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Nelson NR, Rhoney DH. Use of a clinical reasoning scaffolding document improves student performance. CURRENTS IN PHARMACY TEACHING & LEARNING 2024; 16:102102. [PMID: 38714390 DOI: 10.1016/j.cptl.2024.04.018] [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: 12/15/2023] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVE Clinical reasoning is an essential skill set for practicing pharmacists to possess. Given its complex nature, optimal pedagogies for teaching clinical reasoning are largely unknown. The use of scaffolding to expand a student's zone of proximal development and improve clinical reasoning performance was assessed in this study. METHODS This prospective, observational cohort study of second professional year (P2) students compared performance of those who were exposed to a clinical reasoning scaffolding tool (CRST) to historic control P2 students (No CRST) on FARMR notes in alignment with the Pharmacists' Patient Care Process. Student performance was assessed using an entrustment-like scale for each of 5 sections (Findings, Assessment and goals, Recommendations, Monitoring, and Rationale) of the FARMR to link classroom and experiential education settings. RESULTS In total, 141 CRST students from 28 groups were compared to 77 No CRST students from 13 groups. CRST students performed significantly higher in Assessment and goals of therapy, Recommendations, Monitoring, Rationale sections but no difference in Findings. CONCLUSIONS Scaffolding has been utilized successfully in other health professions education. This study provides evidence of it successfully improving student pharmacist clinical reasoning skills, an essential ability for successful pharmacy practitioners.
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Affiliation(s)
| | - Denise H Rhoney
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
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Durning SJ, Jung E, Kim DH, Lee YM. Teaching clinical reasoning: principles from the literature to help improve instruction from the classroom to the bedside. KOREAN JOURNAL OF MEDICAL EDUCATION 2024; 36:145-155. [PMID: 38835308 DOI: 10.3946/kjme.2024.292] [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: 03/18/2024] [Accepted: 04/30/2024] [Indexed: 06/06/2024]
Abstract
Clinical reasoning has been characterized as being an essential aspect of being a physician. Despite this, clinical reasoning has a variety of definitions and medical error, which is often attributed to clinical reasoning, has been reported to be a leading cause of death in the United States and abroad. Further, instructors struggle with teaching this essential ability which often does not play a significant role in the curriculum. In this article, we begin with defining clinical reasoning and then discuss four principles from the literature as well as a variety of techniques for teaching these principles to help ground an instructors' understanding in clinical reasoning. We also tackle contemporary challenges in teaching clinical reasoning such as the integration of artificial intelligence and strategies to help with transitions in instruction (e.g., from the classroom to the clinic or from medical school to residency/registrar training) and suggest next steps for research and innovation in clinical reasoning.
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Affiliation(s)
- Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, MD, USA
| | - Eulho Jung
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, MD, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Do-Hwan Kim
- Department of Medical Education, Hanyang University College of Medicine, Seoul, Korea
| | - Young-Mee Lee
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
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Kalule AO, Currie K, Price L. Striving for Improved Infection Prevention and Control Practice: A Grounded Theory of Healthcare Workers' Struggles in Implementing Infection Prevention and Control Guidance in Uganda. QUALITATIVE HEALTH RESEARCH 2024:10497323241242660. [PMID: 38769749 DOI: 10.1177/10497323241242660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
There is a scarcity of qualitative research focusing on the implementation of infection prevention and control (IPC) guidance in low-income countries. This study aimed to address this gap by exploring the perspectives of healthcare workers (HCWs) regarding the implementation of IPC guidance at the healthcare facility level in Uganda. The study also sought to generate a theoretical understanding of the processes involved in implementing IPC guidance in these settings. This robust qualitative research employed a design based on constructivist grounded theory methodology, conducting individual interviews with 13 frontline health workers such as doctors, nurses, nurse interns, and laboratory staff. The key findings of the study revealed that HCWs undergo a process of 'striving for improved practice' in their efforts to implement IPC guidance. This process involved four phases: recognising the importance of IPC, playing a role, encountering challenges, and overcoming challenges. However, achieving full implementation proved difficult due to various individual and organisational barriers presented by the low-income setting. HCWs employed improvisation as a means to overcome these obstacles. Additionally, the study identified enabling factors that facilitated the implementation of IPC guidance within these settings. This study is significant as it applies robust qualitative research methods to provide valuable evidence of HCWs' perspectives on an important topic in an under-researched context, with findings transferable to similar settings.
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Affiliation(s)
- Andrew O Kalule
- Safeguarding Health through Infection Prevention, Research Centre for Health, School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Kay Currie
- Safeguarding Health through Infection Prevention, Research Centre for Health, School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lesley Price
- Safeguarding Health through Infection Prevention, Research Centre for Health, School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Mullikin DR, Flanagan RP, Merkebu J, Durning SJ, Soh M. Physiologic measurements of cognitive load in clinical reasoning. Diagnosis (Berl) 2024; 11:125-131. [PMID: 38282337 DOI: 10.1515/dx-2023-0143] [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: 10/12/2023] [Accepted: 01/08/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Cognitive load is postulated to be a significant factor in clinical reasoning performance. Monitoring physiologic measures, such as heart rate variability (HRV) may serve as a way to monitor changes in cognitive load. The pathophysiology of why HRV has a relationship to cognitive load is unclear, but it may be related to blood pressure changes that occur in a response to mental stress. METHODS Fourteen residents and ten attendings from Internal Medicine wore Holter monitors and watched a video depicting a medical encounter before completing a post encounter form used to evaluate their clinical reasoning and standard psychometric measures of cognitive load. Blood pressure was obtained before and after the encounter. Correlation analysis was used to investigate the relationship between HRV, blood pressure, self-reported cognitive load measures, clinical reasoning performance scores, and experience level. RESULTS Strong positive correlations were found between increasing HRV and increasing mean arterial pressure (MAP) (p=0.01, Cohen's d=1.41). There was a strong positive correlation with increasing MAP and increasing cognitive load (Pearson correlation 0.763; 95 % CI [; 95 % CI [-0.364, 0.983]). Clinical reasoning performance was negatively correlated with increasing MAP (Pearson correlation -0.446; 95 % CI [-0.720, -0.052]). Subjects with increased HRV, MAP and cognitive load were more likely to be a resident (Pearson correlation -0.845; 95 % CI [-0.990, 0.147]). CONCLUSIONS Evaluating HRV and MAP can help us to understand cognitive load and its implications on trainee and physician clinical reasoning performance, with the intent to utilize this information to improve patient care.
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Affiliation(s)
- Dolores R Mullikin
- Department of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, USA
| | - Ryan P Flanagan
- Department of Pediatric Cardiology, Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Jerusalem Merkebu
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
| | - Steven J Durning
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
| | - Michael Soh
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
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Albahari D. Perceived opportunities of clinical reasoning learning in postgraduate psychiatry training: Trainees' and faculty's perspectives. Qatar Med J 2024; 2024:14. [PMID: 38650827 PMCID: PMC11034381 DOI: 10.5339/qmj.2024.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/19/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Learning clinical reasoning is less effective in isolation of clinical environments because contextual factors are a significant component in the clinical reasoning process. This study investigated the differences in opinions between novice and expert clinicians on learning clinical reasoning in the workplace. MATERIALS AND METHODS The author used a cross-sectional online survey design to investigate the perceived learning of six clinical reasoning skills in 13 learning opportunities. Questionnaires were emailed to 41 postgraduate psychiatry trainee doctors and 37 faculty members. Data were analyzed descriptively. The Chi-square test was used to compare the responses of the two groups. Statistical significance was set at P < 0.05. RESULTS The combined response rate was 73.07%. The two groups perceived the learning of advanced clinical reasoning skills to be lower than that of basic skills. There were significant differences in the perceived learning of basic clinical reasoning skills in self-study/exam preparations (P = 0.032), general hospital grand rounds (P = 0.049), and clinical rounds (P = 0.024 for consultant-led rounds and P = 0.038 for senior peer-led rounds). There were also significant differences in the perceived learning of advanced clinical reasoning skills among peer-led tutorials (P = 0.04), journal clubs (P = 0.006), morning reports (P = 0.002), and on-call duties (P = 0.031). CONCLUSIONS The trainees showed a significant preference for structured learning environments rather than clinical environments, especially for advanced clinical reasoning skills. Trainees likely struggled with cognitive overload in clinical environments. Local postgraduate psychiatry programs will likely benefit from implementing multiple educational interventions that facilitate teaching and learning clinical reasoning in complex clinical environments.
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Madduri GB, Torwekar EL, Demirel S, Durham M, Hauff KI, Kaul R, Nichols T, Ravid NL, Shaner MA, Rassbach CE. CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2024; 20:11393. [PMID: 38524942 PMCID: PMC10957791 DOI: 10.15766/mep_2374-8265.11393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/04/2024] [Indexed: 03/26/2024]
Abstract
Introduction Clinical reasoning enables safe patient care and is an important competency in medical education but can be challenging to teach. Illness scripts facilitate clinical reasoning but have not been used to create pediatric curricula. Methods We created CRISP (Clinical Reasoning with Illness Scripts in Pediatrics), a curriculum comprising four 1-hour learning sessions that deliberately incorporated clinical reasoning concepts and illness scripts to organize how four common chief complaints were taught to family medicine residents on inpatient pediatric rotations. We performed a multisite curriculum evaluation project over 6 months with family medicine residents at four institutions to assess whether the use of clinical reasoning concepts to structure CRISP was feasible and acceptable for learners and instructors and whether the use of illness scripts increased knowledge of four common pediatric chief complaints. Results For all learning sessions, family medicine residents and pediatric hospitalists agreed that CRISP's format was preferable to traditional didactic lectures. Pre-/posttest scores showed statistically significant increases in family medicine resident knowledge (respiratory distress [n = 42]: pretest, 72%, posttest, 92%; abdominal pain [n = 44]: pretest, 82%, posttest, 96%; acute febrile limp [n = 44]: pretest, 68%, posttest, 81%; well-appearing febrile infant [n = 42]: pretest, 58%, posttest, 73%; ps < .05). Discussion By using clinical reasoning concepts and illness script comparison to structure a pediatric curriculum, CRISP represents a novel instructional approach that can be used by pediatric hospitalists to increase family medicine resident knowledge about diagnoses associated with common pediatric chief complaints.
