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Schmidt HG, Norman GR, Mamede S, Magzoub M. The influence of context on diagnostic reasoning: A narrative synthesis of experimental findings. J Eval Clin Pract 2024; 30:1091-1101. [PMID: 38818694 DOI: 10.1111/jep.14023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024]
Abstract
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.
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Affiliation(s)
- Henk G Schmidt
- Institute of Medical Education Research, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Geoffrey R Norman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Silvia Mamede
- Institute of Medical Education Research, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Mohi Magzoub
- Department of Medical Education, United Arab Emirates University, Al Ain, United Arab Emirates
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Shaw SCK, Carravallah L, Johnson M, O’Sullivan J, Chown N, Neilson S, Doherty M. Barriers to healthcare and a 'triple empathy problem' may lead to adverse outcomes for autistic adults: A qualitative study. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024; 28:1746-1757. [PMID: 37846479 PMCID: PMC11191657 DOI: 10.1177/13623613231205629] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
LAY ABSTRACT Autistic people live with more mental and physical health conditions and, on average, die younger than non-autistic people. Despite widespread commitments to tackling these issues, autistic people still report various barriers to accessing healthcare. This article aims to explore the area in depth, from the perspective of autistic people. This research benefits from being led by autistic people, for autistic people - all of the researchers are autistic, and most of us are also medical doctors. Data, in the form of written comments and stories, were collected as part of a large survey. Here, we explored these for common themes and possible deeper meaning within the experiences. People who took part reported a variety of barriers. Here, our article gives voice to their stories, in their own words. Themes included: early barriers; communication mismatch; doubt - in oneself and from doctors; helplessness and fear; and healthcare avoidance and adverse health outcomes. Our findings allowed us to create a model that aimed to understand and explain the reported barriers in the context of the previously known consequences. We also built on wider autism theories to explain our findings in more depth.
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Sattar R, Lawton R, Janes G, Elshehaly M, Heyhoe J, Hague I, Grindey C. A systematic review of workplace triggers of emotions in the healthcare environment, the emotions experienced, and the impact on patient safety. BMC Health Serv Res 2024; 24:603. [PMID: 38720302 PMCID: PMC11080227 DOI: 10.1186/s12913-024-11011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/18/2024] [Indexed: 05/12/2024] Open
Abstract
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.
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Affiliation(s)
- Raabia Sattar
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK.
| | - Rebecca Lawton
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
| | | | | | - Jane Heyhoe
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
| | - Isabel Hague
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
| | - Chloe Grindey
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
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Driessen J, Hearn R. Development of hidden curriculum skills in a COVID-19 vaccination centre. CLINICAL TEACHER 2024; 21:e13642. [PMID: 37632296 DOI: 10.1111/tct.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, many medical students were deployed as vaccinators. This study set out to capture the lived experience of students at a London-based mass vaccination site, understand what they learned, how this learning compared to their experience of usual medical education and how any identified benefits might be leveraged in a post-pandemic context. METHODS Student vaccinators (n = 8) were recruited from the vaccine clinic workforce and invited to complete semi-structured interviews about their experiences. Thematic analysis was conducted on interview transcripts to identify significant concepts, which were interpreted in the context of available literature. FINDINGS Participants' experiences aligned broadly with the undergraduate curriculum. However, many also identified hidden curriculum areas developed through their work as vaccinators, including professionalism, self-regulating learning and ethical decision-making. DISCUSSION The need for adequate support, whilst promoting autonomy, was highlighted as vital in supporting professional identity formation within a community of practice, benchmarking clinical knowledge and performance, and in support of student wellbeing, in the face of challenging real-world clinical encounters. CONCLUSION Increased entrustment of clinical activity could be implemented in primary and secondary care settings to reproduce the benefits experienced by student vaccinators in front-line roles during the COVID-19 pandemic. Further work might consider how to maximise these benefits and increase inclusion and participation.
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Affiliation(s)
- Johannes Driessen
- King's Undergraduate Medical Education in the Community (KUMEC), Department of Primary Care and Public Health Sciences, London, UK
| | - Russell Hearn
- King's Undergraduate Medical Education in the Community (KUMEC), Department of Primary Care and Public Health Sciences, London, UK
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Isbell LM, Graber ML, Rovenpor DR, Liu G. Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment. Diagnosis (Berl) 2023; 10:257-266. [PMID: 37185165 DOI: 10.1515/dx-2020-0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 03/22/2023] [Indexed: 05/17/2023]
Abstract
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.
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Affiliation(s)
- Linda M Isbell
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Mark L Graber
- Society to Improve Diagnosis in Medicine, Plymouth, MA, USA
- Stony Brook University, NY, USA
| | | | - Guanyu Liu
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
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van Sassen C, Mamede S, Bos M, van den Broek W, Bindels P, Zwaan L. Do malpractice claim clinical case vignettes enhance diagnostic accuracy and acceptance in clinical reasoning education during GP training? BMC MEDICAL EDUCATION 2023; 23:474. [PMID: 37365590 DOI: 10.1186/s12909-023-04448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
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.
