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Danielson JH, Jones M, O'Connor SK, Grice G, Adams J. Words matter: Comments in support of diagnosis education in pharmacy. CURRENTS IN PHARMACY TEACHING & LEARNING 2024; 16:102105. [PMID: 38796399 DOI: 10.1016/j.cptl.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/28/2024]
Abstract
Diagnosis education is explicitly included in the Draft Accreditation Standards 2025 and should be wholeheartedly supported. To address the staggering number of diagnostic errors in the US, the National Academy of Medicine advocates for diagnosis education for all health professions. Misperceptions of pharmacists' involvement in diagnosis are exacerbated by use of implicit language and euphemisms, and it's long overdue that we provide clarity. Pharmacists are engaged in diagnosis and diagnostic reasoning in everyday practice whether realized or not. Diagnosis education is implicitly included in US pharmacy curricula in the Pharmacists' Patient Care Process, and it is time to give students the language to engage in it responsibly to be practice-ready in all states. The explicit inclusion of diagnosis in the Draft Standards 2025 has positive implications for education, practice, and graduates.
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Affiliation(s)
- Jennifer Hookstra Danielson
- School of Pharmacy, Southern Illinois University Edwardsville, 200 University Park Drive, Edwardsville, IL 62025, USA.
| | - Mandy Jones
- College of Pharmacy, University of Kentucky, 789 S. Limestone St., Lexington, KY 40505, USA.
| | - Shanna K O'Connor
- College of Pharmacy and Allied Health Professions, South Dakota State University, 2400 S Minnesota Ave, Sioux Falls, SD 57105, USA.
| | - Gloria Grice
- St. Louis College of Pharmacy, University of Health Sciences and Pharmacy, 1 Pharmacy Place, St. Louis, MO 63110, USA.
| | - Jen Adams
- College of Pharmacy, Idaho State University, 1311 E. Central Dr, Meridian, ID 83642, USA.
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Saga E, Egilsdottir HÖ, Bing-Jonsson PC, Lindholm E, Skovdahl K. It's not the task, it's the shifting exploring physicians' and leaders' perspectives on task shifting in emergency departments in Norway. BMC Nurs 2024; 23:571. [PMID: 39152457 PMCID: PMC11330047 DOI: 10.1186/s12912-024-02246-8] [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: 05/28/2024] [Accepted: 08/08/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND Task shifting is an approach where specific tasks are transferred, when convenient, from health workers with high qualifications to health workers with less training and lower qualifications. This approach is mainly used to utilize the available human resources for health. Tasks that are traditionally linked to the physician role have increasingly been transferred to registered nurses during the last decade. Knowledge regarding the experiences and reflections of physicians and their leaders related to giving up tasks or how such policies can best be implemented is limited. This study aimed to explore physicians' and their leaders' perspectives on task shifting, especially to registered nurses, in different Norwegian emergency departments. METHODS The study was carried out from June to October 2022. It had an explorative and descriptive qualitative design and an inductive approach, semi-structured interviews was used. The study involved ten physicians and leaders from three different regional hospitals in south-eastern Norway. Manifest and latent content analysis were used to analyse the data. The COREQ guidelines were applied in the study. RESULTS From the three categories 1) The rationale for task shifting, 2) Teambuilding and 3) Implementation of task shifting, with nine subcategories. One overall main theme emerged: It is not the task, it is the shifting - moving towards a person-centred culture. CONCLUSIONS The study indicates that developing a person-centred culture and fostering a team approach in emergency departments is more important than simply shifting tasks, as task shifting may lead to fragmented care and resistance from physicians. Hospital leaders must invest time and effort into organising teams and providing clear leadership to support the redesign of professional roles, recognising the cultural and traditional challenges involved. Policymakers should promote guideline development, team training programs, and cooperation methods to support a person-centred culture and effective task shifting in emergency departments.
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Affiliation(s)
- Elin Saga
- Division of Emergency Department, Vestfold Hospital Trust, Halfdan Wilhelmsens Allé 17, Tønsberg, 3103, Norway.
| | - H Ösp Egilsdottir
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Grønland 58, Drammen, 3045, Norway
| | - Pia C Bing-Jonsson
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Raveien 215, Borre, 3184, Norway
| | - Espen Lindholm
- Department of Anaesthesiology, Vestfold Hospital Trust, Halfdan Wilhelmsens Allé 17, Tønsberg, 3103, Norway
| | - Kirsti Skovdahl
- Faculty of Health, Welfare and Organisation, Østfold University College, Halden, NO-1757, Norway
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Parsons AS, Wijesekera TP, Olson APJ, Torre D, Durning SJ, Daniel M. Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research. MEDICAL TEACHER 2024:1-12. [PMID: 38835283 DOI: 10.1080/0142159x.2024.2359963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.
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Affiliation(s)
- Andrew S Parsons
- Medicine and Public Health, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Andrew P J Olson
- Medicine and Pediatrics, Medical Education Outcomes Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Dario Torre
- Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Steven J Durning
- Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michelle Daniel
- Emergency Medicine, University of California San Diego School of Medicine San Diego, CA, USA
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McQuade CN, Simonson MG, Lister J, Olson APJ, Zwaan L, Rothenberger SD, Bonifacino E. Characteristics differentiating problem representation synthesis between novices and experts. J Hosp Med 2024; 19:468-474. [PMID: 38528679 DOI: 10.1002/jhm.13335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Formulating a thoughtful problem representation (PR) is fundamental to sound clinical reasoning and an essential component of medical education. Aside from basic structural recommendations, little consensus exists on what characterizes high-quality PRs. OBJECTIVES To elucidate characteristics that distinguish PRs created by experts and novices. METHODS Early internal medicine residents (novices) and inpatient teaching faculty (experts) from two academic medical centers were given two written clinical vignettes and were instructed to write a PR and three-item differential diagnosis for each. Deductive content analysis described the characteristics comprising PRs. An initial codebook of characteristics was refined iteratively. The primary outcome was differences in characteristic frequencies between groups. The secondary outcome was characteristics correlating with diagnostic accuracy. Mixed-effects regression with random effects modeling compared case-level outcomes by group. RESULTS Overall, 167 PRs were analyzed from 30 novices and 54 experts. Experts included 0.8 fewer comorbidities (p < .01) and 0.6 more examination findings (p = .01) than novices on average. Experts were less likely to include irrelevant comorbidities (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.8) or a diagnosis (OR = 0.3, 95% CI = 0.1-0.8) compared with novices. Experts encapsulated clinical data into higher-order terms (e.g., sepsis) than novices (p < .01) while including similar numbers of semantic qualifiers (SQs). Regardless of expertise level, PRs following a three-part structure (e.g., demographics, temporal course, and clinical syndrome) and including temporal SQs were associated with diagnostic accuracy (p < .01). CONCLUSIONS Compared with novices, expert PRs include less irrelevant data and synthesize information into higher-order concepts. Future studies should determine whether targeted educational interventions for PRs improve diagnostic accuracy.
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Affiliation(s)
- Casey N McQuade
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael G Simonson
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Julia Lister
- Division of Hospital Medicine, Department of Internal Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
- Division of Hospital Medicine, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Andrew P J Olson
- Division of Hospital Medicine, Department of Internal Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
- Division of Hospital Medicine, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Laura Zwaan
- Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, the Netherlands
| | - Scott D Rothenberger
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Eliana Bonifacino
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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5
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Miyagami T, Watari T, Nishizaki Y, Shimizu T, Tokuda Y. Association of diagnostic error education and recognition frequency among Japanese medical students: a nationwide cross-sectional study. Diagnosis (Berl) 2024; 11:192-194. [PMID: 37804538 DOI: 10.1515/dx-2023-0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/10/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVES Diagnostic errors pose a significant risk to patient safety and have substantial medical and economic consequences. Despite their importance, diagnostic error education is currently lacking in standard pre-graduate curricula. This study aimed to investigate the incidence of diagnostic errors and the frequency of recognition among medical students in Japan. METHODS A pilot survey was conducted immediately after the General Medicine In-Training Examination (GM-ITE), a comprehensive post-graduation test, administered to new residents right after graduation from medical school. The survey assessed whether they received education on diagnostic errors during their formal undergraduate medical education and whether they recognized diagnostic errors during their clinical training. RESULTS Of the 564 examinees, 421 participated in the study. The majority of participants (63.9 %) reported receiving education on diagnostic errors, and 15.7 % recognized diagnostic errors during their clinical training. Significantly, those who received education on diagnostic errors had a higher rate of recognizing such errors compared to those who did not (19.7 vs. 8.6 %; p=0.0017). CONCLUSIONS These findings suggest that the recognition rate of diagnostic errors increases with improved literacy in diagnostic error education. This highlights the importance of incorporating diagnostic error education into medical curricula to develop effective strategies to prevent and manage diagnostic errors, and thereby enhance medical and patient safety. However, this study did not examine the specific educational content of the errors or the details of the recognition, necessitating further investigation in the future.