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Affiliation(s)
- Gayatri B. Madduri
- Assistant Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine; Family Medicine Inpatient Pediatrics Rotation Director, John Muir Medical Center
| | - Elizabeth L. Torwekar
- GME Director of Pediatric Education and Pediatric Hospitalist, Department of Pediatrics, Randall Children's Hospital, Legacy Health
| | - Shaban Demirel
- Vice President of Research, Legacy Research Institute, and Director of Clinical Research, Legacy Health
| | - Megan Durham
- Clinical Instructor, Department of Pediatrics, Randall Children's Hospital, Legacy Health
| | - Kimberlee I. Hauff
- Associate Professor, Department of Family Medicine, University of Washington; Family Medicine Inpatient Pediatrics Rotation Director, Swedish Medical Center
| | - Rajat Kaul
- Associate Professor, Division of Hospital Medicine, Department of Pediatrics, Ebeid Children's Hospital; Pediatric Clerkship Director, University of Toledo College of Medicine and Life Sciences
| | - Tristan Nichols
- Assistant Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine; Family Medicine Inpatient Pediatrics Rotation Director, John Muir Medical Center
| | - Noga L. Ravid
- Assistant Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine; Chair, Department of Pediatrics, John Muir Medical Center
| | - Mason A. Shaner
- Third-Year Medical Student, University of Michigan Medical School
| | - Caroline E. Rassbach
- Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, and Program Director, Pediatrics Residency and Pediatrics-Anesthesiology Residency, Stanford University School of Medicine
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Colquhoun-Flannery E, Goodwin D, Walshe C. How clinicians recognise people who are dying: An integrative review. Int J Nurs Stud 2024; 151:104666. [PMID: 38134558 DOI: 10.1016/j.ijnurstu.2023.104666] [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: 07/01/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Timely recognition of dying is important for high quality end-of-life care however, little is known about how clinicians recognise dying. Late recognition is common and can lead to futile treatment that can prolong or increase suffering and prevent a change in the focus of care. AIM To explore how clinicians caring for dying people recognise that they are in the last days or hours of life, as well as the factors that influence the recognition of dying. DESIGN A systematically constructed integrative review of the literature. METHODS Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature, PsycInfo and Allied and Complementary Medicine were searched in July 2022. Papers were included if they were original research, discussed how clinicians recognise dying, available in English language and published in 2012 or later. A constant comparison approach was applied to the analysis and synthesis of the literature. RESULTS 24 papers met the inclusion criteria. There were 3 main categories identified: 'Clues and signals' refers to prompts and signs that lead a clinician to believe a person is dying, incorporating the sub-categories 'knowing the patient over time', and 'intuition and experience'. 'Recognition by others' is where clinicians come to recognise someone is dying through others. This can be through a change in the context of care such as a tool or care plan or by communication with the team. 'Culture, system and practice' refers to the cultural beliefs of a setting that influences awareness of dying and denial of death as a possibility and avoidance of naming death and dying directly. System and practice of the setting also impact on recognition of dying. This involves work pace and intensity, shift systems and timing of senior reviews of patients. Uncertainty and its impact on recognition of dying are evident throughout the findings of this review. The seeking of certainty and the absence of the possibility of dying contributes to late recognition of dying. DISCUSSION Recognition of dying is a complex process that occurs over time, involving a combination of intuition and gathering of information, that is influenced by contextual factors. A culture where dying is not openly acknowledged or even named explicitly contributes to late recognition of dying. A shared language and consistent terminology for explicitly naming dying are needed. Uncertainty is intrinsic to the recognition of dying and therefore a shift to recognising the possibility of dying rather than seeking certainty is needed. REGISTRATION (PROSPERO) CRD42022360900. Registered September 2022.
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Affiliation(s)
- Elizabeth Colquhoun-Flannery
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK.
| | - Dawn Goodwin
- Lancaster Medical School, Lancaster University, Lancaster, UK.
| | - Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK.
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Syed A, Jacob MS. Languaging psychopathology: neurobiology and metaphor. Front Psychiatry 2024; 15:1320771. [PMID: 38374980 PMCID: PMC10875027 DOI: 10.3389/fpsyt.2024.1320771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/12/2024] [Indexed: 02/21/2024] Open
Abstract
Explanatory models of the mind inform our working assumptions about mental illness with direct implications for clinical practice. Neurobiological models assert that the mind can be understood in terms of genetics, chemistry, and neuronal circuits. Growing evidence suggests that clinical deployment of neurobiological models of illness may have unintended adverse effects on patient attitudes, public perception, provider empathy, and the effectiveness of psychiatric treatment. New approaches are needed to find a better language for describing (let alone explaining) the experience of mental illness. To address this gap, we draw upon interdisciplinary sources and semiotic theory to characterize the role of metaphor in the conceptualization and communication of psychopathology. We examine the metaphors recruited by contemporary neurobiological models and metaphor's role in facilitating descriptive clarity or evocative creativity, depending on intention and context. These multiple roles reveal the implications of metaphorical reasoning in clinical practice, including cognitive flexibility, personalized communication, and uncertainty tolerance. With this analysis, we propose a clinical approach that embraces the meta-process of ongoing novel metaphor generation and co-elaboration, or languaging metaphors of psychopathology. Our goal is to bring attention to the value of employing ever-evolving, shapeable metaphorical depictions of psychiatric illness: metaphors that enable a capacity for change in individuals and society, reduce stigma, and nurture recovery.
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Affiliation(s)
- Adnan Syed
- Mental Health Service, San Francisco Veterans Affairs (VA) Medical Center, San Francisco, CA, United States
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Michael S. Jacob
- Mental Health Service, San Francisco Veterans Affairs (VA) Medical Center, San Francisco, CA, United States
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
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O'Brien K, Zhang B, Anderl E, Kothari S. Special Considerations in Behavioral Assessments for Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:93-108. [PMID: 37993196 DOI: 10.1016/j.pmr.2023.07.007] [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] [Indexed: 11/24/2023]
Abstract
Behavioral assessment remains the cornerstone of the clinical evaluation of disorders of consciousness (DoC). Because the basic approach to these evaluations has been extensively reviewed elsewhere, this article focuses on special considerations in the behavioral assessment of patients with a DoC. All therapy disciplines (physical therapy/occupational therapy/speech language pathologist) have a significant role to play and other staff and family members should also be encouraged to share their observations. Finally, the assessment with standardized scales should be supplemented by qualitative behavioral observations as well as, when appropriate, an individualized quantitative behavioral assessment.
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Affiliation(s)
- Katherine O'Brien
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, 1333 Moursund Street, Houston, TX 77030, USA; Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA; H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Bei Zhang
- Division of Physical Medicine and Rehabilitation, Department of Neurology, Texas Tech University Health Sciences Center, 3601 4th Street, STOP 8321, Lubbock, TX 79430, USA. https://twitter.com/BeiZhangMD
| | - Elizabeth Anderl
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, 1333 Moursund Street, Houston, TX 77030, USA
| | - Sunil Kothari
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, 1333 Moursund Street, Houston, TX 77030, USA; H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
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Dufayet L, Piot MA, Geoffroy PA, Oulès B, Petitjean-Brichant C, Peiffer-Smadja N, Bouzid D, Tran Dinh A, Mirault T, Faye A, Lemogne C, Ruszniewski P, Peyre H, Vodovar D. CARECOS study: Medical students' empathy as assessed with the CARE measure by examiners versus standardized patients during a formative Objective and Structured Clinical Examination (OSCE) station. MEDICAL TEACHER 2024:1-9. [PMID: 38285021 DOI: 10.1080/0142159x.2024.2306840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 01/15/2024] [Indexed: 01/30/2024]
Abstract
PURPOSE To assess the Consultation And Relational Empathy (CARE) measure as a tool for examiners to assess medical students' empathy during Objective and Structured Clinical Examinations (OSCEs), as the best tool for assessing empathy during OSCEs remains unknown. METHODS We first assessed the psychometric properties of the CARE measure, completed simultaneously by examiners and standardized patients (SP, either teachers - SPteacher - or civil society members - SPcivil society), for each student, at the end of an OSCE station. We then assessed the qualitative/quantitative agreement between examiners and SP. RESULTS We included 129 students, distributed in eight groups, four groups for each SP type. The CARE measure showed satisfactory psychometric properties in the context of the study but moderate, and even poor inter-rater reliability for some items. Considering paired observations, examiners scored lower than SPs (p < 0.001) regardless of the SP type. However, the difference in score was greater when the SP was a SPteacher rather than a SPcivil society (p < 0.01). CONCLUSION Despite acceptable psychometric properties, inter-rater reliability of the CARE measure between examiners and SP was unsatisfactory. The choice of examiner as well as the type of SP seems critical to ensure a fair measure of empathy during OSCEs.
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Affiliation(s)
- Laurene Dufayet
- UFR de médecine, Université Paris Cité, Paris, France
- Unité Médico-judiciaire, Hôtel-Dieu, AP-HP, Paris, France
- Centre Antipoison de Paris, Hôpital Fernand-Widal, AP-HP, Paris, France
- INSERM, UMRS-1144, Faculté de pharmacie, Paris, France
| | - Marie-Aude Piot
- UFR de médecine, Université Paris Cité, Paris, France
- Département de psychiatrie de l'enfant et de l'adolescent, Hôpital Necker, AP-HP, Paris, France
- INSERM, UMR 1018, Université Paris-Saclay, Villejuif cedex, France
| | - Pierre-Alexis Geoffroy
- UFR de médecine, Université Paris Cité, Paris, France
- Département de psychiatrie et d'addictologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
- Psychiatrie & Neurosciences, Hôpital Saint-Anne, GHU Paris, Paris, France
- Université de Paris, NeuroDiderot, Inserm, FHU I2-D2, Paris, France
| | - Bénédicte Oulès
- UFR de médecine, Université Paris Cité, Paris, France
- Service de dermatologie, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Clara Petitjean-Brichant
- Département de psychiatrie et d'addictologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Nathan Peiffer-Smadja
- UFR de médecine, Université Paris Cité, Paris, France
- Service de maladies infectieuses et tropicales, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
- Université Paris Cité, INSERM UMR1137, IAME, Paris, France
| | - Donia Bouzid
- UFR de médecine, Université Paris Cité, Paris, France
- Université Paris Cité, INSERM UMR1137, IAME, Paris, France
- Service d'accueil des urgences, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Alexy Tran Dinh
- UFR de médecine, Université Paris Cité, Paris, France
- Département d'anesthésie-réanimation, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Tristan Mirault
- UFR de médecine, Université Paris Cité, Paris, France
- Service de médecine vasculaire, Hôpital Européen Georges Pompidou, Paris, France
| | - Albert Faye
- UFR de médecine, Université Paris Cité, Paris, France
- Service de Pédiatrie générale, Maladies infectieuses et Médecine interne, Hôpital Robert Debré, AP-HP, Paris, France
| | - Cédric Lemogne
- UFR de médecine, Université Paris Cité, Paris, France
- Service de Psychiatrie de l'adulte, AP-HP, Hôpital Hôtel-Dieu, Paris, France
- Center for Research in Epidemiology and StatisticS (CRESS), Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Paris, France
| | - Philippe Ruszniewski
- UFR de médecine, Université Paris Cité, Paris, France
- Service de gastro-entérologie et pancréatologie, Hôpital Beaujon AP-HP, Clichy, France
| | - Hugo Peyre
- UFR de médecine, Université Paris Cité, Paris, France
- Service de psychiatrie de l'enfant et de l'adolescent, Hôpital Robert Debré, APHP, Paris, France
- INSERM UMR 1141, Université Paris Cité, Paris, France
| | - Dominique Vodovar
- UFR de médecine, Université Paris Cité, Paris, France
- Centre Antipoison de Paris, Hôpital Fernand-Widal, AP-HP, Paris, France
- INSERM, UMRS-1144, Faculté de pharmacie, Paris, France
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Mohd Tambeh SN, Yaman MN. Clinical reasoning training sessions for health educators-A scoping review. J Taibah Univ Med Sci 2023; 18:1480-1492. [PMID: 37434867 PMCID: PMC10331482 DOI: 10.1016/j.jtumed.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/02/2023] [Accepted: 06/02/2023] [Indexed: 07/13/2023] Open
Abstract
Objectives Clinical reasoning (CR) is important in health professions, because it ensures patient safety and decreases morbidity. CR should be introduced early in medical school. Health educators play a major role in advocating for the use of CR among students; however, educators themselves can be a barrier to the incorporation of CR; consequently, CR training sessions for educators have been proposed as a potential solution. This scoping review was conducted to highlight studies on CR training among health educators. Methods A scoping review was performed to identify studies on CR training sessions for health educators. PubMed, SciVerse Scopus, Web of Science Core Collection, EBSCO Medline Complete and ERIC databases were searched with terms including clinical reasoning, diagnostic reasoning, teacher and trainer, to identify articles published between 1991 and 2021. Results The initial search yielded 6587 articles; after careful selection, n = 12 articles were included in this scoping review. Most CR training sessions were in the medical field, were conducted in North America, and involved clinical educators. The sessions focused on the fundamentals and steps of CR; biases and debiasing strategies; and learners' difficulties with various teaching formats, such as didactic presentations, facilitated small group sessions with case discussions, roleplay, and use of tools and a mobile application. Educators and students had positive perceptions regarding the conduct and effectiveness of the training sessions. Conclusions These training sessions were rated highly; however, longitudinal feedback regarding the application of learnt CR teaching strategies is necessary.