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Affiliation(s)
- Charlotte van Sassen
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Rotterdam, The Netherlands
| | - Michiel Bos
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Walter van den Broek
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick Bindels
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
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Fryburg DA. Kindness Isn't Just about Being Nice: The Value Proposition of Kindness as Viewed through the Lens of Incivility in the Healthcare Workplace. Behav Sci (Basel) 2023; 13:457. [PMID: 37366709 DOI: 10.3390/bs13060457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviors, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modeling positive behaviors as well as the deterrence of negative behaviors, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.
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Townsley A, Li-Wang J, Katta R. When Patient Rudeness Impacts Care: A Review of Incivility in Healthcare. Cureus 2023; 15:e40521. [PMID: 37461785 PMCID: PMC10350303 DOI: 10.7759/cureus.40521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
Healthcare workers increasingly face incivility and rude behaviors from patients, families, and visitors. Although these are less severe than other types of mistreatment, studies have documented that they may still impact healthcare worker well-being and patient care. Defining and measuring incivility can be challenging because current research relies on the perceptions of the targets. Furthermore, there is often overlap among different types of mistreatment, and much of it goes unreported by those who experience it. Nevertheless, multiple studies have documented that incivility is common in healthcare and has been associated with burnout and intent to leave. In clinical settings, multiple consequences for patient care have been documented, including adverse consequences in the diagnostic and intervention performance of teams, as well as team processes. One theory is that incivility incidents divert cognitive resources away from the intervention and that these experiences may interfere with higher-order reasoning. Although limited research has been performed in the areas of prevention, response to incidents of incivility, and best practices for ameliorating the effects of incivility, some promising interventions have been reported in the literature.
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Affiliation(s)
| | | | - Rajani Katta
- Internal Medicine, Baylor College of Medicine, Houston, USA
- Dermatology, University of Texas Health Science Center at Houston, Houston, USA
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Tamura H, Shikino K, Sogai D, Yokokawa D, Uchida S, Li Y, Yanagita Y, Yamauchi Y, Kojima J, Ishizuka K, Tsukamoto T, Noda K, Uehara T, Imaizumi T, Kataoka H, Ikusaka M. Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study. J Gen Intern Med 2023; 38:1843-1847. [PMID: 36385409 PMCID: PMC10271945 DOI: 10.1007/s11606-022-07936-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Hiroki Tamura
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan.
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Daichi Sogai
- Department of General Medicine, Sanmu Medical Center, Chiba, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Shun Uchida
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Yu Li
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Yasutaka Yanagita
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Yosuke Yamauchi
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Jumpei Kojima
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Kazukata Noda
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Takahiro Imaizumi
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Hitomi Kataoka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
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Huff NR, Chimowitz H, DelPico MA, Gleason KT, Nanavati JD, Smulowitz P, Isbell LM. The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases. Int J Nurs Stud 2023; 143:104507. [PMID: 37196607 DOI: 10.1016/j.ijnurstu.2023.104507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 05/19/2023]
Abstract
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).
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Affiliation(s)
- Nathan R Huff
- Psychological and Brain Sciences, University of Massachusetts Amherst, 135 Hicks Way, Amherst, MA 01003, United States of America
| | - Hannah Chimowitz
- Psychological and Brain Sciences, University of Massachusetts Amherst, 135 Hicks Way, Amherst, MA 01003, United States of America
| | - Maria A DelPico
- Psychological and Brain Sciences, University of Massachusetts Amherst, 135 Hicks Way, Amherst, MA 01003, United States of America
| | - Kelly T Gleason
- School of Nursing, Johns Hopkins University, 525 N. Wolfe Street, Baltimore, MD 21205, United States of America
| | - Janvi D Nanavati
- Psychological and Brain Sciences, University of Massachusetts Amherst, 135 Hicks Way, Amherst, MA 01003, United States of America
| | - Peter Smulowitz
- Department of Emergency Medicine, UMass Chan Medical School, 55 Lake Ave North, Worcester, MA 01605, United States of America
| | - Linda M Isbell
- Psychological and Brain Sciences, University of Massachusetts Amherst, 135 Hicks Way, Amherst, MA 01003, United States of America.
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11
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Abdelhadi N, Drach-Zahavy A, Srulovici E. Toward understanding nurses' decisions whether to miss care: A discrete choice experiment. Int J Nurs Stud 2023; 139:104448. [PMID: 36746011 DOI: 10.1016/j.ijnurstu.2023.104448] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Nasra Abdelhadi
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel.
| | - Anat Drach-Zahavy
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel.
| | - Einav Srulovici
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel.