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Affiliation(s)
- Taiju Miyagami
- Department of General Medicine, Faculty of Medicine, Juntendo University, Bunkyo-Ku, Tokyo, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Izumo Shi, Shimane, Japan
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Yuji Nishizaki
- Department of General Medicine, Faculty of Medicine, Juntendo University, Bunkyo-Ku, Tokyo, Japan
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan
| | - Yasuharu Tokuda
- Muribushi Okinawa Project for Teaching Hospitals, Okinawa, Japan
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Penner JC, Schuwirth L, Durning SJ. From Noise to Music: Reframing the Role of Context in Clinical Reasoning. J Gen Intern Med 2024; 39:851-857. [PMID: 38243110 PMCID: PMC11043232 DOI: 10.1007/s11606-024-08612-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024]
Affiliation(s)
- John C Penner
- Department of Medicine, University of California, San Francisco, CA, USA.
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Lambert Schuwirth
- Prideaux Discipline of Clinical Education, Flinders University, Adelaide, SA, Australia
| | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Boyle JG, Walters MR, Jamieson S, Durning SJ. Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159. MEDICAL TEACHER 2023; 45:1323-1333. [PMID: 37043405 DOI: 10.1080/0142159x.2023.2190479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthew R Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Susan Jamieson
- Health Professions Education Programme, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Steven J Durning
- Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Griffith PB, Mariani B, Kelly MM. Diagnostic Reasoning Competency and Accuracy by Nurse Practitioner Students Following the Use of Structured Reflection in Simulation: A Mixed-Methods Experiment. Nurs Educ Perspect 2023; 44:E18-E24. [PMID: 37404060 DOI: 10.1097/01.nep.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
AIM The aim of this study was to examine the effect of structured reflection used during a simulated patient's diagnostic workup on diagnostic reasoning competency and accuracy and explore participants' cognitive bias experience and perceived utility of structured reflection. BACKGROUND Reasoning flaws may lead to diagnostic errors. Medical learners who used structured reflection demonstrated improved diagnosis accuracy. METHOD Embedded mixed-methods experiment examined diagnostic reasoning competency and accuracy of nurse practitioner students who did and did not use structured reflection. Cognitive bias experience and perceptions of structured reflection's utility were explored. RESULTS Diagnostic Reasoning Assessment mean competency scores and categories were not changed. Accuracy trended toward improvement with structured reflection. The theme, diagnostic verification, prompted diagnosis change by both structured reflection users and control participants. CONCLUSION Despite no changes in quantitative outcomes, explicit users of structured reflection believed that this strategy is helpful to their reasoning, and control participants used the strategy's components with the same noted benefits.
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Affiliation(s)
- Patricia B Griffith
- About the Authors Patricia B. Griffith, PhD, CRNP, ACNP-BC, is advanced senior lecturer, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania. Bette Mariani, PhD, RN, ANEF, FAAN, is vice dean of academic affairs and a professor, Villanova University M. Louise Fitzpatrick College of Nursing, Villanova, Pennsylvania. Michelle M. Kelly, PhD, CRNP, CNE, FAANP, is associate professor, Villanova University M. Louise Fitzpatrick College of Nursing. Dr. Mariani, Research Briefs editor for Nursing Education Perspectives , had no role in the review or selection of this article. This work was supported by the National League for Nursing Education Scholarship and the Pennsylvania Higher Education Nursing Schools Association Nursing Education Research funding. For more information, contact Dr. Griffith at
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Vally ZI, Khammissa RA, Feller G, Ballyram R, Beetge M, Feller L. Errors in clinical diagnosis: a narrative review. J Int Med Res 2023; 51:3000605231162798. [PMID: 37602466 PMCID: PMC10467407 DOI: 10.1177/03000605231162798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 02/22/2023] [Indexed: 08/22/2023] Open
Abstract
Diagnostic errors are often caused by cognitive biases and sometimes by other cognitive errors, which are driven by factors specific to clinicians, patients, diseases, and health care systems. An experienced clinician diagnoses routine cases intuitively, effortlessly, and automatically through non-analytic reasoning and uses deliberate, cognitively effortful analytic reasoning to diagnose atypical or complicated clinical cases. However, diagnostic errors can never be completely avoided. To minimize the frequency of diagnostic errors, it is advisable to rely on multiple sources of information including the clinician's personal experience, expert opinion, principals of statistics, evidence-based data, and well-designed algorithms and guidelines, if available. It is also important to frequently engage in thoughtful, reflective, and metacognitive practices that can serve to strengthen the clinician's diagnostic skills, with a consequent reduction in the risk of diagnostic error. The purpose of this narrative review was to highlight certain factors that influence the genesis of diagnostic errors. Understanding the dynamic, adaptive, and complex interactions among these factors may assist clinicians, managers of health care systems, and public health policy makers in formulating strategies and guidelines aimed at reducing the incidence and prevalence of the phenomenon of clinical diagnostic error, which poses a public health hazard.
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Affiliation(s)
- Zunaid Ismail Vally
- School of Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Razia A.G. Khammissa
- School of Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Gal Feller
- Department of Radiation Oncology, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Academic Hospital, Johannesburg, South Africa
| | - Raoul Ballyram
- School of Dentistry, Sefako Makgatho University, Pretoria, South Africa
| | - Michaela Beetge
- School of Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Dreicer JJ, Parsons AS, Joudi T, Stern S, Olson APJ, Rencic JJ. Framework and Schema are False Synonyms: Defining Terms to Improve Learning. PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:294-303. [PMID: 37520506 PMCID: PMC10377745 DOI: 10.5334/pme.947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023]
Abstract
Clinical reasoning is an essential expertise of health care professionals that includes the complex cognitive processes that lead to diagnosis and management decisions. In order to optimally teach, learn, and assess clinical reasoning, it is imperative for teachers and learners to have a shared understanding of the language. Currently, educators use the terms schema and framework interchangeably but they are distinct concepts. In this paper, we offer definitions for schema and framework and use the high-stakes field of aviation to demonstrate the interplay of these concepts. We offer examples of framework and schema in the medical education field and discuss how a clear understanding of these concepts allows for greater intentionality when teaching and assessing clinical reasoning.
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Affiliation(s)
- Jessica J. Dreicer
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Andrew S. Parsons
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Tony Joudi
- Fourth-year medical student at the Boston University Chobanian and Avedisian School of Medicine, US
| | - Scott Stern
- University of Chicago, Chicago, Illinois, US
| | - Andrew P. J. Olson
- Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, US
| | - Joseph J. Rencic
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, US
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Caddick ZA, Fraundorf SH, Rottman BM, Nokes-Malach TJ. Cognitive perspectives on maintaining physicians' medical expertise: II. Acquiring, maintaining, and updating cognitive skills. Cogn Res Princ Implic 2023; 8:47. [PMID: 37488460 PMCID: PMC10366061 DOI: 10.1186/s41235-023-00497-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/20/2023] [Indexed: 07/26/2023] Open
Abstract
Over the course of training, physicians develop significant knowledge and expertise. We review dual-process theory, the dominant theory in explaining medical decision making: physicians use both heuristics from accumulated experience (System 1) and logical deduction (System 2). We then discuss how the accumulation of System 1 clinical experience can have both positive effects (e.g., quick and accurate pattern recognition) and negative ones (e.g., gaps and biases in knowledge from physicians' idiosyncratic clinical experience). These idiosyncrasies, biases, and knowledge gaps indicate a need for individuals to engage in appropriate training and study to keep these cognitive skills current lest they decline over time. Indeed, we review converging evidence that physicians further out from training tend to perform worse on tests of medical knowledge and provide poorer patient care. This may reflect a variety of factors, such as specialization of a physician's practice, but is likely to stem at least in part from cognitive factors. Acquired knowledge or skills gained may not always be readily accessible to physicians for a number of reasons, including an absence of study, cognitive changes with age, and the presence of other similar knowledge or skills that compete in what is brought to mind. Lastly, we discuss the cognitive challenges of keeping up with standards of care that continuously evolve over time.
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Affiliation(s)
- Zachary A Caddick
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott H Fraundorf
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA.
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Benjamin M Rottman
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy J Nokes-Malach
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
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Griffith PB, Mariani BA, Kelly MM. The Effect of Structured Reflection on Nurse Practitioner Students’ Diagnostic Reasoning Within Simulation: Qualitative Outcomes of a Mixed Methods Experiment. Clin Simul Nurs 2023. [DOI: 10.1016/j.ecns.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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13
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Harris CK, Chen Y, Alston EL, Brown A, Chabot-Richards D, Dintzis SM, Graber ML, Jackups Jr. R, Lomo LC, Laudadio J, Markwood PS, Nielson KJ, Samedi V, Sampson B, Haspel RL, Zafar N, Montone KT, Childs J, White KL, Heher YK. The next phase in patient safety education: Towards a standardized, tools-based pathology patient safety curriculum: A call to action from the Association of Pathology Chairs' Residency Program Directors Section Training Residents in Patient Safety Workgroup. Acad Pathol 2023; 10:100081. [PMID: 37313035 PMCID: PMC10258240 DOI: 10.1016/j.acpath.2023.100081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 06/15/2023] Open
Abstract
Patient safety education is a mandated Common Program Requirement of the Accreditation Council for Graduate Medical Education and for the Royal College of Physicians and Surgeons of Canada in all medical residency and fellowship programs. Although many hospitals and healthcare environments have general patient safety education tools for trainees, few to none focus on the unique training milieu of pathologists, including a mix of highly automated and manual error-prone processes, frequent multiplicity of events, and lack of direct patient relationships for error disclosure. We established a national Association of Pathology Chairs-Program Directors Section Workgroup focused on patient safety education for pathology trainees entitled Training Residents in Patient Safety (TRIPS). TRIPS included diverse representatives from across the United States, as well as representatives from pathology organizations including the American Board of Pathology, the American Society for Clinical Pathology, the United States and Canadian Academy of Pathology, the College of American Pathologists, and the Society to Improve Diagnosis in Medicine. Objectives of the workgroup included developing a standardized patient safety curriculum, designing teaching and assessment tools, and refining them with pilot sites. Here we report the establishment of TRIPS as well as data from national needs assessment of Program Directors across the country, who confirmed the need for a standardized patient safety curriculum.
