the effect of hurting patients, the impact of perfectionism, responsibility for patient's self-care, the emotional impact of difficult situations as a foundation dentist. Participants were also asked for their views on the structure and contents of the proposed stress management package. Verbatim transcripts were subjected to thematic analysis.Results and discussion Dentists described the impact of these stressors and their current coping methods; thematic analysis revealed nine themes which covered the above concepts and a further overall theme of need for control. The findings are elaborated in connection to their relevant stress, coping and emotion psychological theory. Their implications for personal well-being and clinical outcomes are discussed.Conclusion Dentists' stressful and coping experiences are complex and it is essential that any stress management programme reflects this and that the skills are easily accessible and sustainable within the context of a busy dental practice.