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12
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Shikino K, Mito T, Ohira Y, Yokokawa D, Katsuyama Y, Ota T, Sato E, Hirose Y, Yamashita S, Suzuki S, Noda K, Uehara T, Ikusaka M. Frequency of Difficult Patient Encounters in a Japanese University Hospital and Community Hospitals: A Cross-sectional Study. Intern Med 2023; 62:533-537. [PMID: 35793958 PMCID: PMC10017258 DOI: 10.2169/internalmedicine.0085-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Community-based Medical Education, Graduate School of Medicine, Chiba University, Japan
| | - Tsutomu Mito
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yoshiyuki Ohira
- Department of General Medicine, Chiba University Hospital, Japan
- Department of General Medicine, International University of Health and Welfare Narita Hospital, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yota Katsuyama
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Community-based Medical Education, Graduate School of Medicine, Chiba University, Japan
- Department of General Medicine, Sanmu Medical Center, Japan
| | - Takahiro Ota
- Department of General Medicine, Chiba University Hospital, Japan
| | - Eri Sato
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yuta Hirose
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shiho Yamashita
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shingo Suzuki
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Internal Medicine, Chiba Central Medical Center, Japan
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Japan
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13
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Schmidt HG, Mamede S. Improving diagnostic decision support through deliberate reflection: a proposal. Diagnosis (Berl) 2023; 10:38-42. [PMID: 36000188 DOI: 10.1515/dx-2022-0062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Henk G Schmidt
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sílvia Mamede
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
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14
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Mamede S, Schmidt HG. Deliberate reflection and clinical reasoning: Founding ideas and empirical findings. MEDICAL EDUCATION 2023; 57:76-85. [PMID: 35771936 PMCID: PMC10083910 DOI: 10.1111/medu.14863] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/15/2022] [Accepted: 06/26/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus MC; Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
| | - Henk G. Schmidt
- Institute of Medical Education Research Rotterdam, Erasmus MC; Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
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15
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Crijns T, Al Salman A, Bashour L, Ring D, Teunis T. Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit? PEC INNOVATION 2022; 1:100043. [PMID: 37213725 PMCID: PMC10194092 DOI: 10.1016/j.pecinn.2022.100043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 04/11/2022] [Accepted: 04/16/2022] [Indexed: 05/23/2023]
Abstract
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.
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Affiliation(s)
- Tom Crijns
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Aresh Al Salman
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Laura Bashour
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
- Corresponding author at: Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building; MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
| | - Teun Teunis
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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16
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Liu G, Chimowitz H, Isbell LM. Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities. Diagnosis (Berl) 2022; 9:295-305. [PMID: 34981701 PMCID: PMC9424059 DOI: 10.1515/dx-2021-0115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/13/2021] [Indexed: 01/08/2023]
Abstract
Psychological research consistently demonstrates that affect can play an important role in decision-making across a broad range of contexts. Despite this, the role of affect in clinical reasoning and medical decision-making has received relatively little attention. Integrating the affect, social cognition, and patient safety literatures can provide new insights that promise to advance our understanding of clinical reasoning and lay the foundation for novel interventions to reduce diagnostic errors and improve patient safety. In this paper, we briefly review the ways in which psychologists differentiate various types of affect. We then consider existing research examining the influence of both positive and negative affect on clinical reasoning and diagnosis. Finally, we introduce an empirically supported theoretical framework from social psychology that explains the cognitive processes by which these effects emerge and demonstrates that cognitive interventions can alter these processes. Such interventions, if adapted to a medical context, hold great promise for reducing errors that emerge from faulty thinking when healthcare providers experience different affective responses.
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Affiliation(s)
- Guanyu Liu
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Hannah Chimowitz
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Linda M. Isbell
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
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17
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Peel M, Tremlett D. Assessing and managing people exposed to conducted energy device (Taser) discharge. Emerg Nurse 2022; 30:16-23. [PMID: 35132846 DOI: 10.7748/en.2022.e2125] [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] [Accepted: 11/23/2021] [Indexed: 01/13/2024]
Abstract
The use of conducted energy devices - better known under the brand name Taser - by police officers is subject to scrutiny. Consequently, the clinical assessment and management of people who have been exposed to Taser discharge is also subject to scrutiny. In 2021 the Conducted Energy Device Joint Working Group published a new guideline on assessment in police custody after Taser discharge. The guideline enables any appropriately trained and competent healthcare professional, including nurses, to undertake post-Taser assessments and determine the person's fitness to be detained in police custody. This would be done in the first instance by nurses working in police custody suites, but emergency department (ED) nurses may also be involved, as people who have been 'tasered' may need referral to the ED. This article explains how Tasers work, their physiological effects and potential complications, and the required approaches to clinical assessment and management as outlined in the new guideline.
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Affiliation(s)
- Matthew Peel
- Leeds Community Healthcare NHS Trust, Leeds, England
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18
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Halpin SN, Konomos M, Roulston K. Using conversation analysis to appraise how novel educational videos impact patient medical education. PATIENT EDUCATION AND COUNSELING 2022; 105:2027-2032. [PMID: 34887157 DOI: 10.1016/j.pec.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Sean N Halpin
- College of Education, University of Georgia, 308 River's Crossing, 850 College Station Road, Athens, GA 30602, United States.