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Affiliation(s)
- Cynthia K. Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- The New York City Office of Chief Medical Examiner, New York, NY, USA
| | - Yigu Chen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Erin L. Alston
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ali Brown
- American Society for Clinical Pathology, Chicago, IL, USA
| | | | - Suzanne M. Dintzis
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Mark L. Graber
- Society to Improve Diagnosis in Medicine, Evanston, IL, USA
| | - Ronald Jackups Jr.
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Lesley C. Lomo
- Department of Pathology, University of Utah Health, Salt Lake City, UT, USA
| | - Jennifer Laudadio
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Von Samedi
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Barbara Sampson
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard L. Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nadeem Zafar
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Kathleen T. Montone
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John Childs
- Department of Pathology, Geisinger Medical Center, Danville, PA, USA
| | - Kristie L. White
- Departments of Pathology and Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yael K. Heher
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
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Burt L, Olson A. Development and psychometric testing of the Diagnostic Competency During Simulation-based (DCDS) learning tool. J Prof Nurs 2023; 45:51-59. [PMID: 36889893 DOI: 10.1016/j.profnurs.2023.01.008] [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: 07/12/2022] [Revised: 01/11/2023] [Accepted: 01/18/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Despite diagnostic errors impacting an estimated 12 million people yearly in the United States, educational strategies that foster diagnostic performance among nurse practitioner (NP) students remain elusive. One possible solution is to focus explicitly on competencies fundamental for diagnostic excellence. Currently, no educational tools were found that comprehensively address individual diagnostic reasoning competencies during simulated-based learning experiences. PURPOSE Our research team developed and explored psychometric properties of the "Diagnostic Competency During Simulation-based (DCDS) Learning Tool." METHOD Items and domains were developed based on existing frameworks. Content validity was determined by a convenience sample of eight experts. Inter-rater reliability was determined by four faculty rating eight simulation scenarios. RESULTS Final individual competency domain scale content validity index (CVI) scores ranged between 0.9175 and 1.0; total scale CVI score was 0.98. The intra-class correlation coefficient (ICC) for the tool was 0.548 (p < 0.0001, 95 % confidence interval CI [0.482-0.612]). CONCLUSIONS Results suggest that the DCDS Learning Tool is relevant to diagnostic reasoning competencies and may be implemented with moderate reliability across varied simulation scenarios and performance levels. The DCDS tool expands the landscape of diagnostic reasoning assessment by providing NP educators with granular, actionable, competency-specific assessment measures to foster improvement.
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Affiliation(s)
- Leah Burt
- University of Illinois Chicago College of Nursing, Department of Biobehavioral Nursing Science, United States of America.
| | - Andrew Olson
- Division of Hospital Medicine, Department of Medicine and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota Medical School, United States of America
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15
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Jagannath AD, Dreicer JJ, Penner JC, Dhaliwal G. The cognitive apprenticeship: advancing reasoning education by thinking aloud. Diagnosis (Berl) 2023; 10:9-12. [PMID: 36450097 DOI: 10.1515/dx-2022-0043] [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: 07/04/2022] [Accepted: 10/25/2022] [Indexed: 12/03/2022]
Abstract
Teaching clinical reasoning has long challenged educators because it requires familiarity with reasoning concepts, experience with describing thinking, and comfort with exposing uncertainty and error. We propose that teachers adopt the cognitive apprenticeship model and a method of disclosing uncertainty known as intellectual streaking. These approaches reflect a shift in the educator's mindset from transmitting medical knowledge to broadcasting cognition. We provide several examples to guide the adoption of these strategies and make recommendations for teachers and training programs to improve the teaching of clinical reasoning.
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Affiliation(s)
- Anand D Jagannath
- Division of Hospital Medicine, VA Portland Healthcare System, Portland, OR, USA.,Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jessica J Dreicer
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - John C Penner
- Medical Service, VA San Francisco Healthcare System, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Medical Service, VA San Francisco Healthcare System, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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16
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Goldowsky A, Rencic J. Self-regulated learning and the future of diagnostic reasoning education. Diagnosis (Berl) 2023; 10:24-30. [PMID: 36476651 DOI: 10.1515/dx-2022-0066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022]
Abstract
Diagnostic reasoning is a foundational ability of health professionals. The goal of enhancing clinical reasoning education is improved diagnostic accuracy and reduced diagnostic error. In order to do so, health professions educators need not only help learners improve their clinical reasoning, but teach them how to develop expert performance. An evidence-based learning strategy that is strongly associated with expert performance is self-regulated learning (SRL). SRL is the modulation of "self-generated thoughts, feelings, and actions that are planned and cyclically adapted to the attainment of personal goals". At this time, there is little data on the use of SRL to improve diagnostic reasoning. However, there appear to be numerous opportunities to utilize SRL in novel ways to improve diagnostic reasoning given what is already known about this competency. Examples that are discussed include the role SRL can play in simulation, clinical experiences, assessment, and novel technologies such as virtual reality, artificial intelligence, and machine learning. SRL is central to the philosophy that health professionals are life-long learners, as it teaches learners "how to learn". SRL has the potential to help achieve the goal of improved diagnostic accuracy and reduced diagnostic error.
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Affiliation(s)
- Alexander Goldowsky
- Division of Gastroenterology and Hepatology, Boston University School of Medicine, Boston, MA, USA
| | - Joseph Rencic
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
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17
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Schaye V, Parsons AS, Graber ML, Olson APJ. The future of diagnosis - where are we going? Diagnosis (Berl) 2023; 10:1-3. [PMID: 36720463 DOI: 10.1515/dx-2023-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Verity Schaye
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Andrew S Parsons
- Department of Medicine, Section of Hospital Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Mark L Graber
- Founder and President Emeritus, Society to Improve Diagnosis in Medicine, Plymouth, MA, USA.,Professor Emeritus, Stony Brook University, NY, USA
| | - Andrew P J Olson
- Division of Hospital Medicine, Department of Medicine, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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18
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Gamborg ML, Mehlsen M, Paltved C, Vetter SS, Musaeus P. Clinical decision-making and adaptive expertise in residency: a think-aloud study. BMC MEDICAL EDUCATION 2023; 23:22. [PMID: 36635669 PMCID: PMC9835279 DOI: 10.1186/s12909-022-03990-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.
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Affiliation(s)
- Maria Louise Gamborg
- Centre for Educational Development, Aarhus University, Aarhus C, Denmark.
- Coporate HR MidtSim & Department of Clinical Medicine, Faculty of Health, Aarhus University, Central Denmark Region, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark.
| | - Mimi Mehlsen
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Bartholins Allé 11, 8000, Aarhus C, Denmark
| | - Charlotte Paltved
- Coporate HR MidtSim & Department of Clinical Medicine, Faculty of Health, Aarhus University, Central Denmark Region, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark
| | - Sigrid Strunge Vetter
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Bartholins Allé 11, 8000, Aarhus C, Denmark
| | - Peter Musaeus
- Centre for Educational Development, Aarhus University, Aarhus C, Denmark
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19
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Elvén M, Welin E, Wiegleb Edström D, Petreski T, Szopa M, Durning SJ, Edelbring S. Clinical Reasoning Curricula in Health Professions Education: A Scoping Review. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231209093. [PMID: 37900617 PMCID: PMC10605682 DOI: 10.1177/23821205231209093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/09/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVES This scoping review aimed to explore and synthesize current literature to advance the understanding of how to design clinical reasoning (CR) curricula for students in health professions education. METHODS Arksey and O'Malley's 6-stage framework was applied. Peer-reviewed articles were searched in PubMed, Web of Science, CINAHL, and manual searches, resulting in the identification of 2932 studies. RESULTS Twenty-six articles were included on CR in medical, nursing, physical therapy, occupational therapy, midwifery, dentistry, and speech language therapy education. The results describe: features of CR curriculum design; CR theories, models, and frameworks that inform curricula; and teaching content, methods, and assessments that inform CR curricula. CONCLUSIONS Several CR theories, teaching, and assessment methods are integrated into CR curricula, reflecting the multidimensionality of CR among professions. Specific CR elements are addressed in several curricula; however, no all-encompassing CR curriculum design has been identified. These findings offer useful insights for educators into how CR can be taught and assessed, but they also suggest the need for further guidance on educational strategies and assessments while learners progress through an educational program.