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Affiliation(s)
- Siti N. Mohd Tambeh
- Department of Medical Education, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Physiology, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Mohamad N. Yaman
- Department of Medical Education, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Gauss T, Perkins Z, Tjardes T. Current knowledge and availability of machine learning across the spectrum of trauma science. Curr Opin Crit Care 2023; 29:713-721. [PMID: 37861197 DOI: 10.1097/mcc.0000000000001104] [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: 10/21/2023]
Abstract
PURPOSE OF REVIEW Recent technological advances have accelerated the use of Machine Learning in trauma science. This review provides an overview on the available evidence for research and patient care. The review aims to familiarize clinicians with this rapidly evolving field, offer perspectives, and identify existing and future challenges. RECENT FINDINGS The available evidence predominantly focuses on retrospective algorithm construction to predict outcomes. Few studies have explored actionable outcomes, workflow integration, or the impact on patient care. Machine Learning and data science have the potential to simplify data capture and enhance counterfactual causal inference research from observational data to address complex issues. However, regulatory, legal, and ethical challenges associated with the use of Machine Learning in trauma care deserve particular attention. SUMMARY Machine Learning holds promise for actionable decision support in trauma science, but rigorous proof-of-concept studies are urgently needed. Future research should assess workflow integration, human-machine interaction, and, most importantly, the impact on patient outcome. Machine Learning enhanced causal inference for observational data carries an enormous potential to change trauma research as complement to randomized studies. The scientific trauma community needs to engage with the existing challenges to drive progress in the field.
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Affiliation(s)
- Tobias Gauss
- Anesthesia and Critical Care, Grenoble Alpes, University Hospital, Grenoble, France
| | - Zane Perkins
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Thorsten Tjardes
- Department of Trauma Surgery, Orthopedic Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
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Messager G, Loewenhaupt T, Veyriere A, Ghulam S. [Developing ISP skills: the challenge facing the Sdis medical training department]. SOINS; LA REVUE DE REFERENCE INFIRMIERE 2023; 68:52-56. [PMID: 37778857 DOI: 10.1016/j.soin.2023.08.013] [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: 10/03/2023]
Abstract
Teaching can be taught! In order to develop and maintain the skills of its caregivers, the Departemental Fire and Rescue Service 77 Health Sub-Directorate is engaged in an innovative pedagogical dynamic, combining a real engineering of its training programs in compliance with the principles of active pedagogy, full and regular training of its teaching teams.
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Affiliation(s)
- Grégory Messager
- Service départemental d'incendie et de secours de Seine-et-Marne (Sdis 77), 56 avenue de Corbeil, 77000 Melun, France.
| | - Thomas Loewenhaupt
- Service départemental d'incendie et de secours de Seine-et-Marne (Sdis 77), 56 avenue de Corbeil, 77000 Melun, France
| | - Aurore Veyriere
- Service départemental d'incendie et de secours de Seine-et-Marne (Sdis 77), 56 avenue de Corbeil, 77000 Melun, France
| | - Saïqa Ghulam
- Service départemental d'incendie et de secours de Seine-et-Marne (Sdis 77), 56 avenue de Corbeil, 77000 Melun, France
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14
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Fraundorf SH, Caddick ZA, Nokes-Malach TJ, Rottman BM. Cognitive perspectives on maintaining physicians' medical expertise: III. Strengths and weaknesses of self-assessment. Cogn Res Princ Implic 2023; 8:58. [PMID: 37646932 PMCID: PMC10469193 DOI: 10.1186/s41235-023-00511-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
Is self-assessment enough to keep physicians' cognitive skills-such as diagnosis, treatment, basic biological knowledge, and communicative skills-current? We review the cognitive strengths and weaknesses of self-assessment in the context of maintaining medical expertise. Cognitive science supports the importance of accurately self-assessing one's own skills and abilities, and we review several ways such accuracy can be quantified. However, our review also indicates a broad challenge in self-assessment is that individuals do not have direct access to the strength or quality of their knowledge and instead must infer this from heuristic strategies. These heuristics are reasonably accurate in many circumstances, but they also suffer from systematic biases. For example, information that feels easy to process in the moment can lead individuals to overconfidence in their ability to remember it in the future. Another notable phenomenon is the Dunning-Kruger effect: the poorest performers in a domain are also the least accurate in self-assessment. Further, explicit instruction is not always sufficient to remove these biases. We discuss what these findings imply about when physicians' self-assessment can be useful and when it may be valuable to supplement with outside sources.
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Affiliation(s)
- Scott H Fraundorf
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA.
- Department of Psychology, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA.
| | - Zachary A Caddick
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, 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, 3420 Forbes Ave., Pittsburgh, PA, 15260, 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, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
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15
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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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Harendza S, Bußenius L, Gärtner J, Heuser M, Ahles J, Prediger S. "Fit for the finals" - project report on a telemedical training with simulated patients, peers, and assessors for the licensing exam. GMS JOURNAL FOR MEDICAL EDUCATION 2023; 40:Doc17. [PMID: 37361248 PMCID: PMC10285374 DOI: 10.3205/zma001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/11/2023] [Accepted: 02/06/2023] [Indexed: 06/28/2023]
Abstract
Background Undergraduate medical students take the licensing exam (M3) as a two-day oral-practical examination. The main requirements are to demonstrate history taking skills and coherent case presentations. The aim of this project was to establish a training in which students can test their communication skills during history taking and their clinical reasoning skills in focused case presentations. Methods In the newly developed training, final-year students took four telemedical histories in the role of physicians from simulated patients (SP). They received further findings for two SPs and presented these in a handover, in which they also received a handover of two SPs which they had not seen themselves. Each student presented one of the two received SPs in a case discussion with a senior physician. Feedback was given to the participants on their communication and interpersonal skills by the SPs with the ComCare questionnaire and on the case presentation by the senior physician. Sixty-two students from the universities of Hamburg and Freiburg in their final year participated in September 2022 and evaluated the training. Results Participants felt that the training was very appropriate for exam preparation. The SPs' feedback on communication and the senior physician's feedback on clinical reasoning skills received the highest ratings in importance to the students. Participants highly valued the practice opportunity for structured history taking and case presentation and would like to have more such opportunities in the curriculum. Conclusion Essential elements of the medical licensing exam can be represented, including feedback, in this telemedical training and it can be offered independent of location.
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Affiliation(s)
- Sigrid Harendza
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Lisa Bußenius
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Julia Gärtner
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Miriam Heuser
- Albert-Ludwigs-Universität Freiburg, Medizinische Fakultät, Studiendekanat, Freiburg, Germany
| | - Jonathan Ahles
- Albert-Ludwigs-Universität Freiburg, Medizinische Fakultät, Studiendekanat, Freiburg, Germany
| | - Sarah Prediger
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
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Nelson NR, Rhoney DH. Analysis of Expert Feedback to Determine Intellectual Standards for Student Pharmacist Clinical Reasoning Development. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2023; 87:ajpe8975. [PMID: 36347540 PMCID: PMC10159038 DOI: 10.5688/ajpe8975] [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: 11/17/2021] [Accepted: 07/21/2022] [Indexed: 05/03/2023]
Abstract
Objectives. Clinical reasoning (CR) is one of the most important skills for pharmacy learners. Feedback has been proposed as a pedagogy to improve CR skills; however, essential components of CR have yet to be determined within pharmacy education. This study sought to streamline feedback to align with the Pharmacists' Patient Care Process (PPCP).Methods. The investigators used deidentified clinical reasoning "Keep," "Start," or "Stop" (KSS) feedback comments from student-written CR "think-aloud" sessions with pharmacy students in their third professional year. Sections were mapped to the PPCP and were coded by 2 independent investigators according to proposed essential components of CR, using an adapted grounded-theory approach. Investigators could inductively add codes after conferring with the other. Coded feedback was analyzed using a summative content approach. Intercoder reliability was calculated via Holsti index.Results. Five essential components of CR were identified after analysis of 635 KSS comments. The 5 essential components of CR were coded 1178 times. "Accurate," "Concise," "Specific," and "Thorough" were identified a priori, while "Connected" was discovered during feedback comment review. Literature analysis added supporting data to these results through the Paul-Elder Critical Thinking Framework. To maintain consistency in language, these essential components will be referred to as "intellectual standards" moving forward.Conclusion. This novel study successfully identified 5 key intellectual standards of CR. These intellectual standards provide a framework for pharmacy educators to focus feedback to improve student CR. Future research of other intellectual standards pertinent to experiential education is imperative.