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19
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Howard S, Akhlaghi H, Watson T, O'Reilly GM, Karro J. Attitudes and regard for specific medical conditions among Australian emergency medicine clinicians. Emerg Med Australas 2022; 34:812-817. [DOI: 10.1111/1742-6723.14004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 03/28/2022] [Accepted: 04/10/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Stuart Howard
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Hamed Akhlaghi
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Victoria Australia
| | - Tess Watson
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Gerard M O'Reilly
- Emergency and Trauma Centre Alfred Health Melbourne Victoria Australia
- School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
- National Trauma Research Institute Alfred Health Melbourne Victoria Australia
| | - Jonathan Karro
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
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20
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Sacre M, Albert R, Hoe J. What are the experiences and the perceptions of service users attending Emergency Department for a mental health crisis? A systematic review. Int J Ment Health Nurs 2022; 31:400-423. [PMID: 34941023 DOI: 10.1111/inm.12968] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Historically, dualistic healthcare systems have resulted in limited mental healthcare provision within physical health settings, with service users reporting poor care specifically while attending emergency departments (EDs) in a mental health crisis. Modern approaches to healthcare recognize these inequalities and are moving towards integrating healthcare systems that allow more holistic and seamless experiences for service users. This mixed-method review examines the experiences and perceptions of service users attending EDs for a mental health crisis. Systematic searches of eight databases on two platforms (EBSCO, OVID) and grey literature databases (Open Grey, Base) were conducted. Studies were systematically screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesized using thematic synthesis. Ten studies consisting of qualitative and mixed-method designs were included in the review. Five overarching themes emerged from the synthesis: social constructs, service provider, service provision, effectiveness, and emotional impact. The findings from this review show that service users continue to have negative experiences in EDs due to stigmatizing attitudes and low skill in managing mental health needs, whereas more positive experiences are attributed to the availability of mental health liaison services. Tackling stigma, improving communication and staff training, providing calm environments, and addressing structural issues that promote better interagency working and reduce gaps in services are needed to improve mental health service user experience. Future research should focus on trauma-informed approaches in EDs to improve person-centred care for service users experiencing a mental health crisis.
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Affiliation(s)
- Maya Sacre
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
| | - Rikke Albert
- Tower Hamlets Mental Health Liaison and Psychological Medicine, Royal London Hospital, London, UK
| | - Juanita Hoe
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
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21
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Screening, brief intervention, and referral to treatment (SBIRT) training reduces stigma and prepares orthopaedic providers to identify and intervene in opioid misuse. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Ryan M. Care of the Challenging Patient. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Representation, interaction and interpretation. Making sense of the context in clinical reasoning. MEDICAL EDUCATION 2022; 56:98-109. [PMID: 33932248 DOI: 10.1111/medu.14545] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/06/2021] [Accepted: 04/26/2021] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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24
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Abstract
Recognition of autism and the associated co-occurring physical and mental health issues has increased over recent years. However, undergraduate and postgraduate curricula take time to adapt and to impact on what is delivered in training so healthcare professionals, including doctors, report little training on these topics. Doctors need to know when someone might be autistic in order to respond to them appropriately. This article sets out the reasons why recognition of autism is important and the positive impacts of recognising and understanding autism on health outcomes, service delivery and patient experience. The negative consequences of not recognising autism or understanding the impact of autistic traits on the person are also explored. A companion article then covers how practice can be made more appropriate for autistic people to improve outcomes.
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Affiliation(s)
- Mary Doherty
- Department of Anaesthesia, Our Lady's Hospital, Navan, Ireland
| | - Clair Haydon
- Department of Adult Autism Services, Cheshire and Wirral Partnership NHS Foundation Trust and Centre for Autism, Neuro-Developmental Disorders and Intellectual Disability (CANDDID), Chester, UK
| | - Ian A Davidson
- Department of Adult Mental Health, Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
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25
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Ramos JGR, Ranzani OT, Dias RD, Forte DN. Impact of nonclinical factors on intensive care unit admission decisions: a vignette-based randomized trial (V-TRIAGE). Rev Bras Ter Intensiva 2021; 33:219-230. [PMID: 34231802 PMCID: PMC8275078 DOI: 10.5935/0103-507x.20210029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/16/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To assess the impact of intensive care unit bed availability, distractors and choice framing on intensive care unit admission decisions. METHODS This study was a randomized factorial trial using patient-based vignettes. The vignettes were deemed archetypical for intensive care unit admission or refusal, as judged by a group of experts. Intensive care unit physicians were randomized to 1) an increased distraction (intervention) or a control group, 2) an intensive care unit bed scarcity or nonscarcity (availability) setting, and 3) a multiple-choice or omission (status quo) vignette scenario. The primary outcome was the proportion of appropriate intensive care unit allocations, defined as concordance with the allocation decision made by the group of experts. RESULTS We analyzed 125 physicians. Overall, distractors had no impact on the outcome; however, there was a differential drop-out rate, with fewer physicians in the intervention arm completing the questionnaire. Intensive care unit bed availability was associated with an inappropriate allocation of vignettes deemed inappropriate for intensive care unit admission (OR = 2.47; 95%CI 1.19 - 5.11) but not of vignettes appropriate for intensive care unit admission. There was a significant interaction with the presence of distractors (p = 0.007), with intensive care unit bed availability being associated with increased intensive care unit admission of vignettes inappropriate for intensive care unit admission in the distractor (intervention) arm (OR = 9.82; 95%CI 2.68 - 25.93) but not in the control group (OR = 1.02; 95%CI 0.38 - 2.72). Multiple choices were associated with increased inappropriate allocation in comparison to the omission group (OR = 5.18; 95%CI 1.37 - 19.61). CONCLUSION Intensive care unit bed availability and cognitive biases were associated with inappropriate intensive care unit allocation decisions. These findings may have implications for intensive care unit admission policies.