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Affiliation(s)
- Maria Elvén
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Elisabet Welin
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Desiree Wiegleb Edström
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Tadej Petreski
- Institute for Biomedical Sciences, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Magdalena Szopa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Steven J. Durning
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Samuel Edelbring
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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20
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Rowat J, Suneja M. Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum. Diagnosis (Berl) 2022; 9:468-475. [PMID: 36082516 DOI: 10.1515/dx-2022-0046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/12/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The acquisition of clinical reasoning (CR) skills is essential for future healthcare providers as they advance through their education. There is growing consensus that CR skills should be longitudinally integrated into undergraduate curriculum for acquisition/application of these skills. However, only a minority of schools reported having CR focused teaching sessions, citing a lack of curricular time and faculty expertise as the largest barriers. We describe the design and implementation of this theme and report the effects of its early introduction in Phase One as measured by the Diagnostic Thinking Inventory (DTI). METHODS The Carver College of Medicine developed and implemented a longitudinal four-year clinical reasoning theme (CRT) with a special emphasis on introducing concepts in the preclinical years (Phase One). Educational strategies used to implement the theme relied on following principles: 1) new skills are best acquired in context of application; 2) contextual learning stimulates transfer of knowledge; and 3) knowledge of pathophysiology is necessary but alone is not sufficient to develop CR skills. A patient-centered CR schema served as the framework for developing the theme. Specific focus areas, pedagogies and assessment strategies were established for each of the three phases. RESULTS The cohort with CRT demonstrated a significant increase in total DTI score after theme implementation compared to the cohort without. CONCLUSIONS A formal 4-year longitudinal CR theme is feasible, allowing for integration of pathophysiology, social determinants of health, and clinical skills. Early introduction of CR concepts as assessed by DTI showed improvement in student reasoning skills post-intervention.
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Affiliation(s)
- Jane Rowat
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Manish Suneja
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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21
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Griffith PB, Mariani B, Kelly MM. Diagnostic Reasoning Outcomes in Nurse Practitioner Education: A Scoping Review. J Nurs Educ 2022; 61:579-586. [DOI: 10.3928/01484834-20220803-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Johnson MW, Gheihman G, Thomas H, Schiff G, Olson APJ, Begin AS. The impact of clinical uncertainty in the graduate medical education (GME) learning environment: A mixed-methods study. MEDICAL TEACHER 2022; 44:1100-1108. [PMID: 35666840 DOI: 10.1080/0142159x.2022.2058383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Uncertainty is ubiquitous in medicine. Studies link intolerance of uncertainty to burnout, ineffective communication, cognitive bias, and inappropriate resource use. Little is known about how uncertainty manifests in the clinical learning environment. We aimed to explore the perceptions and experiences of uncertainty among residents and attendings. METHODS We conducted a mixed-methods study including a survey, semi-structured interviews, and ethnographic observations during rounds with residents and attendings at an academic medical center. The survey included three validated instruments: Physicians' Reaction to Uncertainty Scale; Maslach Burnout Inventory 2-item; and Educational Climate Inventory. RESULTS 35/60 (58%) of eligible residents and 14/21 (67%) attendings completed the survey. Residents reported higher anxiety due to uncertainty than attendings, higher concern about bad outcomes, and greater reluctance to disclose uncertainty to patients. Residents reported increased symptoms of burnout (p < .05). Perceiving the learning environment as more competitive correlated with reluctance to disclose uncertainty (r = -0.44; p < .01). Qualitative themes included: recognizing and facing uncertainty, and consequences for the learning environment. Observations revealed senior clinicians have greater comfort acknowledging uncertainty. CONCLUSIONS Medical curricula should be developed to promote recognition and acknowledgement of uncertainty. Greater acknowledgement of uncertainty, specifically by attendings and senior residents, may positively impact the clinical learning environment.
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Affiliation(s)
- Mark W Johnson
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Galina Gheihman
- Department of Neurology, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, MA, USA
| | - Horatio Thomas
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Gordon Schiff
- Division of General Internal Medicine, Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School Center for Primary Care, Hospitals and Health Care, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Andrew P J Olson
- Development and Scholarship, Medical Education Outcomes Center, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Arabella Simpkin Begin
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Center for Educational Innovation and Scholarship, Massachusetts General Hospital, Boston, MA, USA
- Internal Medicine Residency at Massachusetts General Hospital, Boston, MA, USA
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23
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Linnavuori E, Leino-Kilpi H, Stolt M. Healthcare Professionals' Electroencephalography Competency: A Disconnect Between Self-Assessment and Objective Testing. J Neurosci Nurs 2022; 54:153-158. [PMID: 35522797 DOI: 10.1097/jnn.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: The role of the healthcare professional (HCP) in performing high-quality electroencephalography (EEG) is critical to ensuring accurate results. This study analyzes HCPs' subjectively and objectively assessed EEG competence to provide information on their EEG competence and competence needs for the development of their education and training. METHODS: The study was a descriptive cross-sectional study. The target group of the study was HCPs working in the clinical neurophysiology departments of university hospitals in Finland. The research data were collected using the EEG Competence instrument created for this research. The instrument consisted of a self-assessment section and a knowledge test component. RESULTS: The participants (N = 65; response rate, 81%) consisted of 34 registered nurses and 31 laboratory technologists. In the self-assessment section, the highest mean score was in patient observation (mean, 4.6) and the lowest was in EEG theoretical knowledge (mean, 3.9). In the test section, most of the respondents (73.8%) answered all questions correctly (maximum, 6 points). There was a positive correlation between age, work experience, own satisfaction with EEG competence, and subjective self-assessment. Those familiar with EEG guidelines and who participated in training days assessed their competence as significantly better ( P < .05). Respondents who read EEG-related literature on their own identified artifacts better ( P = .005). CONCLUSIONS: Laboratory technologists' and registered nurses' subjectively and objectively assessed EEG competence was high. In the future, the EEG competence instrument should be developed further, and more research is needed to assess its psychometric properties to provide more information on HCPs' competence in the diagnostic process.
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24
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Miyata K, Aita Y, Nakajima S, Sekimoto M, Setaka Y, Tagoya Y, Aoyama T, Maeno T, Monma M, Tomita K, Ninomiya H. Effectiveness of a case-based digital learning interprofessional workshop involving undergraduates in medical technology, radiological science, and physical therapy: A pre–post intervention study. PLoS One 2022; 17:e0270864. [PMID: 35881638 PMCID: PMC9321744 DOI: 10.1371/journal.pone.0270864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/16/2022] [Indexed: 11/18/2022] Open
Abstract
All healthcare professionals must understand information on a patient’s biophysical functions, and it is important to educate professionals on how to use this information in an interprofessional team for diagnosis. However, there is little interprofessional education for students of medical technology and radiological science involved in biophysical function diagnosis. In the present study, we developed a case-based interprofessional learning tool for using biophysical information for diagnosis. The study examined the effects of a collaborative exercise workshop for healthcare professional students using the tool. Participants were 234 students from three healthcare professions (medical technology, radiological science, and physical therapy). They completed the Japanese version of the Readiness for Interprofessional Learning Scale before and after the workshops. The workshops incorporated digital materials that allowed students to examine the test results of a virtual patient, answer questions, and discuss their diagnoses and prognoses. For analysis, a two-way analysis of variance was performed on the total score on the Readiness for Interprofessional Learning Scale of the three departments, and the effectiveness of the workshop for the three departments was compared. Statistical analyses showed no interaction between time and department (p = 0.283). After the workshop, students from all three departments showed significant improvements in total scores on the Readiness for Interprofessional Learning Scale (p < 0.01) with medium to large effect sizes (r = 0.33–0.52). In the comparison between departments, there was a significant difference in the awareness levels of only medical technology and radiological science students before the workshop (p = 0.015). This study conducted case-based learning workshops with students from three departments, in which a patient’s biophysical information was conveyed between occupational practices. The workshops improved the awareness of interprofessional education in students from all departments and revealed that interprofessional education is important for healthcare professions involved in biophysical function diagnosis.
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Affiliation(s)
- Kazuhiro Miyata
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan
| | - Yuichi Aita
- Department of Medical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Syuichi Nakajima
- Department of Radiological Sciences, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan
| | - Michiharu Sekimoto
- Department of Radiological Technology, Niigata University of Health and Welfare, Niigata-city, Niigata, Japan
| | - Yukako Setaka
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan
| | - Yoshika Tagoya
- Department of Radiological Sciences, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan
| | - Toshiyuki Aoyama
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan
| | - Takami Maeno
- Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Masahiko Monma
- Department of Radiological Sciences, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan
| | - Kazuhide Tomita
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan
- * E-mail:
| | - Haruhiko Ninomiya
- Department of Medical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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25
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Schaye V, Guzman B, Burk-Rafel J, Marin M, Reinstein I, Kudlowitz D, Miller L, Chun J, Aphinyanaphongs Y. Development and Validation of a Machine Learning Model for Automated Assessment of Resident Clinical Reasoning Documentation. J Gen Intern Med 2022; 37:2230-2238. [PMID: 35710676 PMCID: PMC9296753 DOI: 10.1007/s11606-022-07526-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Residents receive infrequent feedback on their clinical reasoning (CR) documentation. While machine learning (ML) and natural language processing (NLP) have been used to assess CR documentation in standardized cases, no studies have described similar use in the clinical environment. OBJECTIVE The authors developed and validated using Kane's framework a ML model for automated assessment of CR documentation quality in residents' admission notes. DESIGN, PARTICIPANTS, MAIN MEASURES Internal medicine residents' and subspecialty fellows' admission notes at one medical center from July 2014 to March 2020 were extracted from the electronic health record. Using a validated CR documentation rubric, the authors rated 414 notes for the ML development dataset. Notes were truncated to isolate the relevant portion; an NLP software (cTAKES) extracted disease/disorder named entities and human review generated CR terms. The final model had three input variables and classified notes as demonstrating low- or high-quality CR documentation. The ML model was applied to a retrospective dataset (9591 notes) for human validation and data analysis. Reliability between human and ML ratings was assessed on 205 of these notes with Cohen's kappa. CR documentation quality by post-graduate year (PGY) was evaluated by the Mantel-Haenszel test of trend. KEY RESULTS The top-performing logistic regression model had an area under the receiver operating characteristic curve of 0.88, a positive predictive value of 0.68, and an accuracy of 0.79. Cohen's kappa was 0.67. Of the 9591 notes, 31.1% demonstrated high-quality CR documentation; quality increased from 27.0% (PGY1) to 31.0% (PGY2) to 39.0% (PGY3) (p < .001 for trend). Validity evidence was collected in each domain of Kane's framework (scoring, generalization, extrapolation, and implications). CONCLUSIONS The authors developed and validated a high-performing ML model that classifies CR documentation quality in resident admission notes in the clinical environment-a novel application of ML and NLP with many potential use cases.