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Affiliation(s)
- Nicholas R Nelson
- University of North Carolina at Chapel Hill, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Denise H Rhoney
- University of North Carolina at Chapel Hill, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
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18
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Raharjanti NW, Soemantri D, Wiguna T, Findyartini A, Purwadianto A, Indriatmi W, Poerwandari EK, Mahajudin MS, Nugrahadi NR, Roekman AE, Leonardo R, Ramadianto AS, Levania MK. Defining the tasks of clinical reasoning in forensic psychiatric evaluation: Psychomedicolegal analysis competency. Heliyon 2023; 9:e14077. [PMID: 36915550 PMCID: PMC10006738 DOI: 10.1016/j.heliyon.2023.e14077] [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: 04/11/2022] [Revised: 02/08/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
Objective Inconsistency in the quality of forensic psychiatry report has been criticized for several years. Yet, there are limited guidelines to provide minimally satisfactory forensic psychiatry evaluation conducted by psychiatrists. In addition to the impact towards the forensic psychiatry service, this lack of standardized guidelines may impact the relevant competency development and its various teaching methods of forensic psychiatry among general psychiatrists. Therefore, this study aims to identify components of psychomedicolegal analysis competency as a form of clinical reasoning in forensic psychiatry. Methods A comprehensive literature review and expert panel discussions were conducted simultaneously to formulate an initial list of psychomedicolegal analysis competency. A total of fourteen experts were chosen based on their expertise in different disciplines that have intersections with forensic psychiatry and the general psychiatry curriculum (e.g. general psychiatrist, forensic psychiatrists and psychologist, law practitioner, and medical education director). The expert panel were instructed to score and provide feedbacks on the items of the initial list. Four-point Likert scale were used in order for the experts to express the relevancy of the core competence to forensic psychiatry practice until it reached the consensus. Results The final 60 items of psychomedicolegal analysis competency were developed after three rounds of Delphi technique and reached a consensus (>70% and medians score of at least 3,25). These competency then categorized into four steps 1) preparing the case (Item 1-11), 2) conducting the evaluation (Item 12-41), 3) writing the report (42-51), and 4) giving expert opinion in court (Item 52-60). Conclusion We developed 60 items of psychomedicolegal analysis competency that can be used as a standardized guide for psychiatrists to conduct forensic psychiatry evaluation, write the report and provide expert opinion in court. Implementation of this guideline can be used to shape further forensic psychiatry education for general psychiatrist and psychiatry residency.
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Affiliation(s)
| | | | - Tjhin Wiguna
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | - Agus Purwadianto
- Forensic Department, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Wresti Indriatmi
- Dermatology and Venerology Department, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | - Marlina S Mahajudin
- Department of Psychiatry, Airlangga University, Surabaya, East Java, Indonesia
| | | | | | - Ronald Leonardo
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | - Monika Kristi Levania
- Department of Psychiatry, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Croskerry P, Campbell SG, Petrie DA. The challenge of cognitive science for medical diagnosis. Cogn Res Princ Implic 2023; 8:13. [PMID: 36759370 PMCID: PMC9911579 DOI: 10.1186/s41235-022-00460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/23/2022] [Indexed: 02/11/2023] Open
Abstract
The historical tendency to view medicine as both an art and a science may have contributed to a disinclination among clinicians towards cognitive science. In particular, this has had an impact on the approach towards the diagnostic process which is a barometer of clinical decision-making behaviour and is increasingly seen as a yardstick of clinician calibration and performance. The process itself is more complicated and complex than was previously imagined, with multiple variables that are difficult to predict, are interactive, and show nonlinearity. They appear to characterise a complex adaptive system. Many aspects of the diagnostic process, including the psychophysics of signal detection and discrimination, ergonomics, probability theory, decision analysis, factor analysis, causal analysis and more recent developments in judgement and decision-making (JDM), especially including the domain of heuristics and cognitive and affective biases, appear fundamental to a good understanding of it. A preliminary analysis of factors such as manifestness of illness and others that may impede clinicians' awareness and understanding of these issues is proposed here. It seems essential that medical trainees be explicitly and systematically exposed to specific areas of cognitive science during the undergraduate curriculum, and learn to incorporate them into clinical reasoning and decision-making. Importantly, this understanding is needed for the development of cognitive bias mitigation and improved calibration of JDM in clinical practice.
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Affiliation(s)
- Pat Croskerry
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada.
| | - Samuel G. Campbell
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - David A. Petrie
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
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Gao Y, Dligach D, Miller T, Caskey J, Sharma B, Churpek MM, Afshar M. DR.BENCH: Diagnostic Reasoning Benchmark for Clinical Natural Language Processing. J Biomed Inform 2023; 138:104286. [PMID: 36706848 PMCID: PMC9993808 DOI: 10.1016/j.jbi.2023.104286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/13/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
The meaningful use of electronic health records (EHR) continues to progress in the digital era with clinical decision support systems augmented by artificial intelligence. A priority in improving provider experience is to overcome information overload and reduce the cognitive burden so fewer medical errors and cognitive biases are introduced during patient care. One major type of medical error is diagnostic error due to systematic or predictable errors in judgement that rely on heuristics. The potential for clinical natural language processing (cNLP) to model diagnostic reasoning in humans with forward reasoning from data to diagnosis and potentially reduce cognitive burden and medical error has not been investigated. Existing tasks to advance the science in cNLP have largely focused on information extraction and named entity recognition through classification tasks. We introduce a novel suite of tasks coined as Diagnostic Reasoning Benchmarks, Dr.Bench, as a new benchmark for developing and evaluating cNLP models with clinical diagnostic reasoning ability. The suite includes six tasks from ten publicly available datasets addressing clinical text understanding, medical knowledge reasoning, and diagnosis generation. DR.BENCH is the first clinical suite of tasks designed to be a natural language generation framework to evaluate pre-trained language models for diagnostic reasoning. The goal of DR. BENCH is to advance the science in cNLP to support downstream applications in computerized diagnostic decision support and improve the efficiency and accuracy of healthcare providers during patient care. We fine-tune and evaluate the state-of-the-art generative models on DR.BENCH. Experiments show that with domain adaptation pre-training on medical knowledge, the model demonstrated opportunities for improvement when evaluated in DR. BENCH. We share DR. BENCH as a publicly available GitLab repository with a systematic approach to load and evaluate models for the cNLP community. We also discuss the carbon footprint produced during the experiments and encourage future work on DR.BENCH to report the carbon footprint.
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Affiliation(s)
- Yanjun Gao
- ICU Data Science Lab, Department of Medicine, University of Wisconsin Madison, 1685 Highland Ave, Madison, 53792, WI, USA.
| | - Dmitriy Dligach
- Department of Computer Science, Loyola University Chicago, 1032 W Sheridan Rd, Chicago, 60660, IL, USA
| | - Timothy Miller
- Boston Children's Hospital, Harvard University, 300 Longwood Ave, Boston, 02115, MA, USA
| | - John Caskey
- ICU Data Science Lab, Department of Medicine, University of Wisconsin Madison, 1685 Highland Ave, Madison, 53792, WI, USA
| | - Brihat Sharma
- ICU Data Science Lab, Department of Medicine, University of Wisconsin Madison, 1685 Highland Ave, Madison, 53792, WI, USA
| | - Matthew M Churpek
- ICU Data Science Lab, Department of Medicine, University of Wisconsin Madison, 1685 Highland Ave, Madison, 53792, WI, USA
| | - Majid Afshar
- ICU Data Science Lab, Department of Medicine, University of Wisconsin Madison, 1685 Highland Ave, Madison, 53792, WI, USA
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Chrismawaty BE, Emilia O, Rahayu GR, Ana ID. Clinical reasoning pattern used in oral health problem solving - A case study in Indonesian undergraduate dental students. BMC MEDICAL EDUCATION 2023; 23:52. [PMID: 36690982 PMCID: PMC9872386 DOI: 10.1186/s12909-022-03808-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 10/17/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Health professionals are known to use various combinations of knowledge and skills, such as critical thinking, clinical reasoning, clinical judgment, problem-solving, and decision-making, in conducting clinical practice. Clinical reasoning development is influenced by knowledge and experience, the more knowledge and experience, the more sophisticated clinical reasoning will be. However, clinical reasoning research in dentistry shows varying results . AIMS This study aims to observe the clinical reasoning pattern of undergraduate dental students when solving oral health problems, and their accordance with their knowledge acquisition. MATERIAL AND METHODS This qualitative study employed the think-aloud method and the result was assessed through verbal protocol analyses. Five respondents from final year dental undergraduate students were agreed to participate. A unique hypothetical clinical scenario was used as a trigger. The audio data were transcribed, interpreted, and categorized as a clinical reasoning pattern; and the concept maps created were assessed by a Structure of Learning Outcomes (SOLO) taxonomy as knowledge acquisition. RESULTS Observations on clinical reasoning patterns and the level of knowledge acquisition in five undergraduate dental students showed varying results. They applied clinical reasoning patterns according to their knowledge acquisition during didactical phase. Learners with inadequate knowledge relied on guessing, meanwhile learners with adequate knowledge applied more sophisticated reasoning pattern when solving problems. CONCLUSIONS Various problem-solving strategies were encountered in this study, which corresponded to the level of knowledge acquisition. Dental institutions must set minimum standards regarding the acquisition of conceptual knowledge accompanied by improvement of clinical reasoning skills, as well as refinement of knowledge and procedural skills.
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Affiliation(s)
- B E Chrismawaty
- Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Jl. Denta 1, Sekip Utara, Yogyakarta 55281, Indonesia.
| | - O Emilia
- Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Jl. Denta 1, Sekip Utara, Yogyakarta 55281, Indonesia
| | - G R Rahayu
- Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Jl. Denta 1, Sekip Utara, Yogyakarta 55281, Indonesia
| | - I D Ana
- Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Jl. Denta 1, Sekip Utara, Yogyakarta 55281, Indonesia
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22
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Aquino YSJ, Rogers WA, Braunack-Mayer A, Frazer H, Win KT, Houssami N, Degeling C, Semsarian C, Carter SM. Utopia versus dystopia: Professional perspectives on the impact of healthcare artificial intelligence on clinical roles and skills. Int J Med Inform 2023; 169:104903. [PMID: 36343512 DOI: 10.1016/j.ijmedinf.2022.104903] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/23/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Alongside the promise of improving clinical work, advances in healthcare artificial intelligence (AI) raise concerns about the risk of deskilling clinicians. This purpose of this study is to examine the issue of deskilling from the perspective of diverse group of professional stakeholders with knowledge and/or experiences in the development, deployment and regulation of healthcare AI. METHODS We conducted qualitative, semi-structured interviews with 72 professionals with AI expertise and/or professional or clinical expertise who were involved in development, deployment and/or regulation of healthcare AI. Data analysis using combined constructivist grounded theory and framework approach was performed concurrently with data collection. FINDINGS Our analysis showed participants had diverse views on three contentious issues regarding AI and deskilling. The first involved competing views about the proper extent of AI-enabled automation in healthcare work, and which clinical tasks should or should not be automated. We identified a cluster of characteristics of tasks that were considered more suitable for automation. The second involved expectations about the impact of AI on clinical skills, and whether AI-enabled automation would lead to worse or better quality of healthcare. The third tension implicitly contrasted two models of healthcare work: a human-centric model and a technology-centric model. These models assumed different values and priorities for healthcare work and its relationship to AI-enabled automation. CONCLUSION Our study shows that a diverse group of professional stakeholders involved in healthcare AI development, acquisition, deployment and regulation are attentive to the potential impact of healthcare AI on clinical skills, but have different views about the nature and valence (positive or negative) of this impact. Detailed engagement with different types of professional stakeholders allowed us to identify relevant concepts and values that could guide decisions about AI algorithm development and deployment.