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Affiliation(s)
- João Gabriel Rosa Ramos
- Clínica Florence - Salvador (BA), Brasil.,Unidade de Terapia Intensiva, Hospital São Rafael, Rede D'Or São Luiz - Salvador (BA), Brasil.,Instituto D'Or de Pesquisa e Ensino - Salvador, Brasil
| | - Otavio Tavares Ranzani
- Divisão Pulmonar, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Roger Daglius Dias
- STRATUS Center for Medical Simulation, Brigham and Women's Hospital - Boston, MA, Estados Unidos
| | - Daniel Neves Forte
- Equipe de Cuidados Paliativos, Hospital Sírio-Libanês - São Paulo (SP), Brasil
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26
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Appel JM. When All the PICU's a Platform. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:75-77. [PMID: 34152923 DOI: 10.1080/15265161.2021.1926575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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27
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Helmke N. Risk of Cognitive Bias Associated With the Treatment of Urinary Tract Infection in Patients With Psychiatric Disorders. J Acad Consult Liaison Psychiatry 2021; 62:555-556. [PMID: 34083159 DOI: 10.1016/j.jaclp.2021.03.004] [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: 01/05/2021] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Nicole Helmke
- Department of Psychiatry and Behavioral Sciences and Department of Medicine, Duke University School of Medicine, Durham, NC.
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28
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Unravelling the polyphony in clinical reasoning research in medical education. J Eval Clin Pract 2021; 27:438-450. [PMID: 32573080 DOI: 10.1111/jep.13432] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Afshari NA, Lian RR. Cultivating the Physician-Patient Relationship in Ophthalmology. Am J Ophthalmol 2021; 223:A1-A3. [PMID: 33249053 DOI: 10.1016/j.ajo.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/19/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
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30
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Ryan M. Care of the Challenging Patient. Fam Med 2021. [DOI: 10.1007/978-1-4939-0779-3_61-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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31
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Kuhn J, van den Berg P, Mamede S, Zwaan L, Diemers A, Bindels P, van Gog T. Can We Teach Reflective Reasoning in General-Practice Training Through Example-Based Learning and Learning by Doing? HEALTH PROFESSIONS EDUCATION 2020. [DOI: 10.1016/j.hpe.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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32
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Ostomy Care During Hospital Stay for Ostomy Surgery and the United Ostomy Associations of America Patient Bill of Rights. J Wound Ostomy Continence Nurs 2020; 47:589-593. [DOI: 10.1097/won.0000000000000709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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33
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Einfluss patientenspezifischer Faktoren auf die Notarztdiagnose. Notf Rett Med 2020. [DOI: 10.1007/s10049-019-00633-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Abdelhadi N, Drach‐Zahavy A, Srulovici E. The nurse’s experience of decision‐making processes in missed nursing care: A qualitative study. J Adv Nurs 2020. [DOI: 10.1111/jan.14387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/03/2020] [Accepted: 03/25/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Nasra Abdelhadi
- The Cheryl Spencer Department of Nursing University of Haifa Haifa Israel
| | - Anat Drach‐Zahavy
- The Cheryl Spencer Department of Nursing University of Haifa Haifa Israel
| | - Einav Srulovici
- The Cheryl Spencer Department of Nursing University of Haifa Haifa Israel
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35
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Konopasky A, Durning SJ, Artino AR, Ramani D, Battista A. The Linguistic Effects of Context Specificity: Exploring Affect, Cognitive Processing, and Agency in Physicians' Think-Aloud Reflections. ACTA ACUST UNITED AC 2020; 7:273-280. [PMID: 32304298 DOI: 10.1515/dx-2019-0103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/09/2020] [Indexed: 11/15/2022]
Abstract
Background The literature suggests that affect, higher-level cognitive processes (e.g. decision-making), and agency (the capacity to produce an effect) are important for reasoning; however, we do not know how these factors respond to context. Using situated cognition theory as a framework, and linguistic tools as a method, we explored the effects of context specificity [a physician seeing two patients with identical presentations (symptoms and findings), but coming to two different diagnoses], hypothesizing more linguistic markers of cognitive load in the presence of contextual factors (e.g. incorrect diagnostic suggestion). Methods In this comparative and exploratory study, 64 physicians each completed one case with contextual factors and one without. Transcribed think-aloud reflections were coded by Linguistic Inquiry and Word Count (LIWC) software for markers of affect, cognitive processes, and first-person pronouns. A repeated-measures multivariate analysis of variance was used to inferentially compare these LIWC categories between cases with and without contextual factors. This was followed by exploratory descriptive analysis of subcategories. Results As hypothesized, participants used more affective and cognitive process markers in cases with contextual factors and more I/me pronouns in cases without. These differences were statistically significant for cognitive processing words but not affective and pronominal words. Exploratory analysis revealed more negative emotions, cognitive processes of insight, and third-person pronouns in cases with contextual factors. Conclusions This study exposes linguistic differences arising from context specificity. These results demonstrate the value of a situated cognition view of patient encounters and reveal the utility of linguistic tools for examining clinical reasoning.