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Affiliation(s)
- Verity Schaye
- NYU Grossman School of Medicine, New York, NY, USA. .,NYC Health & Hospitals/Bellevue, New York, NY, USA.
| | | | | | - Marina Marin
- NYU Grossman School of Medicine, New York, NY, USA
| | | | | | - Louis Miller
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jonathan Chun
- Stanford University School of Medicine, Stanford, CA, USA
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Schaye V, Miller L, Kudlowitz D, Chun J, Burk-Rafel J, Cocks P, Guzman B, Aphinyanaphongs Y, Marin M. Development of a Clinical Reasoning Documentation Assessment Tool for Resident and Fellow Admission Notes: a Shared Mental Model for Feedback. J Gen Intern Med 2022; 37:507-512. [PMID: 33945113 PMCID: PMC8858363 DOI: 10.1007/s11606-021-06805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability. OBJECTIVE Our goal was to develop a valid and reliable assessment tool for clinical reasoning documentation building off the IDEA assessment tool. DESIGN, PARTICIPANTS, AND MAIN MEASURES The Revised-IDEA assessment tool was developed by four clinician educators through iterative review of admission notes written by medicine residents and fellows and subsequently piloted with additional faculty to ensure response process validity. A random sample of 252 notes from July 2014 to June 2017 written by 30 trainees across several chief complaints was rated. Three raters rated 20% of the notes to demonstrate internal structure validity. A quality cut-off score was determined using Hofstee standard setting. KEY RESULTS The Revised-IDEA assessment tool includes the same four domains as the IDEA assessment tool with more detailed descriptive prompts, new Likert scale anchors, and a score range of 0-10. Intraclass correlation was high for the notes rated by three raters, 0.84 (95% CI 0.74-0.90). Scores ≥6 were determined to demonstrate high-quality clinical reasoning documentation. Only 53% of notes (134/252) were high-quality. CONCLUSIONS The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.
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Affiliation(s)
- Verity Schaye
- NYU Grossman School of Medicine, New York, NY, USA. .,NYC Health + Hospitals/Bellevue, New York, NY, USA.
| | - Louis Miller
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | | | - Jonathan Chun
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | - Marina Marin
- NYU Grossman School of Medicine, New York, NY, USA
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27
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Enomoto K, Kosaka C, Kimura T, Watanuki S, Kurihara M, Watari T, Schaye V. Pharmacists can improve diagnosis and help prevent diagnostic errors. Diagnosis (Berl) 2022; 9:385-389. [PMID: 35089657 DOI: 10.1515/dx-2021-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
We present two cases that highlight the role of pharmacists in the diagnostic process and illustrate how a culture of safety and teamwork between pharmacists and physicians can help prevent diagnostic errors.
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Affiliation(s)
- Kiichi Enomoto
- Department of Pharmacy, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Chintaro Kosaka
- Department of Internal Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Toru Kimura
- Department of Rehabilitation, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Satoshi Watanuki
- Division of Emergency and General Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masaru Kurihara
- Department of Patient Safety, Nagoya University, Nagoya, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University, Shimane, Japan
| | - Verity Schaye
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Connor DM, Narayana S, Dhaliwal G. A clinical reasoning curriculum for medical students: an interim analysis. Diagnosis (Berl) 2022; 9:265-273. [PMID: 34904425 DOI: 10.1515/dx-2021-0112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/22/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis. METHODS In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies. RESULTS Students rated DR highly (range 4.13-4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis. CONCLUSIONS Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.
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Affiliation(s)
- Denise M Connor
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Sirisha Narayana
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
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Gottlieb M, Chan TM, Zaver F, Ellaway R. Confidence-competence alignment and the role of self-confidence in medical education: A conceptual review. MEDICAL EDUCATION 2022; 56:37-47. [PMID: 34176144 DOI: 10.1111/medu.14592] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/20/2021] [Accepted: 06/21/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT There have been significant advances in competency-based medical education (CBME) within health professions education. While most of the efforts have focused on competency, less attention has been paid to the role of confidence as a factor in preparing for practice. This paper seeks to address this deficit by exploring the role of confidence and the calibration of confidence with regard to competence. METHODS This paper presents a conceptual review of confidence and the calibration of confidence in different medical education contexts. Building from an initial literature review, the authors engaged in iterative discussions exploring divergent and convergent perspectives, which were then supplemented with targeted literature reviews. Finally, a stakeholder consultation was conducted to situate and validate the provisional findings. RESULTS A series of axioms were developed to guide perceptions and responses to different states of confidence in health professionals: (a) confidence can shape how we act and is optimised when it closely corresponds to reality; (b) self-confidence is task-specific, but also inextricably influenced by the individual self-conceptualisation, the surrounding system and society; (c) confidence is shaped by many external factors and the context of the situation; (d) confidence must be considered in conjunction with competence and (e) the confidence-competence ratio (CCR) changes over time. It is important to track learners' CCRs and work with them to maintain balance. CONCLUSION Confidence is expressed in different ways and is shaped by a variety of modifiers. While CBME primarily focuses on competency, proportional confidence is an integral component in ensuring safe and professional practice. As such, it is important to consider both confidence and competence, as well as their relationship in CBME. The CCR can serve as a key construct in developing mindful and capable health professionals. Future research should evaluate strategies for assessing CCR, identify best practices for teaching confidence and guiding self-calibration of CCR and explore the role of CCR in continuing professional development for individuals and teams.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Teresa M Chan
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Fareen Zaver
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Rachel Ellaway
- Department of Community Health Sciences and Director of the Office of Health and Medical Education Scholarship, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Graber ML, Holmboe E, Stanley J, Danielson J, Schoenbaum S, Olson AP. A call to action: next steps to advance diagnosis education in the health professions. Diagnosis (Berl) 2021; 9:166-175. [PMID: 34881533 DOI: 10.1515/dx-2021-0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/19/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly in education and training across the health professions. METHODS We focused on medicine, nursing, and pharmacy as examples. A literature review was conducted to survey the state of diagnosis education in these fields, and a consensus group was convened to specify next steps, using formal approaches to rank suggestions. RESULTS The literature review confirmed initial but insufficient progress towards addressing diagnosis-related education. By consensus, we identified the next steps necessary to advance diagnosis education, and five required elements relevant to every profession: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis. CONCLUSIONS The primary stakeholders, representing education, certification, accreditation, and licensure, in each profession must now take action in their own areas to encourage, promote, and enable improved diagnosis, and move these recommendations forward.
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Affiliation(s)
- Mark L Graber
- Society to Improve Diagnosis in Medicine, Plymouth, MA, USA
| | - Eric Holmboe
- Accreditation Council for Graduate Medical Education, Chicago, IL, USA
| | - Joan Stanley
- American Association of Colleges of Nursing, Washington, DC, USA
| | | | | | - Andrew Pj Olson
- University of Minnesota Medical School, Minneapolis, MN, USA
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Somantri I, Sekarwana N, Mediawati AS, Ramoo V, Yahaya NA, Yudianto K. Analysis of Standardized Nursing Languages Application in the Context of Nursing Diagnosis in Hospital in Indonesia. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background. Documentation of nursing care is important in applying care to patients, in terms of their workload coming into the context of indirect nursing care. The focus of his study is to assess the application of nursing diagnoses in hospitals. The phenomenon that occurs in the order of nursing services was found that nurses only focused on documenting nursing assessments, but formulating nursing diagnoses was not clearly illustrated and there are still different perceptions in relation to writing a nursing diagnosis phrase. Objective. The purpose of this study is to identify the application of Standardized Nursing Languages in the context of nursing diagnoses in hospitals in Indonesia.
Method. This study uses a descriptive correlation design using simple random sampling and obtained 132 nurse respondents. Closed questions (with answer choices prepared by the researcher) and open questions (in the form of frequently used diagnostic questions) were used. The instrument was first tested for validity and content validity with a CVI (0.9) and CVR (0.85) value, which means that the instrument is relevant and important to use.