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Affiliation(s)
- Yves Saint James Aquino
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, NSW, Australia.
| | - Wendy A Rogers
- Department of Philosophy and School of Medicine, Macquarie University, NSW, Australia
| | - Annette Braunack-Mayer
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, NSW, Australia
| | - Helen Frazer
- St Vincent's Hospital, Melbourne, VIC, Australia
| | - Khin Than Win
- Centre for Persuasive Technology and Society, School of Computing and Information Technology, University of Wollongong, NSW, Australia
| | - Nehmat Houssami
- School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia; The Daffodil Centre, The University of Sydney, Joint Venture with Cancer Council NSW, Australia
| | - Christopher Degeling
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, NSW, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Australia
| | - Stacy M Carter
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, NSW, Australia
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23
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Eich A, Klichowicz A, Bocklisch F. How automation level influences moral decisions of humans collaborating with industrial robots in different scenarios. Front Psychol 2023; 14:1107306. [PMID: 36968758 PMCID: PMC10035336 DOI: 10.3389/fpsyg.2023.1107306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Digitalization in intelligent manufacturing leads to the development of Industry 4.0/5.0 and human-cyber-physical systems. As many production technologies rely on teaming of human workers and intelligent cyber-physical systems such as industrial robots, human-robot collaboration is an intensively investigated topic in this transdisciplinary research area. To design industrial robots in a human-centered way, psychological knowledge concerning judgment and decision-making needs to be gained and integrated. Method This paper reports results from an experimental study (N = 222, 2 × 4 within-subjects design) using eight moral dilemmas framed in the context of human-robot-collaboration to examine the influence of spatial distance of an industrial robot and humans (no direct contact, different tasks vs. no direct contact, same task vs. handing-over contact, same task vs. direct contact, same task) on moral decisions. Additionally, the type of dilemma was varied, with every four dilemmas depicting a life-or-death and an injury scenario. Participants responded on a four-point-response scale which actions they would take indicating deontological or utilitarian moral decision-making. Results Results show a large effect of the proximity of the cooperation between robots and humans. The closer the collaboration the more a human tends to choose utilitarian moral choices. Discussion It is argued that this effect might stem from an adaptation of human rationality to the robot or overreliance and shift of responsibility to the robot team partner.
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Dargahi H, Monajemi A, Soltani A, Nejad Nedaie HH, Labaf A. Anchoring Errors in Emergency Medicine Residents and Faculties. Med J Islam Repub Iran 2022; 36:124. [PMID: 36447549 PMCID: PMC9700406 DOI: 10.47176/mjiri.36.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Indexed: 06/16/2023] Open
Abstract
Background: Clinical reasoning is the basis of all clinical activities in the health team, and diagnostic reasoning is perhaps the most critical of a physician's skills. Despite many advances, medical errors have not been reduced. Studies have shown that most diagnostic errors made in emergency rooms are cognitive errors, and anchoring error was identified as the most common cognitive error in clinical settings. This research intends to determine the frequency and compare the percentage of anchoring bias perceived among faculty members versus residents in the emergency medicine department. Methods: In this quasi-experimental study, Emergency Medicine's Faculties and Residents are evaluated in clinical reasoning by nine written clinical cases. The clinical data for each clinical case was presented to the participants over three pages, based on receiving clinical and para-clinical information in real situations. At the end of each page, participants were asked to write up diagnoses. Data were analyzed using one-way ANOVA test. The SPSS software (Version 16.0) was employed to conduct statistical tests, and a P value < 0.05 was considered to be statistically significant. Results: Seventy-seven participants of the residency program in the Emergency Medical group volunteered to participate in this study. Data showed Faculties were significantly higher in writing correct diagnoses than residents (66% vs. 41%), but the anchoring error ratio was significantly lower in residents (33% vs. 75%). In addition, the number of written diagnoses, time for writing diagnoses, and Clinical experience in faculties and residents were compared. Conclusion: Findings showed that increasing clinical experience increased diagnostic accuracy and changed cognitive medical errors. Faculties were higher than residents in anchoring error ratio. This error could be the result of more exposure and more decision-making in the mode of heuristic or intuitive thinking in faculties.
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Affiliation(s)
- Helen Dargahi
- Department of Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Monajemi
- Department of Philosophy of Sciences, Institute for Humanities and Cultural Studies, Tehran, Iran
| | - Akbar Soltani
- Evidence-Based Medicine Research Center, Endocrinology and Metabolism Clinical Science Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hooman Hossein Nejad Nedaie
- Emergency Department Imam Hospital Complex, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Labaf
- Emergency Department Imam Hospital Complex, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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A C, A S, A G, Pj O. An exploration of the clinical reasoning used by registered osteopaths in their choice of therapeutic approach. INT J OSTEOPATH MED 2022. [DOI: 10.1016/j.ijosm.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Mesquita ET, Toledo MG, Prieto RDSG, Soares AC, Correia ETDO. Clinical Reasoning in Cardiology: Past, Present and Future. Arq Bras Cardiol 2022; 119:S0066-782X2022005013406. [PMID: 36074484 PMCID: PMC9750203 DOI: 10.36660/abc.20220002] [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: 01/02/2022] [Revised: 04/04/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022] Open
Abstract
Clinical reasoning was born 2,500 years ago with Hippocrates, having evolved over the centuries, becoming a mixture of art and science. Several personalities throughout history have contributed to improving diagnostic accuracy. Nonetheless, diagnostic error is still common and causes a severe impact on healthcare systems. To face this challenge, several clinical reasoning models have emerged to systematize the clinical thinking process. This paper describes the history of clinical reasoning and current diagnostic reasoning methods, proposes a new clinical reasoning model, called Integrative Reasoning, and brings perspectives about the future of clinical reasoning.
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Affiliation(s)
- Evandro Tinoco Mesquita
- Complexo Hospitalar de NiteróiNiteróiRJBrasil Complexo Hospitalar de Niterói , Niterói , RJ – Brasil
- Universidade Federal FluminenseHospital Universitário Antônio PedroNiteróiRJBrasil Universidade Federal Fluminense – Hospital Universitário Antônio Pedro , Niterói , RJ – Brasil
| | - Mayara Gabriele Toledo
- Universidade Federal FluminenseHospital Universitário Antônio PedroNiteróiRJBrasil Universidade Federal Fluminense – Hospital Universitário Antônio Pedro , Niterói , RJ – Brasil
| | - Rodrigo da Silva Garcia Prieto
- Universidade Federal FluminenseHospital Universitário Antônio PedroNiteróiRJBrasil Universidade Federal Fluminense – Hospital Universitário Antônio Pedro , Niterói , RJ – Brasil
| | - Amanda Cunha Soares
- UnigranrioDuque de CaxiasRJBrasil Unigranrio , Duque de Caxias , RJ – Brasil
- Universidade Federal FluminensePós-Graduação em Ciências CardiovascularesNiteróiRJBrasil Universidade Federal Fluminense – Pós-Graduação em Ciências Cardiovasculares , Niterói , RJ – Brasil
| | - Eduardo Thadeu de Oliveira Correia
- Universidade Federal FluminenseHospital Universitário Antônio PedroNiteróiRJBrasil Universidade Federal Fluminense – Hospital Universitário Antônio Pedro , Niterói , RJ – Brasil
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Thirsk LM, Panchuk JT, Stahlke S, Hagtvedt R. Cognitive and implicit biases in nurses' judgment and decision-making: A scoping review. Int J Nurs Stud 2022; 133:104284. [PMID: 35696809 DOI: 10.1016/j.ijnurstu.2022.104284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cognitive and implicit biases of healthcare providers can lead to adverse events in healthcare and have been identified as a patient safety concern. Most research on the impact of these systematic errors in judgment has been focused on diagnostic decision-making, primarily by physicians. As the largest component of the workforce, nurses make numerous decisions that affect patient outcomes; however, literature on nurses' clinical judgment often overlooks the potential impact of bias on these decisions. The aim of this study was to map the evidence and key concepts related to bias in nurses' judgment and decision-making, including interventions to correct or overcome these biases. METHODS We conducted a scoping review using Joanna Briggs methodology. In November 2020 we searched CINAHL, PsychInfo, and PubMed databases to identify relevant literature. Inclusion criteria were primary research about nurses' bias; evidence of a nursing decision or action; and English language. No date or geographic limitations were set. RESULTS We found 77 items that met the inclusion criteria. Over half of these items were published in the last 12 years. Most research focused on implicit biases related to racial/ethnic identity, obesity, and gender; other articles examined confirmation, attribution, anchoring, and hindsight biases. Some articles examined heuristics and were included if they described the process of, and the problems with, nurse decision-making. Only 5 studies tested interventions to overcome or correct biases. 61 of the studies relied on vignettes, surveys, or recall methods, rather than examining real-world nursing practice. This could be a serious oversight because contextual factors such as cognitive load, which have a significant impact on judgment and decision-making, are not necessarily captured with vignette or survey studies. Furthermore, survey and vignette studies make it difficult to quantify the impact of these biases in the healthcare system. CONCLUSIONS Given the serious effects that bias has on nurses' clinical judgment, and thereby patient outcomes, a concerted, systematic effort to identify and test debiasing strategies in real-world nursing settings is needed. TWEETABLE ABSTRACT Bias affects nurses' clinical judgment - we need to know how to fix it.
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Affiliation(s)
- Lorraine M Thirsk
- Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada.
| | - Julia T Panchuk
- Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada
| | - Sarah Stahlke
- Department of Sociology, Faculty of Arts, University of Alberta, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- Alberta School of Business, University of Alberta, Edmonton, Alberta, Canada
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Congdon M, Clancy CB, Balmer DF, Anderson H, Muthu N, Bonafide CP, Rasooly IR. Diagnostic Reasoning of Resident Physicians in the Age of Clinical Pathways. J Grad Med Educ 2022; 14:466-474. [PMID: 35991115 PMCID: PMC9380621 DOI: 10.4300/jgme-d-21-01032.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/07/2022] [Accepted: 05/05/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described. OBJECTIVE To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning. METHODS We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework. RESULTS Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process. CONCLUSIONS This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.