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Affiliation(s)
- Abigail Konopasky
- Assistant Professor of Medicine, The Henry M Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Steven J Durning
- Professor of Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Anthony R Artino
- Professor of Health, Human Function and Rehabilitation Sciences, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Divya Ramani
- Research Associate, The Henry M Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alexis Battista
- Assistant Professor of Medicine, The Henry M Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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36
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Heyhoe J, Lawton R. Social emotion and patient safety: an important and understudied intersection. BMJ Qual Saf 2020; 29:1-2. [PMID: 32217700 DOI: 10.1136/bmjqs-2019-010795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Jane Heyhoe
- Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Rebecca Lawton
- Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK.,School of Psychology, University of Leeds, Leeds, UK
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37
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Isbell LM, Tager J, Beals K, Liu G. Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety. BMJ Qual Saf 2020; 29:1-2. [PMID: 31988259 DOI: 10.1136/bmjqs-2019-010110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 12/26/2019] [Accepted: 12/31/2019] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Linda M Isbell
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Julia Tager
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Kendall Beals
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Guanyu Liu
- Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
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38
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Mamede S, de Carvalho-Filho MA, de Faria RMD, Franci D, Nunes MDPT, Ribeiro LMC, Biegelmeyer J, Zwaan L, Schmidt HG. 'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf 2020; 29:550-559. [PMID: 31988257 PMCID: PMC7362774 DOI: 10.1136/bmjqs-2019-010079] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/24/2019] [Accepted: 01/16/2020] [Indexed: 12/14/2022]
Abstract
Background Diagnostic errors have often been attributed to biases in physicians’ reasoning. Interventions to ‘immunise’ physicians against bias have focused on improving reasoning processes and have largely failed. Objective To investigate the effect of increasing physicians’ relevant knowledge on their susceptibility to availability bias. Design, settings and participants Three-phase multicentre randomised experiment with second-year internal medicine residents from eight teaching hospitals in Brazil. Interventions Immunisation: Physicians diagnosed one of two sets of vignettes (either diseases associated with chronic diarrhoea or with jaundice) and compared/contrasted alternative diagnoses with feedback. Biasing phase (1 week later): Physicians were biased towards either inflammatory bowel disease or viral hepatitis. Diagnostic performance test: All physicians diagnosed three vignettes resembling inflammatory bowel disease, three resembling hepatitis (however, all with different diagnoses). Physicians who increased their knowledge of either chronic diarrhoea or jaundice 1 week earlier were expected to resist the bias attempt. Main outcome measurements Diagnostic accuracy, measured by test score (range 0–1), computed for subjected-to-bias and not-subjected-to-bias vignettes diagnosed by immunised and not-immunised physicians. Results Ninety-one residents participated in the experiment. Diagnostic accuracy differed on subjected-to-bias vignettes, with immunised physicians performing better than non-immunised physicians (0.40 vs 0.24; difference in accuracy 0.16 (95% CI 0.05 to 0.27); p=0.004), but not on not-subjected-to-bias vignettes (0.36 vs 0.41; difference −0.05 (95% CI −0.17 to 0.08); p=0.45). Bias only hampered non-immunised physicians, who performed worse on subjected-to-bias than not-subjected-to-bias vignettes (difference −0.17 (95% CI −0.28 to −0.05); p=0.005); immunised physicians’ accuracy did not differ (p=0.56). Conclusions An intervention directed at increasing knowledge of clinical findings that discriminate between similar-looking diseases decreased physicians’ susceptibility to availability bias, reducing diagnostic errors, in a simulated setting. Future research needs to examine the degree to which the intervention benefits other disease clusters and performance in clinical practice. Trial registration number 68745917.1.1001.0068.