Results. It was found that almost half of the respondents (48.49%) nurses did not use a standard diagnosis. Only the level of education has a relationship with the application of the use of standard language nursing in Indonesia (p-value = 0.006) where the higher the education of nursing will have an impact on accuracy in diagnosing. Whereas for other variables such as gender, career ladder level and position in nursing were found no relationship with the ability in the accuracy of writing diagnoses.
Conclussion. As the results shows that the use of the standard language of nursing is not fully used by nurses in Indonesia. Standardization and equalization of perception by nursing professional organizations are needed to be a guide for all nurses in carrying out documentation of nursing care
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Schattner A. Diagnostic errors: Under-appreciated, under-reported and under-researched. Int J Clin Pract 2021; 75:e14913. [PMID: 34549862 DOI: 10.1111/ijcp.14913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/23/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022] Open
Abstract
Diagnostic errors, were given relatively little attention, compared with the effort invested in treatment errors. However, erroneous diagnoses continue to be quite prevalent (10%-15% in every setting investigated), and are often associated with substantial patient harm including increased mortality and frequent permanent disability. Physicians may not be aware of the fact that despite the wide availability of sophisticated diagnostic imaging and new and sensitive tests, diagnosis remains far from infallible, because of a complex interplay of physician, patient and illness factors. Research devoted to misdiagnosis remains difficult to perform and insufficient in scope, but the search for the optimal means to improve diagnostic accuracy continues. Newly achieved insights regarding diagnostic errors are presented, and essential system and individual approaches to improve diagnostic accuracy are proposed.
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, School of Medical, Hebrew University and Hadassah, Jerusalem, Israel
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Abstract
Identification of diagnostic errors is difficult but is not alone sufficient for performance improvement. Instead, cases must be reflected on to identify ways to improve decision-making in the future. There are many tools and modalities to retrospectively reflect on action to study medical decisions and outcomes and improve future performance. Reflection in action-in which diagnostic decisions are considered in real-time-may also improve medical decision-making especially through strategies such as structured reflection. Ongoing regular feedback can normalize the discussion about improving decision-making, enable reflective practice, and improve decision making.
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Affiliation(s)
- Gopi J Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario Street, Suite 1300, Chicago, IL 60611, USA.
| | - Andrew P J Olson
- Department of Medicine and Pediatrics, University of Minnesota Medical School, 420 Delaware Street SE, MMC 284, Minneapolis, MN 55455, USA
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34
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Sudacka M, Adler M, Durning SJ, Edelbring S, Frankowska A, Hartmann D, Hege I, Huwendiek S, Sobočan M, Thiessen N, Wagner FL, Kononowicz AA. Why is it so difficult to implement a longitudinal clinical reasoning curriculum? A multicenter interview study on the barriers perceived by European health professions educators. BMC MEDICAL EDUCATION 2021; 21:575. [PMID: 34772405 PMCID: PMC8588939 DOI: 10.1186/s12909-021-02960-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 09/27/2021] [Indexed: 05/28/2023]
Abstract
BACKGROUND Effective clinical reasoning is a core competency of health professionals that is necessary to assure patients' safety. Unfortunately, adoption of longitudinal clinical reasoning curricula is still infrequent. This study explores the barriers that hinder the explicit teaching of clinical reasoning from a new international perspective. METHODS The context of this study was a European project whose aim is to develop a longitudinal clinical reasoning curriculum. We collected data in semi-structured interviews with responders from several European countries who represent various health professions and have different backgrounds, roles and experience. We performed a qualitative content analysis of the gathered data and constructed a coding frame using a combined deductive/inductive approach. The identified themes were validated by parallel coding and in group discussions among project members. RESULTS A total of 29 respondents from five European countries participated in the interviews; the majority of them represent medicine and nursing sciences. We grouped the identified barriers into eight general themes: Time, Culture, Motivation, Clinical Reasoning as a Concept, Teaching, Assessment, Infrastructure and Others. Subthemes included issues with discussing errors and providing feedback, awareness of clinical reasoning teaching methods, and tensions between the groups of professionals involved. CONCLUSIONS This study provides an in-depth analysis of the barriers that hinder the teaching of explicit clinical reasoning. The opinions are presented from the perspective of several European higher education institutions. The identified barriers are complex and should be treated holistically due to the many interconnections between the identified barriers. Progress in implementation is hampered by the presence of reciprocal causal chains that aggravate this situation. Further research could investigate the perceptual differences between health professions regarding the barriers to clinical reasoning. The collected insights on the complexity and diversity of these barriers will help when rolling out a long-term agenda for overcoming the factors that inhibit the implementation of clinical reasoning curricula.
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Affiliation(s)
- Małgorzata Sudacka
- Department of Medical Education, Jagiellonian University Medical College, Krakow, Poland.
| | | | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Samuel Edelbring
- Learning and Professional Development Group, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Ada Frankowska
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Daniel Hartmann
- Medical Education Sciences, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Inga Hege
- Medical Education Sciences, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute for Medical Education, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Sören Huwendiek
- Institute for Medical Education, University of Bern, Bern, Switzerland
| | - Monika Sobočan
- Centre for Medical Education, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Division of Gynecology and Perinatology, University Medical Centre Maribor, Maribor, Slovenia
| | - Nils Thiessen
- EDU - a degree smarter, Digital Education Holdings Ltd., Kalkara, Malta
| | | | - Andrzej A Kononowicz
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
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Parodis I, Andersson L, Durning SJ, Hege I, Knez J, Kononowicz AA, Lidskog M, Petreski T, Szopa M, Edelbring S. Clinical Reasoning Needs to Be Explicitly Addressed in Health Professions Curricula: Recommendations from a European Consortium. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11202. [PMID: 34769721 PMCID: PMC8583438 DOI: 10.3390/ijerph182111202] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/18/2022]
Abstract
Clinical reasoning entails the application of knowledge and skills to collect and integrate information, typically with the goal of arriving at a diagnosis and management plan based on the patient's unique circumstances and preferences. Evidence-informed, structured, and explicit teaching and assessment of clinical reasoning in educational programs of medical and other health professions remain unmet needs. We herein summarize recommendations for clinical reasoning learning objectives (LOs), as derived from a consensus approach among European and US researchers and health professions educators. A four-step consensus approach was followed: (1) identification of a convenience sample of the most relevant and applied national LO catalogues for health professions educational programs (N = 9) from European and US countries, (2) extraction of LOs related to clinical reasoning and translation into English, (3) mapping of LOs into predefined categories developed within the Erasmus+ Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators (DID-ACT) consortium, and (4) synthesis of analysis findings into recommendations for how LOs related to clinical reasoning could be presented and incorporated in LO catalogues, upon consensus. Three distinct recommendations were formulated: (1) make clinical reasoning explicit, (2) emphasize interprofessional and collaboration aspects of clinical reasoning, and (3) include aspects of teaching and assessment of clinical reasoning. In addition, the consortium understood that implementation of bilingual catalogues with English as a common language might contribute to lower heterogeneity regarding amount, structure, and level of granularity of clinical reasoning LOs across countries. These recommendations will hopefully motivate and guide initiatives towards the implementation of LOs related to clinical reasoning in existing and future LO catalogues.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, 702 81 Örebro, Sweden
| | - Lina Andersson
- School of Health Sciences, Örebro University, 702 81 Örebro, Sweden; (L.A.); (S.E.)
| | - Steven J. Durning
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
| | - Inga Hege
- Medical Education Sciences, Medical School, University of Augsburg, 86159 Augsburg, Germany;
| | - Jure Knez
- Division for Gynaecology and Perinatology, University Medical Centre Maribor and Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
| | - Andrzej A. Kononowicz
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, 30 688 Krakow, Poland;
| | - Marie Lidskog
- School of Medical Sciences, Örebro University, 702 81 Örebro, Sweden;
| | - Tadej Petreski
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor and Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
| | - Magdalena Szopa
- Department of Medical Education, Jagiellonian University Medical College, 30 688 Krakow, Poland;
- Department of Metabolic Diseases, Jagiellonian University Medical College, 30 688 Krakow, Poland
| | - Samuel Edelbring
- School of Health Sciences, Örebro University, 702 81 Örebro, Sweden; (L.A.); (S.E.)
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Croskerry P, Campbell SG. A Cognitive Autopsy Approach Towards Explaining Diagnostic Failure. Cureus 2021; 13:e17041. [PMID: 34522519 PMCID: PMC8426159 DOI: 10.7759/cureus.17041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
Diagnostic failure has emerged as one of the most significant threats to patient safety. It is important to understand the antecedents of such failures both for clinicians in practice as well is those in training. A consensus has developed in the literature that the majority of failures are due to individual or system factors or some combination of the two. A major source of variance in individual clinical performance is cognitive and affective biases; however, their role in clinical decision making has been difficult to assess partly because they are difficult to investigate experimentally. A significant drawback has been that experimental manipulations appear to confound the assessment of the context surrounding the diagnostic process itself. We conducted an exercise on selected actual cases of diagnostic errors to explore the effect of biases in the ‘real world’ emergency medicine (EM) context. Thirty anonymized EM cases were analysed in depth through a process of root cause analysis that included an assessment of error-producing conditions (EPCs), knowledge-based errors, and how clinicians were thinking and deciding during each case. A prominent feature of the exercise was the identification of the occurrence of and interaction between specific cognitive and affective biases, through a process called cognitive autopsy. The cases covered a broad range of diagnoses across a wide variety of disciplines. A total of 24 discrete cognitive and affective biases that contributed to misdiagnosis were identified and their incidence recorded. Five to six biases were detected per case, and observed on 168 occasions across the 30 cases. Thirteen EPCs were identified. Knowledge-based errors were rare, occurring in only five definite instances. The ordinal position in which biases appeared in the diagnostic process was recorded. This experiment provides a baseline for investigating and understanding the critical role that biases play in clinical decision making as well as providing a credible explanation for why diagnoses fail.