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Affiliation(s)
- Morgan Congdon
- Morgan Congdon, MD, MPH, MSEd, is Assistant Professor of Clinical Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Caitlin B. Clancy
- Caitlin B. Clancy, MD, is Assistant Professor of Clinical Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Dorene F. Balmer
- Dorene F. Balmer, PhD, is Professor of Pediatrics and Director of Research on Pediatric Education, Division of General Pediatrics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Hannah Anderson
- Hannah Anderson, MBA, is Clinical Research Associate in Medical Education, Division of General Pediatrics, Children's Hospital of Philadelphia
| | - Naveen Muthu
- Naveen Muthu, MD, MSCE, is Instructor of Clinical Informatics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Christopher P. Bonafide
- Christopher P. Bonafide, MD, MSCE, is Associate Professor of Pediatrics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
| | - Irit R. Rasooly
- Irit R. Rasooly, MD, MSCE, is Clinical Instructor of Pediatrics and Clinical Informatics, Division of General Pediatrics, and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania
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Cowan RP, Rapoport AM, Blythe J, Rothrock J, Knievel K, Peretz AM, Ekpo E, Sanjanwala BM, Woldeamanuel YW. Diagnostic accuracy of an artificial intelligence online engine in migraine: A multi‐center study. Headache 2022; 62:870-882. [PMID: 35657603 PMCID: PMC9378575 DOI: 10.1111/head.14324] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 11/28/2022]
Abstract
Objective This study assesses the concordance in migraine diagnosis between an online, self‐administered, Computer‐based, Diagnostic Engine (CDE) and semi‐structured interview (SSI) by a headache specialist, both using International Classification of Headache Disorders, 3rd edition (ICHD‐3) criteria. Background Delay in accurate diagnosis is a major barrier to headache care. Accurate computer‐based algorithms may help reduce the need for SSI‐based encounters to arrive at correct ICHD‐3 diagnosis. Methods Between March 2018 and August 2019, adult participants were recruited from three academic headache centers and the community via advertising to our cross‐sectional study. Participants completed two evaluations: phone interview conducted by headache specialists using the SSI and a web‐based expert questionnaire and analytics, CDE. Participants were randomly assigned to either the SSI followed by the web‐based questionnaire or the web‐based questionnaire followed by the SSI. Participants completed protocols a few minutes apart. The concordance in migraine/probable migraine (M/PM) diagnosis between SSI and CDE was measured using Cohen’s kappa statistics. The diagnostic accuracy of CDE was assessed using the SSI as reference standard. Results Of the 276 participants consented, 212 completed both SSI and CDE (study completion rate = 77%; median age = 32 years [interquartile range: 28–40], female:male ratio = 3:1). Concordance in M/PM diagnosis between SSI and CDE was: κ = 0.83 (95% confidence interval [CI]: 0.75–0.91). CDE diagnostic accuracy: sensitivity = 90.1% (118/131), 95% CI: 83.6%–94.6%; specificity = 95.8% (68/71), 95% CI: 88.1%–99.1%. Positive and negative predictive values = 97.0% (95% CI: 91.3%–99.0%) and 86.6% (95% CI: 79.3%–91.5%), respectively, using identified migraine prevalence of 60%. Assuming a general migraine population prevalence of 10%, positive and negative predictive values were 70.3% (95% CI: 43.9%–87.8%) and 98.9% (95% CI: 98.1%–99.3%), respectively. Conclusion The SSI and CDE have excellent concordance in diagnosing M/PM. Positive CDE helps rule in M/PM, through high specificity and positive likelihood ratio. A negative CDE helps rule out M/PM through high sensitivity and low negative likelihood ratio. CDE that mimics SSI logic is a valid tool for migraine diagnosis.
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Affiliation(s)
- Robert P. Cowan
- Division of Headache and Facial Pain, Department of Neurology and Neurological Sciences Stanford University School of Medicine Stanford California USA
| | | | - Jim Blythe
- Information Sciences Institute University of Southern California Los Angeles California USA
| | - John Rothrock
- Neurology The George Washington University School of Medicine and Health Sciences Washington District of Columbia USA
| | - Kerry Knievel
- Neurology Barrow Neurological Institute Phoenix Arizona USA
| | - Addie M. Peretz
- Division of Headache and Facial Pain, Department of Neurology and Neurological Sciences Stanford University School of Medicine Stanford California USA
| | - Elizabeth Ekpo
- Neurology University of California Davis Davis California USA
| | - Bharati M. Sanjanwala
- Division of Headache and Facial Pain, Department of Neurology and Neurological Sciences Stanford University School of Medicine Stanford California USA
| | - Yohannes W. Woldeamanuel
- Division of Headache and Facial Pain, Department of Neurology and Neurological Sciences Stanford University School of Medicine Stanford California USA
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Rajeswaran V, Devine L, Lorens E, Robertson S, Huszti E, Panisko DM. Types of clinical reasoning in a summative clerkship oral examination. MEDICAL TEACHER 2022; 44:657-663. [PMID: 35000527 DOI: 10.1080/0142159x.2021.2020230] [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: 06/14/2023]
Abstract
INTRODUCTION Dual-process theory characterizes clinical reasoning (CR) as Type 1 (intuitive) and Type 2 (analytical) thinking. This study examined CR on a summative clinical clerkship structured clinical oral examination (SCOE). METHODS AND SUBJECTS 511 clinical clerks at the University of Toronto underwent SCOEs. Type 1, Type 2, and Global CR performance were compared to other internal medicine clerkship assessments using descriptive statistics and Spearman correlations. RESULTS Clinical clerks achieved mean marks >75% on the three clinical reasoning stations, on Type 1 and 2 CR tasks, and the overall SCOE. Performance on the SCOE CR stations correlated with each of the other clerkship assessments: written examination, inpatient, and ambulatory clinic assessments. The correlation of performance between Type 1 and Type 2 clinical reasoning tasks was statistically significant but weak (rs = 0.28). This suggests that defined measures of Type 1 and Type 2 reasoning were indeed assessing distinct constructs. CONCLUSION Clinical clerks used both Type 1 and Type 2 reasoning with success. This study's characterization of Type 1 and Type 2 CR as separate domains, distinct from existing measures on the SCOE as well as the other clerkship assessments, can suggest a further addition to multimodal clerkship assessment.
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Affiliation(s)
- Vamana Rajeswaran
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Endocrinology, William Osler Health System, Brampton, Canada
| | - Luke Devine
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- The HoPingKong Centre, University Health Network, Toronto, Canada
| | - Edmund Lorens
- Statistics & Evaluation, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sumitra Robertson
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Daniel M Panisko
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- The HoPingKong Centre, University Health Network, Toronto, Canada
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Coen M, Sader J, Junod-Perron N, Audétat MC, Nendaz M. Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic. Intern Emerg Med 2022; 17:979-988. [PMID: 34997906 PMCID: PMC8742156 DOI: 10.1007/s11739-021-02884-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022]
Abstract
Cognitive biases are systematic cognitive distortions, which can affect clinical reasoning. The aim of this study was to unravel the most common cognitive biases encountered in in the peculiar context of the COVID-19 pandemic. Case study research design. Primary care. Single centre (Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland). A short survey was sent to all primary care providers (N = 169) taking care of hospitalised adult patients with COVID-19. Participants were asked to describe cases in which they felt that their clinical reasoning was "disrupted" because of the pandemic context. Seven case were sufficiently complete to be analysed. A qualitative analysis of the clinical cases was performed and a bias grid encompassing 17 well-known biases created. The clinical cases were analyzed to assess for the likelihood (highly likely, plausible, not likely) of the different biases for each case. The most common biases were: "anchoring bias", "confirmation bias", "availability bias", and "cognitive dissonance". The pandemic context is a breeding ground for the emergence of cognitive biases, which can influence clinical reasoning and lead to errors. Awareness of these cognitive mechanisms could potentially reduce biases and improve clinical reasoning. Moreover, the analysis of cognitive biases can offer an insight on the functioning of the clinical reasoning process in the midst of the pandemic crisis.
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Affiliation(s)
- Matteo Coen
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.150338.c0000 0001 0721 9812Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Julia Sader
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988iEh2-Institute for Ethics, History, and the Humanities-Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Noëlle Junod-Perron
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988Institute of Primary Care (IuMFE), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Sisson CB, Waynick J, Gillette C. Dual Process Clinical Reasoning Assessment: Quantifying the Qualitative. J Physician Assist Educ 2022; 33:127-130. [PMID: 35616690 DOI: 10.1097/jpa.0000000000000428] [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: 11/27/2022]
Abstract
PURPOSE The objectives of this study were to: (1) describe a standardized clinical reasoning (CR) assessment process for preclinical physician assistant (PA) students; (2) describe student grades on a checklist by comparing clinical faculty members' judgment on a global rating scale (GRS) with judgments made by a faculty panel; and (3) evaluate interrater reliability between individual faculty members' grading and faculty panel grading. METHODS Three clinical faculty members created a checklist to assess preclinical PA students' CR on a standardized patient assessment. Individual faculty graders and a panel of faculty graders evaluated student performance. Interrater reliability between individual faculty members and the faculty panel was assessed with Cohen's kappa. RESULTS The study participants included 88 PA students (n = 88) and 12 faculty evaluators (n = 12). The faculty panel changed 11 grades (12.5%) from individual faculty members. Cohen's kappa indicated substantial agreement (k = 0.698, [95% CI: 0.54-0.85]) between the individual faculty members' grades and the faculty panel's grades. CONCLUSIONS The process of conducting a comparison of a checklist, the GRS, and a panel review improves the standardization of assessment and reduces grade inflation.
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Affiliation(s)
- Caroline B Sisson
- Caroline B. Sisson, MMS, PA-C, is an assistant professor and vice chair of education and curricular education at Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
- Joshua Waynick, MMS, PA-C, is an assistant professor at the Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
- Chris Gillette, PhD, is an associate professor and assistant director of research and scholarship at the Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
| | - Joshua Waynick
- Caroline B. Sisson, MMS, PA-C, is an assistant professor and vice chair of education and curricular education at Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
- Joshua Waynick, MMS, PA-C, is an assistant professor at the Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
- Chris Gillette, PhD, is an associate professor and assistant director of research and scholarship at the Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
| | - Chris Gillette
- Caroline B. Sisson, MMS, PA-C, is an assistant professor and vice chair of education and curricular education at Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
- Joshua Waynick, MMS, PA-C, is an assistant professor at the Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
- Chris Gillette, PhD, is an associate professor and assistant director of research and scholarship at the Wake Forest School of Medicine, Department of Physician Assistant Studies, in Winston-Salem, North Carolina
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Gerber K, Hayes B, Bloomer MJ, Perich C, Lock K, Slee JA, Lee DCY, Yates DP. The ostrich approach - Prognostic avoidance, strategies and barriers to assessing older hospital patients' risk of dying. Geriatr Nurs 2022; 46:105-111. [PMID: 35659649 DOI: 10.1016/j.gerinurse.2022.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Predicting older patients' life expectancy is an important yet challenging task. Hospital aged care assessment teams advise treating teams on older patients' type and place of care, directly affecting quality of care. Yet, little is known about their experiences with prognostication. METHODS Twenty semi-structured interviews were conducted with seven geriatricians/ registrars, ten nurses and three allied health staff from aged care assessment teams across two hospitals in Melbourne, Australia. Data were analysed thematically. RESULTS To generate prognoses, clinicians used analytical thinking, intuition, assessments from others, and pattern matching. Prognostic tools were an underutilised resource. Barriers to recognition of dying included: diffusion of responsibility regarding whose role it is to identify patients at end-of-life; lack of feedback about whether a prognosis was correct; system pressures to pursue active treatment and vacate beds; avoidance of end-of-life discussions; lack of confidence, knowledge and training in prognostication and pandemic-related challenges.