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Affiliation(s)
- Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands .,Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Marco Antonio de Carvalho-Filho
- Internal Medicine, State University of Campinas, Campinas, Brazil.,Center for Education Development and Research in the Health Professions, University of Groningen, Groningen, The Netherlands
| | - Rosa Malena Delbone de Faria
- Propeudeutics, Federal University of Minas Gerais, Belo Horizonte, Brazil.,Education and Research Center, Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Franci
- Internal Medicine, State University of Campinas, Campinas, Brazil
| | | | | | | | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Henk G Schmidt
- Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands.,Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
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Yamauchi Y, Shiga T, Shikino K, Uechi T, Koyama Y, Shimozawa N, Hiraoka E, Funakoshi H, Mizobe M, Imaizumi T, Ikusaka M. Influence of psychiatric or social backgrounds on clinical decision making: a randomized, controlled multi-centre study. BMC MEDICAL EDUCATION 2019; 19:461. [PMID: 31830962 PMCID: PMC6909470 DOI: 10.1186/s12909-019-1897-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/03/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Yosuke Yamauchi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu/Ichikawa Medical Centre, 3-4-32 Todaijima, Urayasu, Chiba, Japan
- Department of General Medicine, University of Chiba Hospital, 1-8-1 Inohana, Chuo, Chiba, Chiba Japan
| | - Takashi Shiga
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu/Ichikawa Medical Centre, 3-4-32 Todaijima, Urayasu, Chiba, Japan
- Department of Emergency Medicine, International University of Health and Welfare, 537-3 Iguchi, Nasushiobara, Tochigi, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, University of Chiba Hospital, 1-8-1 Inohana, Chuo, Chiba, Chiba Japan
| | - Takahiro Uechi
- Department of General Medicine, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, Japan
| | - Yasuaki Koyama
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, 2-1-1 Tenkubo, Tsukuba, Ibaragi, Japan
| | - Nobuhiko Shimozawa
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine Hospital, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa Japan
| | - Eiji Hiraoka
- Department of General Internal Medicine, Tokyo Bay Urayasu/Ichikawa Medical Centre, 3-4-32 Todaijima, Urayasu, Chiba, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu/Ichikawa Medical Centre, 3-4-32 Todaijima, Urayasu, Chiba, Japan
| | - Michiko Mizobe
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu/Ichikawa Medical Centre, 3-4-32 Todaijima, Urayasu, Chiba, Japan
| | - Takahiro Imaizumi
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, University of Chiba Hospital, 1-8-1 Inohana, Chuo, Chiba, Chiba Japan
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40
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Al Alwan I, Magzoub ME, Al Haqwi A, Badri M, Al Yousif SM, Babiker A, Mamede S, Schmidt HG. Do poor patients suffer from inaccurate diagnoses more than well-to-do patients? A randomized control trial. BMC MEDICAL EDUCATION 2019; 19:386. [PMID: 31640683 PMCID: PMC6805410 DOI: 10.1186/s12909-019-1805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 09/11/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Ibrahim Al Alwan
- Department of Pediatrics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohi Eldin Magzoub
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Ali Al Haqwi
- Department of Family Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Motasin Badri
- College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sarah M. Al Yousif
- Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Amir Babiker
- Department of Pediatrics, King Abdulaziz Medical City, Ministry of the National Guard- Health Affairs, and College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus Medical Centre, and Department of Psychology, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Henk G. Schmidt
- Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Klenk L, von Rütte C, Henssler JF, Sauter TC, Hautz WE, Exadaktylos AK, Müller M. Resource consumption of multi-substance users in the emergency room: A neglected patient group. PLoS One 2019; 14:e0223118. [PMID: 31557239 PMCID: PMC6763017 DOI: 10.1371/journal.pone.0223118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 09/15/2019] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Laurence Klenk
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christina von Rütte
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan F. Henssler
- Department of Psychiatry and Psychotherapy, St. Hedwig Hospital Berlin, Charité University Medicine, Berlin, Germany
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Medical Skills Lab, Charité Medical School Berlin, Berlin, Germany
| | - Wolf E. Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany
- * E-mail:
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42
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Pedersen AF, Andersen CM, Ingeman ML, Vedsted P. Patient-physician relationship and use of gut feeling in cancer diagnosis in primary care: a cross-sectional survey of patients and their general practitioners. BMJ Open 2019; 9:e027288. [PMID: 31289073 PMCID: PMC6629394 DOI: 10.1136/bmjopen-2018-027288] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | - Christina Maar Andersen
- Department of Psychology, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Mads Lind Ingeman
- Acute Medical Admission Unit, Aarhus Universitetshospital, Aarhus, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus Universitet, Aarhus, Denmark
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Mota de Almeida FJ, Flygare L, Knutsson K, Wolf E. ‘Seeing is believing’: a qualitative approach to studying the use of cone beam computed tomography in endodontics in Sweden. Int Endod J 2019; 52:1519-1528. [DOI: 10.1111/iej.13144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/09/2019] [Indexed: 12/11/2022]
Affiliation(s)
| | - L. Flygare
- Department of Radiation Sciences Umeå University UmeåSweden
| | - K. Knutsson
- Department of Oral‐and‐Maxillofacial Radiology Malmö University MalmöSweden
| | - E. Wolf
- Department of Endodontics, Faculty of Odontology Malmö University Malmö Sweden