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Affiliation(s)
- Pat Croskerry
- Division of Continuing Medical Education, Dalhousie University, Halifax, CAN
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Singh M, Collins L, Farrington R, Jones M, Thampy H, Watson P, Warner C, Wilson K, Grundy J. From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme. ACTA ACUST UNITED AC 2021; 9:184-194. [PMID: 34256424 DOI: 10.1515/dx-2021-0031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/08/2021] [Indexed: 11/15/2022]
Abstract
There is consensus that clinical reasoning (CR) is crucial for increasing the value of diagnosis, medical decision-making and error reduction. These skills should be developed throughout medical education, starting with undergraduate study. International guidance provides principles for CR curricula but interventions to date, are short term in nature. In this report, we describe the creation of a longitudinal, spiral CR curriculum within a large UK medical school programme (2500 students). A working group drove systematic evidence-based reform of existing structures. We utilised recognised models for curriculum development and mapping, relating learning outcomes to competency frameworks. Application of multiple teaching methodologies, rooted in enquiry-based learning and reported in CR literature, encourage metacognition for information-processing and illness script development. Development of CR is emphasised with recurrent, progressive learning opportunities, each stage purposefully building upon previous experiences. Formative and summative assessment approaches to drive learning, encouraging students' ability to apply and articulate CR, is constructed via Miller's Prism of Clinical Competence. Implementation of pedagogy is contingent on faculty development. Whilst many clinicians practice sound CR, the ability to articulate it to students is often a novel skill. Engagement in faculty development was strengthened through cross-institutional recognition of teaching workload and flexibility of delivery. We report lessons learned from the implementation phase and plans for measuring impact.
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Affiliation(s)
- Mini Singh
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| | - Lisa Collins
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
| | - Rebecca Farrington
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Matthew Jones
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| | - Harish Thampy
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
| | - Pippa Watson
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Christian Warner
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Kurt Wilson
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
| | - Jessica Grundy
- Manchester Clinical Reasoning Group, School of Medical Sciences, Faculty of Medicine, Biology and Health, The University of Manchester, Manchester, UK
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Różańska A, Rosiński J, Jarynowski A, Baranowska-Tateno K, Siewierska M, Wójkowska-Mach J. Incidence of Surgical Site Infections in Multicenter Study-Implications for Surveillance Practice and Organization. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105374. [PMID: 34070095 PMCID: PMC8158383 DOI: 10.3390/ijerph18105374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/05/2021] [Accepted: 05/13/2021] [Indexed: 11/20/2022]
Abstract
Introduction: WHO core components of healthcare-associated infections (HAIs) prevention and control include their surveillance system. In Poland, there are no widespread multi-center infection surveillance networks based on continuous, targeted, active methodology. One of the most important form of HAIs are surgical site infections (SSIs). The aim of this study was to analyze the incidence of SSIs, in the context of seasonal differentiation. Seasonal differentiation could be connected with weather conditions, but it also can be affected by personnel absence due to holidays and furlough. The second aspect may influence organization of work and increased absenteeism may contribute to lowering the quality of patient care. Healthcare associated infections are the phenomenon which can be especially affected by such factors. Methods: The data used originate from the targeted, active surveillance reports obtained from the six years period, based on the ECDC recommendations. Results: Highest incidence rates of SSIs were found after operations performed in June and August, equal to 1.8% and 1.5% respectively and the lowest in October was 0.8%. These differences were statistically significant: for June incidence: OR 1.6, 95% CI 1.03–2.5, p = 0.015. Another approach showed a significant difference between the level of incidence in the period from November to January together with from June to August (1.35%), comparing to the rest of the year (1.05%). Also the rates of enterococcal and Enterobacterales infections were significantly higher for the period comprising months from November till January and from June to August. In Poland these are periods of increased number of absences associated with summer, national and religious holidays. Conclusions: Our results show that the short-term surveillance data limited to several days or months are not sufficient to obtain a valuable description of the epidemiological situation due to HAI. Efforts should be undertaken in order to implement wide net of hospital acquired infections, including SSI on the country level.
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Affiliation(s)
- Anna Różańska
- Chair of Microbiology, Jagiellonian University Medical College, Czysta Str. 18, 31-121 Krakow, Poland;
- Correspondence: ; Tel.: +48-633-25-67
| | - Jerzy Rosiński
- Institute of Economics, Finance and Management, Faculty of Management and Social Communication, Jagiellonian University, 30-348 Krakow, Poland;
| | | | | | | | - Jadwiga Wójkowska-Mach
- Chair of Microbiology, Jagiellonian University Medical College, Czysta Str. 18, 31-121 Krakow, Poland;
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Gleason K, Harkless G, Stanley J, Olson APJ, Graber ML. The critical need for nursing education to address the diagnostic process. Nurs Outlook 2021; 69:362-369. [PMID: 33455815 PMCID: PMC8178169 DOI: 10.1016/j.outlook.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/10/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes.
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Affiliation(s)
| | | | - Joan Stanley
- American Association of Colleges of Nursing, Washington, DC
| | | | - Mark L Graber
- Society to Improve Diagnosis in Medicine, Chicago, IL
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Burt L, Finnegan L, Schwartz A, Corte C, Quinn L, Clark L, Corbridge S. Diagnostic reasoning: relationships among expertise, accuracy, and ways that nurse practitioner students self-explain. ACTA ACUST UNITED AC 2021; 9:50-58. [PMID: 33901388 DOI: 10.1515/dx-2020-0137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/17/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To improve diagnostic ability, educators should employ multifocal strategies. One promising strategy is self-explanation, the purposeful technique of generating self-directed explanations during problem-solving. Students self-explain information in ways that range from simple restatements to multidimensional thoughts. Successful problem-solvers frequently use specific, high-quality self-explanation types. In a previous phase of research, unique ways that family nurse practitioner (NP) students self-explain during diagnostic reasoning were identified and described. This study aims to (a) explore relationships between ways of self-explaining and diagnostic accuracy levels and (b) compare differences between students of varying expertise in terms of ways of self-explaining and diagnostic accuracy levels. Identifying high-quality diagnostic reasoning self-explanation types may facilitate development of more refined self-explanation educational strategies. METHODS Thirty-seven family NP students enrolled in the Doctor of Nursing Practice program at a large, Midwestern university diagnosed three written case studies while self-explaining. During the quantitative phase of a content analysis, associational and comparative data analysis techniques were applied. RESULTS Expert students voiced significantly more clinical and biological inference self-explanations than did novice students. Diagnostic accuracy scores were significantly associated with biological inference scores. Clinical and biological inference scores accounted for 27% of the variance in diagnostic accuracy scores, with biological inference scores significantly influencing diagnostic accuracy scores. CONCLUSIONS Not only were biologically focused self-explanations associated with diagnostic accuracy, but also their spoken frequency influenced levels of diagnostic accuracy. Educational curricula should support students to view patient presentations in terms of underlying biology from the onset of their education.
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Affiliation(s)
- Leah Burt
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | | | - Alan Schwartz
- University of Illinois College of Medicine, Chicago, IL, USA
| | - Colleen Corte
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Laurie Quinn
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Lou Clark
- M Simulation, University of Minnesota, Minneapolis, MN, USA
| | - Susan Corbridge
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
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Papa FJ. Learning Sciences Theories, Principles, and Practices Comprising a Framework for Designing a New Approach to Health Professions Education. MEDICAL SCIENCE EDUCATOR 2021; 31:241-247. [PMID: 34457879 PMCID: PMC8368221 DOI: 10.1007/s40670-020-01129-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 06/13/2023]
Affiliation(s)
- Frank J. Papa
- University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX 76110 USA
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Cooper N, Bartlett M, Gay S, Hammond A, Lillicrap M, Matthan J, Singh M. Consensus statement on the content of clinical reasoning curricula in undergraduate medical education. MEDICAL TEACHER 2021; 43:152-159. [PMID: 33205693 DOI: 10.1080/0142159x.2020.1842343] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Effective clinical reasoning is required for safe patient care. Students and postgraduate trainees largely learn the knowledge, skills and behaviours required for effective clinical reasoning implicitly, through experience and apprenticeship. There is a growing consensus that medical schools should teach clinical reasoning in a way that is explicitly integrated into courses throughout each year, adopting a systematic approach consistent with current evidence. However, the clinical reasoning literature is 'fragmented' and can be difficult for medical educators to access. The purpose of this paper is to provide practical recommendations that will be of use to all medical schools. METHODS Members of the UK Clinical Reasoning in Medical Education group (CReME) met to discuss what clinical reasoning-specific teaching should be delivered by medical schools (what to teach). A literature review was conducted to identify what teaching strategies are successful in improving clinical reasoning ability among medical students (how to teach). A consensus statement was then produced based on the agreed ideas and the literature review, discussed by members of the consensus statement group, then edited and agreed by the authors. RESULTS The group identified 30 consensus ideas that were grouped into five domains: (1) clinical reasoning concepts, (2) history and physical examination, (3) choosing and interpreting diagnostic tests, (4) problem identification and management, and (5) shared decision making. The literature review demonstrated a lack of effectiveness for teaching the general thinking processes involved in clinical reasoning, whereas specific teaching strategies aimed at building knowledge and understanding led to improvements. These strategies are synthesised and described. CONCLUSION What is taught, how it is taught, and when it is taught can facilitate clinical reasoning development more effectively through purposeful curriculum design and medical schools should consider implementing a formal clinical reasoning curriculum that is horizontally and vertically integrated throughout the programme.