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Affiliation(s)
- Katrin Gerber
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Parkville VIC, 3052 Australia; Melbourne School of Psychological Science, University of Melbourne, Parkville VIC, 3010 Australia.
| | - Barbara Hayes
- Cancer Services, Northern Health, Bundoora VIC, 3083 Australia; Northern Clinical School, University of Melbourne, Bundoora VIC, 3083 Australia
| | - Melissa J Bloomer
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, 3220, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, VIC, 3220 Australia; School of Nursing and Midwifery, Griffith University, Griffith, QLD, 4222 Australia; Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, 4102 Australia
| | - Carol Perich
- Ageing, Cancer and Continuing Care Division, Western Health, Williamstown VIC, 3016 Australia
| | - Kayla Lock
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Parkville VIC, 3052 Australia
| | - Jo-Anne Slee
- Quality, Improvement and Patient Experience, The Royal Melbourne Hospital, Parkville VIC, 3052 Australia
| | - Dr Cik Yin Lee
- Centre for Medicine Use and Safety, Monash University; Parkville VIC, 3052 Australia; Department of Nursing, University of Melbourne, Parkville VIC, 3052 Australia
| | - Dr Paul Yates
- Department of Geriatric Medicine, Austin Health, Heidelberg VIC, 3084 Australia
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Shaaban R, Richburg CM. Examining Audiology Students' Clinical Collaboration Skills When Using Virtual Audiology Cases Aided With No Collaboration, Live Collaboration, and Virtual Collaboration. Am J Audiol 2022; 31:101-111. [PMID: 35044841 DOI: 10.1044/2021_aja-21-00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The purpose of this study was to examine students' ability to use effective clinical collaboration online in a designed scaffolded environment. Three groups were formed to achieve this goal: two control groups (one using no collaboration and one using live, face-to-face collaboration) and one treatment group using virtual collaboration. METHOD A quasi-experimental design was conducted at two U.S. universities to examine whether there is a significant difference in clinical reasoning skills between three treatment groups using IUP Audiosim software. Two computer-based audiology case simulations were developed, and participants were randomly placed into the three groups. The clinical reasoning data were analyzed using one-way analysis of variance and Tukey's post hoc analyses. RESULTS The results indicated that there was a significant difference in clinical reasoning skills between the three treatment groups. The score obtained by the no-collaboration group was significantly less than the scores obtained by the virtual and live collaboration groups. CONCLUSIONS The results imply that lower scores were associated with students receiving more instructor-designed content and higher scores with students receiving less instructor-designed content. Students who received more scaffolds with the collaborations may have demonstrated better decision-making outside the training exercise than those who did not receive scaffolds. However, lower scores on the exercise did not necessarily imply lower skill. Lower scores simply implied a different path toward mastery.
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Affiliation(s)
- Ramy Shaaban
- Department of Instructional Technology and Learning Sciences, Utah State University, Logan
| | - Cynthia M. Richburg
- Department of Communication Sciences and Disorders, Wichita State University, KS
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Gordon D, Rencic JJ, Lang VJ, Thomas A, Young M, Durning SJ. Advancing the assessment of clinical reasoning across the health professions: Definitional and methodologic recommendations. PERSPECTIVES ON MEDICAL EDUCATION 2022; 11:108-114. [PMID: 35254653 PMCID: PMC8940991 DOI: 10.1007/s40037-022-00701-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/24/2022] [Accepted: 02/04/2022] [Indexed: 06/14/2023]
Abstract
The importance of clinical reasoning in patient care is well-recognized across all health professions. Validity evidence supporting high quality clinical reasoning assessment is essential to ensure health professional schools are graduating learners competent in this domain. However, through the course of a large scoping review, we encountered inconsistent terminology for clinical reasoning and inconsistent reporting of methodology, reflecting a somewhat fractured body of literature on clinical reasoning assessment. These inconsistencies impeded our ability to synthesize across studies and appropriately compare assessment tools. More specifically, we encountered: 1) a wide array of clinical reasoning-like terms that were rarely defined or informed by a conceptual framework, 2) limited details of assessment methodology, and 3) inconsistent reporting of the steps taken to establish validity evidence for clinical reasoning assessments. Consolidating our experience in conducting this review, we provide recommendations on key definitional and methodologic elements to better support the development, description, study, and reporting of clinical reasoning assessments.
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Affiliation(s)
- David Gordon
- Division of Emergency Medicine, Duke University, Durham, NC, USA.
| | - Joseph J Rencic
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Valerie J Lang
- Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Aliki Thomas
- School of Physical and Occupational Therapy, Institute of Health Sciences Education, McGill University, Montreal, QC, Canada
| | - Meredith Young
- Department of Medicine and Institute of Health Sciences Education, McGill University, Montreal, QC, Canada
| | - Steven J Durning
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Kalindjian N, Hourantier C, Ludot M, De La Londe JG, Corcos M, Cadwallader JS, Moro MR, Lachal J, Piot MA. Experiences of French medical students during their clerkship in adolescent psychiatry: a qualitative study. Eur Child Adolesc Psychiatry 2022:10.1007/s00787-021-01940-1. [PMID: 35171376 DOI: 10.1007/s00787-021-01940-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
Abstract
The epidemiology of adolescent psychiatric disorders and the relational complexity of their management make exposure to adolescent psychiatry essential during medical school. However, some clinical particularities can complicate the students' learning experiences. Our work aimed to explore the experience of being a medical student during clerkships in adolescent psychiatry. Following the Interpretative Phenomenological Analysis qualitative approach, 20 semi-structured face-to-face interviews were conducted with medical students at the end of their clerkship in adolescent psychiatry. Three super-ordered themes emerged to describe their experience: in-depth self-exploration calling on emotions, thoughts and experiences; changes in the view of adolescent mental health; better understanding of the role and meaning of adolescent psychiatric care and how to approach it. Identification between students and patients could result from time-related factors (the end of adolescent brain remodeling, long, demanding studies, and financial and material dependence). In addition, the predominant use of non-analytical clinical reasoning processes-less valued in the rest of the graduate curriculum-poses a challenge for students. Indeed, for a student to find his or her place in adolescent psychiatry requires the student to reinvent him or herself, because the codes are different (no gown, less well-defined tasks, etc.). Finally, the excess prevalence of mental disorders among medical students requires increased vigilance on the part of tutors. For all these reasons, close, attentive tutoring seems essential to support students, while these clerkships afford a real opportunity for students to broaden their interpersonal skills.
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Affiliation(s)
- Nina Kalindjian
- Institut Mutualiste Montsouris, Adolescent Mental Health Department, 42 Boulevard Jourdan, 75014, Paris, France.,Université de Paris Cité- Health faculty, medical school, 15, rue de l'école de médecine, 75006, Paris, France
| | - Christelle Hourantier
- Institut Mutualiste Montsouris, Adolescent Mental Health Department, 42 Boulevard Jourdan, 75014, Paris, France.,Université de Paris Cité- Health faculty, medical school, 15, rue de l'école de médecine, 75006, Paris, France
| | - Maude Ludot
- Université de Paris Cité- Health faculty, medical school, 15, rue de l'école de médecine, 75006, Paris, France.,Adolescent Mental Health Department, Hôpital Cochin, Maison de Solenn, 27, boulevard Port Royal, 75014, Paris, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Team DevPsy, 16, avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Julie Gilles De La Londe
- Université de Paris Cité- Health faculty, medical school, 15, rue de l'école de médecine, 75006, Paris, France
| | - Maurice Corcos
- Institut Mutualiste Montsouris, Adolescent Mental Health Department, 42 Boulevard Jourdan, 75014, Paris, France.,Université de Paris Cité- Health faculty, medical school, 15, rue de l'école de médecine, 75006, Paris, France
| | - Jean-Sebastien Cadwallader
- Department of General Practice, Sorbonne University, 75012, Paris, France.,Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), INSERM, Sorbonne University, 75012, Paris, France
| | - Marie Rose Moro
- Université de Paris Cité- Health faculty, medical school, 15, rue de l'école de médecine, 75006, Paris, France.,Adolescent Mental Health Department, Hôpital Cochin, Maison de Solenn, 27, boulevard Port Royal, 75014, Paris, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Team DevPsy, 16, avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Jonathan Lachal
- Université Paris-Saclay, UVSQ, Inserm, CESP, Team DevPsy, 16, avenue Paul Vaillant Couturier, 94800, Villejuif, France.,Service de Psychiatrie de l'Enfant et de l'Adolescent, CHU de Clermont-Ferrand, 63000, Clermont-Ferrand, France.,Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Marie-Aude Piot
- Institut Mutualiste Montsouris, Adolescent Mental Health Department, 42 Boulevard Jourdan, 75014, Paris, France. .,Université de Paris Cité- Health faculty, medical school, 15, rue de l'école de médecine, 75006, Paris, France. .,Université Paris-Saclay, UVSQ, Inserm, CESP, Team DevPsy, 16, avenue Paul Vaillant Couturier, 94800, Villejuif, France.
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Urbane UN, Petrosina E, Zavadska D, Pavare J. Integrating Clinical Signs at Presentation and Clinician's Non-analytical Reasoning in Prediction Models for Serious Bacterial Infection in Febrile Children Presenting to Emergency Department. Front Pediatr 2022; 10:786795. [PMID: 35547543 PMCID: PMC9082163 DOI: 10.3389/fped.2022.786795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Development and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's "gut feeling," and "sense of reassurance. MATERIALS AND METHODS Febrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's "gut feeling" of something wrong and "sense of reassurance" were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019. RESULTS The derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus "gut feeling" and "sense of reassurance." The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683-0.805) in the derivation cohort and 0.692 (95% CI, 0.604-0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727-0.839) and 0.752 (0.674-0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (-0.129; -0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in "low risk," "gray area," and "high risk" for SBI. CONCLUSION Both CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables "gut feeling" and "sense of reassurance" in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.
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Affiliation(s)
- Urzula Nora Urbane
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Eva Petrosina
- Statistics Unit, Riga Stradins University, Riga, Latvia
| | - Dace Zavadska
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Jana Pavare
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
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Virtual Wards: A Rapid Adaptation to Clinical Attachments in MBChB During the COVID-19 Pandemic. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1356:95-116. [PMID: 35146619 DOI: 10.1007/978-3-030-87779-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
When the COVID-19 pandemic suddenly prevented medical students from attending their clinical attachments, the faculty involved in the third year of medical school (MBChB3) at the University of Glasgow created Virtual Wards. The focus of the Virtual Wards was to continue teaching of clinical reasoning remotely whilst COVID-19 restrictions were in place. Virtual Wards were mapped to the common and important presentations and conditions and provided opportunity for history-taking, clinical examination skills, requesting investigations, interpreting results, diagnosis and management. The Virtual Wards were successful, and further wards were developed the following academic year for MBChB4 students. This chapter describes the theoretical underpinnings of the Virtual Wards and the technological considerations, followed by a description of the Wards themselves. We then analyse an evaluation of the Virtual Wards and provide both a faculty and student perspective. Throughout the chapter, we provide tips for educators developing Virtual Ward environments.