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44
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Hautz WE, Kämmer JE, Hautz SC, Sauter TC, Zwaan L, Exadaktylos AK, Birrenbach T, Maier V, Müller M, Schauber SK. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med 2019; 27:54. [PMID: 31068188 PMCID: PMC6505221 DOI: 10.1186/s13049-019-0629-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/12/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Wolf E. Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
- Centre for Educational Measurement, University of Oslo, Gaustadallén 30, 0373 Oslo, Norway
| | - Juliane E. Kämmer
- Max Planck Institute for Human Development, Center for Adaptive Rationality (ARC), Lentzeallee 94, 14195 Berlin, Germany
- AG Progress Test Medizin, Charité Medical School, Hannoversche Straße 19, 10115 Berlin, Germany
| | - Stefanie C. Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
- Skills Lab Lernzentrum, Charité Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
| | - Tanja Birrenbach
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
- Department of General Internal Medicine, Inselspital University Hospital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland
| | - Volker Maier
- Department of General Internal Medicine, Inselspital University Hospital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
| | - Stefan K. Schauber
- Centre for Educational Measurement, University of Oslo, Gaustadallén 30, 0373 Oslo, Norway
- Centre for Health Sciences Education, Faculty of Medicine, University of Oslo, Oslo, Norway
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TASER-Einsatz – ein notfallmedizinisches Problemfeld? Notf Rett Med 2018. [DOI: 10.1007/s10049-018-0544-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Surry LT, Torre D, Trowbridge RL, Durning SJ. A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions. BMC MEDICAL EDUCATION 2018; 18:277. [PMID: 30470223 PMCID: PMC6251119 DOI: 10.1186/s12909-018-1372-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/31/2018] [Indexed: 05/13/2023]
Abstract
BACKGROUND Cognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error). METHODS Using the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures. RESULTS Among 14 participants, there were 3 cognitive disposition to respond categories - Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities - with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070). CONCLUSION This study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.
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Affiliation(s)
- Luke T Surry
- Department of Medicine, Uniformed Services University of the Health Sciences - F. Hébert School of Medicine, Bethesda, MD, 20814, USA.
| | - Dario Torre
- Department of Medicine, Uniformed Services University of the Health Sciences - F. Hébert School of Medicine, Bethesda, MD, 20814, USA
| | - Robert L Trowbridge
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Centre, Portland, ME, USA
| | - Steven J Durning
- Department of Medicine, Uniformed Services University of the Health Sciences - F. Hébert School of Medicine, Bethesda, MD, 20814, USA
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Frallicciardi A, Lotterman S, Ledford M, Prenovitz I, Meter RV, Kuo C, Nowicki T, Fuller R. Training for Failure: A Simulation Program for Emergency Medicine Residents to Improve Communication Skills in Service Recovery. AEM EDUCATION AND TRAINING 2018; 2:277-287. [PMID: 30386837 PMCID: PMC6194038 DOI: 10.1002/aet2.10116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/08/2018] [Accepted: 06/10/2018] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Alise Frallicciardi
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
| | - Seth Lotterman
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
| | - Matthew Ledford
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
| | - Ilana Prenovitz
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
| | - Rochelle Van Meter
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
| | - Chia‐Ling Kuo
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
| | - Thomas Nowicki
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
- Emergency DepartmentHartford HospitalHartfordCT
| | - Robert Fuller
- Department of Emergency MedicineUniversity of Connecticut School of MedicineFarmingtonCT
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Schlögl M, Schietzel S, Kunz R, Savaskan E, Kressig RW, Riese F. [The Physical Examination of an 'Uncooperative' Elderly Patient]. PRAXIS 2018; 107:1021-1030. [PMID: 30227797 DOI: 10.1024/1661-8157/a003038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Mathias Schlögl
- 1 Klinik für Geriatrie, Universitätsspital Zürich
- 2 Klinik für Alterspsychiatrie, Psychiatrische Universitätsklinik Zürich
| | - Simeon Schietzel
- 1 Klinik für Geriatrie, Universitätsspital Zürich
- 2 Klinik für Alterspsychiatrie, Psychiatrische Universitätsklinik Zürich
| | - Roland Kunz
- 3 Universitäre Klinik für Akutgeriatrie, Stadtspital Waid, Zürich
| | - Egemen Savaskan
- 2 Klinik für Alterspsychiatrie, Psychiatrische Universitätsklinik Zürich
| | - Reto W Kressig
- 4 Universitäre Altersmedizin Basel, Felix Platter-Spital, Klinische Professur für Geriatrie, Universität Basel
| | - Florian Riese
- 2 Klinik für Alterspsychiatrie, Psychiatrische Universitätsklinik Zürich
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Bretherton R, Chapman HR, Chipchase S. A study to explore specific stressors and coping strategies in primary dental care practice. Br Dent J 2018; 220:471-8. [PMID: 27173706 DOI: 10.1038/sj.bdj.2016.334] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2016] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- R Bretherton
- School of Psychology, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS
| | - H R Chapman
- School of Psychology, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS.,School of Psychology, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS
| | - S Chipchase
- Paul Lowe Dentistry, 31 Farmhouse Way, Monkspath, Solihull, B90 4EH
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50
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An Exploration of Emergency Physicians’ Attitudes Toward Patients With Substance Use Disorder. J Addict Med 2018; 12:132-135. [DOI: 10.1097/adm.0000000000000377] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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