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Affiliation(s)
- Nicola Cooper
- Medical Education Centre, University of Nottingham, Nottingham, UK
| | | | - Simon Gay
- School of Medicine, University of Leicester, Leicester, UK
| | | | - Mark Lillicrap
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Joanna Matthan
- School of Dental Sciences, Newcastle University, Newcastle, UK
| | - Mini Singh
- Division of Medical Education, University of Manchester, Manchester, UK
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43
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Jones M, Romanelli F. A model for implementing diagnostic instruction within Doctor of Pharmacy degree programs. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mandy Jones
- Department of Pharmacy Practice and Science College of Pharmacy, University of Kentucky Lexington Kentucky USA
| | - Frank Romanelli
- Department of Pharmacy Practice and Science College of Pharmacy, University of Kentucky Lexington Kentucky USA
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Mays SA. A dual process model for paleopathological diagnosis. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2020; 31:89-96. [PMID: 33132164 DOI: 10.1016/j.ijpp.2020.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/25/2020] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This paper aims to provide an explicit theoretical model for the cognitive processes involved in paleopathological diagnosis. METHODS The approach adopted is a dual process model (DPM). DPMs recognize that cognition is a result of both Type 1 (intuitive) and Type 2 (analytical) processes. DPMs have been influential for understanding decision-making in a range of fields, including diagnosis in clinical medicine. Analogies are drawn between diagnosis in a clinical and a paleopathological setting. RESULTS In clinical medicine, both Type 1 and Type 2 processes play a part in diagnosis. In paleopathology the role of Type 1 processes has been unacknowledged. However, like clinical diagnosis, paleopathological diagnosis is inherently a result of a combination of both Type 1 and Type 2 processes. A model is presented by which Type 1 processes can be explicitly incorporated into a scientific approach to diagnosis from skeletal remains, and in which diagnosis is formalized as a process of hypothesis testing. SIGNIFICANCE Accurately modelling our diagnostic processes allows us to understand the biases and limitations in our work and potentially helps us to improve our procedures, including how we impart diagnostic skills in pedagogical settings. LIMITATIONS This work provides a theoretical model for paleopathological diagnosis. However, such models are by their nature dynamic and developing rather than static entities; it is hoped that this work stimulates further debate and discussion in this important area.
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Affiliation(s)
- S A Mays
- Investigative Science, Historic England, UK; Department of Archaeology, University of Southampton, UK; School of History, Classics and Archaeology, University of Edinburgh, UK.
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Torre D, Durning SJ, Rencic J, Lang V, Holmboe E, Daniel M. Widening the lens on teaching and assessing clinical reasoning: from "in the head" to "out in the world". Diagnosis (Berl) 2020; 7:181-190. [PMID: 32142479 DOI: 10.1515/dx-2019-0098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/12/2020] [Indexed: 11/15/2022]
Abstract
Traditional teaching and assessment of clinical reasoning has focused on the individual clinician because of the preeminence of the information processing (IP) theory perspective. The clinician's mind has been viewed as the main source of effective or ineffective reasoning, and other participants, the environment and their interactions have been largely ignored. A social cognitive theoretical lens could enhance our understanding of how reasoning and error and the environment are linked. Therefore, a new approach in which the clinical reasoning process is situated and examined within the context may be required. The theories of embodied cognition, ecological psychology, situated cognition (SitCog) and distributed cognition (DCog) offer new insights to help the teacher and assessor enhance the quality of clinical reasoning instruction and assessment. We describe the teaching and assessment implications of clinical reasoning and error through the lens of this family of theories. Direct observation in different contexts focused on individual and team performance, simulation (with or without enhancement of technology), stimulated recall, think-aloud, and modeling are examples of teaching and assessment strategies grounded in this family of social cognitive theories. Educators may consider the instructional design of learning environments and educational tools that promote a situated educational approach to the teaching and assessment of clinical reasoning.
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Affiliation(s)
- Dario Torre
- Associate Director of Evaluation and Long-Term Outcomes in Health Professions Education, Professor of Medicine, Department of Internal Medicine, F. Edward Hébert School of Medicine, "America's Medical School", Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4712, USA
| | - Steven J Durning
- Department of Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Joseph Rencic
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Valerie Lang
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Eric Holmboe
- Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Michelle Daniel
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
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Olson AP, Graber ML. Improving Diagnosis Through Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1162-1165. [PMID: 31977340 PMCID: PMC7382536 DOI: 10.1097/acm.0000000000003172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Diagnosis is the cornerstone of providing safe and effective medical care. Still, diagnostic errors are all too common. A key to improving diagnosis in practice is improving diagnosis education, yet formal education about diagnosis is often lacking, idiosyncratic, and not evidence based. In this Invited Commentary, the authors describe the outcomes of a national consensus project to identify key competencies for diagnosis and the themes that emerged as part of this work. The 12 competencies the authors describe span 3 categories-individual, teamwork, and system related-and address ideal diagnostic practice for all health professionals. In addition, the authors identify strategies for improving diagnosis education, including the use of theory-based pedagogy and interprofessional approaches, the recognition of the role of the health care system to enhance or inhibit the diagnostic process, and the need to focus on the individual attributes necessary for high-quality diagnosis, such as humility and curiosity. The authors conclude by advocating for increasing and improving the assessment of individual and team-based diagnostic performance in health professions education programs.
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Affiliation(s)
- Andrew P.J. Olson
- A.P.J. Olson is associate professor, Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mark L. Graber
- M.L. Graber is chief medical officer, Society to Improve Diagnosis in Medicine, New York, New York
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47
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Olson APJ, Durning SJ, Fernandez Branson C, Sick B, Lane KP, Rencic JJ. Teamwork in clinical reasoning - cooperative or parallel play? ACTA ACUST UNITED AC 2020; 7:307-312. [PMID: 32697754 DOI: 10.1515/dx-2020-0020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/25/2020] [Indexed: 11/15/2022]
Abstract
Teamwork is fundamental for high-quality clinical reasoning and diagnosis, and many different individuals are involved in the diagnostic process. However, there are substantial gaps in how these individuals work as members of teams and, often, work is done in parallel, rather than in an integrated, collaborative fashion. In order to understand how individuals work together to create knowledge in the clinical context, it is important to consider social cognitive theories, including situated cognition and distributed cognition. In this article, the authors describe existing gaps and then describe these theories as well as common structures of teams in health care and then provide ideas for future study and improvement.
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Affiliation(s)
- Andrew P J Olson
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.,Departments of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Steven J Durning
- Departments of Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Brian Sick
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.,Departments of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kathleen P Lane
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Joseph J Rencic
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Docherty MA. Sociocultural learning in emergency medicine: a holistic examination of competence. Diagnosis (Berl) 2020; 7:325-332. [DOI: 10.1515/dx-2020-0001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 05/20/2020] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
In the medical community of practice, the resident is situated in systems of professional and cultural activities. How diagnostic competence manifests in their sociocultural context is examined through situativity and systems theories. A holistic model is proposed that could examine diagnostic competence across micro (individual), meso (activity), and macro (cultural) systems.
Methods
Two short scenarios are presented resulting from observations of emergency medicine residents and their supervising physicians. These scenarios are analyzed using a trans-theoretical model of situativity and systems theories to understand how diagnostic competence manifests in practice (activity system).
Results
Assessment of diagnostic competence in a sociocultural context may require assessment of responses to contextual factors that seem immaterial to clinical reasoning. This information may signal that the resident also has the skills to identify appropriate information channels within an activity system and can accurately collect and prioritize clinical information within those channels. Therefore, the formal assessment of competent clinical reasoning performance, as a situated practice, may benefit from delineating how much of the context of an activity system is required to be competently managed and synthesized across the competency milestones.
Conclusions
The examination of diagnostic competence as a sociocultural practice can provide a unique and holistic examination of clinical reasoning performance and assessment.
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Affiliation(s)
- Marcia A. Docherty
- Institute for Social Innovation, Fielding Graduate University , 2020 De la Vina Street , Santa Barbara , CA 93105-3814 , USA
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49
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Graber ML. Progress understanding diagnosis and diagnostic errors: thoughts at year 10. Diagnosis (Berl) 2020; 7:151-159. [DOI: 10.1515/dx-2020-0055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/02/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Mark L. Graber
- Society to Improve Diagnosis in Medicine , Evanston , IL , USA
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50
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Olson APJ, Rosenberg ME. From Nihilism to Opportunity. Clin J Am Soc Nephrol 2020; 15:917-919. [PMID: 32579129 PMCID: PMC7341766 DOI: 10.2215/cjn.07260520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Andrew P J Olson
- Office of Medical Education, University of Minnesota Medical School, Minneapolis, Minnesota
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