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Lam Wai Shun P, Swaine B, Bottari C. Clinical reasoning underlying acute care occupational therapists' assessment of rehabilitation potential after stroke or brain injury: A constructivist grounded theory study. Aust Occup Ther J 2021; 69:177-189. [PMID: 34939206 DOI: 10.1111/1440-1630.12781] [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: 07/09/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In acute care hospitals, clinicians are expected to rapidly provide recommendations regarding patients' rehabilitation potential and candidacy for postacute rehabilitation. Some studies have investigated factors influencing referral to rehabilitation, but few have examined clinical reasoning underlying referral decisions. This study aimed to investigate what occupational therapists were thinking about (factors influencing reasoning), how they reasoned (thought processes) when evaluating stroke or traumatic brain injury patients' rehabilitation potential, and how they decided on referral to postacute rehabilitation. METHODS Using a constructivist grounded theory approach, the clinical reasoning of 10 acute care occupational therapists working in a large Canadian city was examined. Participant recruitment, data collection, and analysis were performed simultaneously following theoretical sampling procedures. Therapists' thoughts on patients' rehabilitation potential were collected twice (during chart consultation and initial patient assessment) using think-aloud protocols and semi-structured interviews. Constant comparison, memoing, and diagramming methods were employed during coding to help categorisation and conceptualisation. FINDINGS Numerous patient, clinician, and organisation-related factors were found to influence clinical reasoning. Occupational therapists interpreted these factors in an attempt to (1) predict recovery, (2) estimate rehabilitation potential, and (3) determine rehabilitation candidacy. They used two types of thought processes: (1) building a representation of patients' rehabilitation potential (involving eight steps including gathering and interpreting factors); (2) activating bottom-up and top-down scripts (comparing the expected impact of impairments on activity performance to behaviours observed during activity performance). Furthermore, an algorithm was developed describing how occupational therapists decide on referral to postacute rehabilitation. CONCLUSION Findings can be used to teach students and novice occupational therapists how to identify and interpret key factors in the assessment of stroke or traumatic brain injury patients' rehabilitation potential. Results also provide insight on cognitive processes that can be taught for efficient assessment of rehabilitation potential and decision-making regarding referral to postacute rehabilitation.
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Affiliation(s)
- Priscilla Lam Wai Shun
- Occupational Therapy, School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Québec, Canada
| | - Bonnie Swaine
- Occupational Therapy, School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Québec, Canada
| | - Carolina Bottari
- Occupational Therapy, School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Québec, Canada
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Chirillo M, Silverthorn DU, Vujovic P. Core concepts in physiology: teaching homeostasis through pattern recognition. ADVANCES IN PHYSIOLOGY EDUCATION 2021; 45:812-828. [PMID: 34633855 DOI: 10.1152/advan.00106.2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Abstract
Homeostasis is a core concept in systems physiology that future clinicians and biomedical professionals will apply in their careers. Despite this, many students struggle to transfer the principles governing homeostasis to concrete examples. Precourse assessments conducted on 72 undergraduate biology students enrolled in an introductory systems physiology course at the University of Belgrade during the February-May semester of 2021 revealed that students had a vague, fragmentary understanding of homeostasis and its related concepts that was often conflated with topics touched on during their previous coursework. We formalized and implemented an approach to teaching homeostasis that focused heavily on consistent reinforcement of physiological reflex patterns throughout the course. To that end, we employed a variety of activities aimed at getting students to view organ system integration holistically. After the semester, postcourse assessment demonstrated that students were better able to provide concrete examples of organ system contributions to homeostasis and were more adept at applying basic principles to novel physiological scenarios. Comparison of final grades with previous semesters revealed that students outperformed their peers who had taken the course previously. In this article, we summarize the findings of pre- and postcourse assessments, describe the general approach we took to teaching homeostasis as well as the specific techniques used in the classroom, and compare student performance with previous semesters.
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Affiliation(s)
- Michael Chirillo
- Center for Learning and Memory, The University of Texas at Austin, Austin, Texas
| | - Dee U Silverthorn
- Department of Medical Education, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Predrag Vujovic
- Department for Comparative Physiology and Ecophysiology, Institute for Physiology and Biochemistry "Ivan Djaja," Faculty of Biology, University of Belgrade, Belgrade, Serbia
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Philp F, Faux-Nightingale A, Woolley S, de Quincey E, Pandyan A. Evaluating the clinical decision making of physiotherapists in the assessment and management of paediatric shoulder instability. Physiotherapy 2021; 115:46-57. [DOI: 10.1016/j.physio.2021.12.330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 10/21/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
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Dercksen B, Struys MMRF, Cnossen F, Paans W. Qualitative development and content validation of the "SPART" model; a focused ethnography study of observable diagnostic and therapeutic activities in the emergency medical services care process. BMC Emerg Med 2021; 21:135. [PMID: 34773982 PMCID: PMC8590330 DOI: 10.1186/s12873-021-00526-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/22/2021] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Clinical reasoning is a crucial task within the Emergency Medical Services (EMS) care process. Both contextual and cognitive factors make the task susceptible to errors. Understanding the EMS care process' structure could help identify and address issues that interfere with clinical reasoning. The EMS care process is complex and only basically described. In this research, we aimed to define the different phases of the process and develop an overarching model that can help detect and correct potential error sources, improve clinical reasoning and optimize patient care. METHODS We conducted a focused ethnography study utilizing non-participant video observations of real-life EMS deployments combined with thematic analysis of peer interviews. After an initial qualitative analysis of 7 video observations, we formulated a tentative conceptual model of the EMS care process. To test and refine this model, we carried out a qualitative, thematic analysis of 28 video-recorded cases. We validated the resulting model by evaluating its recognizability with a peer content analysis utilizing semi-structured interviews. RESULTS Based on real-life observations, we were able to define and validate a model covering the distinct phases of an EMS deployment. We have introduced the acronym "SPART" to describe ten different phases: Start, Situation, Prologue, Presentation, Anamnesis, Assessment, Reasoning, Resolution, Treatment, and Transfer. CONCLUSIONS The "SPART" model describes the EMS care process and helps to understand it. We expect it to facilitate identifying and addressing factors that influence both the care process and the clinical reasoning task embedded in this process.
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Affiliation(s)
- Bert Dercksen
- University Medical Centre Groningen-department of anesthesiology/HEMS, Hanzeplein 1, 9713GZ, Gn, Groningen, The Netherlands. .,UMCG Ambulance Care, Vriezerweg 10, 9482TB, Dr, Tynaarlo, The Netherlands. .,Faculty of Medical Sciences, University of Groningen, Antonius Deusinglaan 1, 9713AV, Groningen, The Netherlands.
| | - Michel M R F Struys
- University Medical Centre Groningen-department of anesthesiology/HEMS, Hanzeplein 1, 9713GZ, Gn, Groningen, The Netherlands.,Faculty of Medical Sciences, University of Groningen, Antonius Deusinglaan 1, 9713AV, Groningen, The Netherlands
| | - Fokie Cnossen
- Faculty of Science and Engineering Artificial Intelligence, Bernoulli Institute, University of Groningen, Nijenborgh 9, 9747AG, Groningen, The Netherlands
| | - Wolter Paans
- Hanze University of Applied Sciences-Nursing Diagnostics and Centre of Expertise Healthy Ageing, Zernikelaan 6, 9747AA, Groningen, the Netherlands
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Piot MA, Köenig M, Michelet D, Loubière C, Layat Burn C, Rethans JJ, Lemogne C, Hadchouel A, Cadwallader JS, Tesniere A, Falissard B. Medical students' learning processes the first time they role-play in psychiatry: A grounded theory study. Encephale 2021; 48:254-264. [PMID: 34686318 DOI: 10.1016/j.encep.2021.05.003] [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: 12/11/2020] [Revised: 04/20/2021] [Accepted: 05/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Recent changes in psychiatric care and teaching that limit patient contact for medical students can be overcome in part by simulation-based education. Understanding the learning processes of medical students involved in psychiatric simulation-based programmes could usefully inform efforts to improve this teaching. This study explored the learning processes of medical students the first time they role-play in psychiatry. METHODS We used constructivist grounded theory to analyse semi-structured interviews of 13 purposively sampled medical students and the six psychiatrists who trained them. To improve the triangulation process, the results of this analysis were compared with those of the analyses of the role-play video and the debriefing audio-tapes. RESULTS Five organising themes emerged: improving the students' immediate perception of patients with mental disorders; cultivating clinical reasoning; managing affect; enhancing skills and attitudes and fostering involvement in learning psychiatry. CONCLUSION Results suggest that psychiatric role-playing can improve students' progressive understanding of psychiatry through the development of intuition and by allaying affects. Emotional elaboration and student involvement appear to be key features.
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Affiliation(s)
- M-A Piot
- Université de Paris, Institute Mutualiste Montsouris, Département de Psychiatrie, Université Paris-Saclay, UVSQ, INSERM 1018, CESP, Centre de simulation en santé iLumens, Paris, France.
| | - M Köenig
- Laboratoire de recherche en Santé Mentale, Sciences Humaines et Sociales. GHU Paris Psychiatrie & Neurosciences, Paris, France
| | - D Michelet
- Department de pédiatrie anesthésique, CHU de Reims, Hôpital Maison Blanche, Reims, France
| | - C Loubière
- Psycom, GHU Psychiatrie et Neuroscience, Hôpital Saint-Anne, Paris, France
| | - C Layat Burn
- Department of orthopaedic surgery, La Providence Hospital, Neuchâtel, France; Department of Psychotherapy, Berger Psychotherapeutic Centre, Neuchâtel, France
| | - J-J Rethans
- Laboratoire de recherche en Santé Mentale, Sciences Humaines et Sociales. GHU Paris Psychiatrie & Neurosciences, Paris, France; Institute for Education/Skillslab, Faculty of Health, Medicine & Life Sciences, Maastricht University, The Netherlands
| | - C Lemogne
- Université de Paris, AP-HP, Hôpital Hôtel-Dieu, DMU Psychiatrie et Addictologie, Service de Psychiatrie de l'adulte, INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Paris, France
| | - A Hadchouel
- AP-HP, Service de Pneumologie Pédiatrique, Hôpital Universitaire Necker-Enfants Malades, Centre de Référence pour les Maladies Respiratoires Rares de l'Enfant, Paris, France; Centre de simulation en santé iLumens, Faculté de Médecine, Université de Paris, Paris, France; Institut Necker Enfants Malades, INSERM U 1151, Paris, France
| | - J-S Cadwallader
- Department of General Practice, Sorbonne University, 75012 Paris, France; INSERM, Sorbonne University, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 75012 Paris, France
| | - A Tesniere
- Université de Paris, AP-HP, Hospital Cochin, Department d'anesthésie, Centre de simulation en santé iLumens, Paris, France
| | - B Falissard
- Université Paris Saclay, UFR de Médecine, Département de santé publique, INSERM 1018, CESP, Villejuif, 75012 Île-de-France, France
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Owora AH, Tepper RS, Ramsey CD, Becker AB. Decision tree-based rules outperform risk scores for childhood asthma prognosis. Pediatr Allergy Immunol 2021; 32:1464-1473. [PMID: 33938038 DOI: 10.1111/pai.13530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/02/2021] [Accepted: 04/24/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are no widely accepted prognostic tools for childhood asthma; this is in part due to the multifactorial and time-dependent nature of mechanisms and risk factors that contribute to asthma development. Our study objective was to develop and evaluate the prognostic performance of conditional inference decision tree-based rules using the Pediatric Asthma Risk Score (PARS) predictors as an alternative to the existing logistic regression-based risk score for childhood asthma prediction at 7 years in a high-risk population. METHODS The Canadian Asthma Primary Prevention Study data were used to develop, compare, and contrast the prognostic performance (area under the curve [AUC], sensitivity, and specificity) of conditional inference tree-based decision rules to the pediatric asthma risk score for the prediction of childhood asthma at 7 years. RESULTS Conditional inference decision tree-based rules have higher prognostic performance (AUC: 0.85; 95% CI: 0.81, 0.88; sensitivity = 47%; specificity = 93%) than the pediatric asthma risk score at an optimal cutoff of ≥6 (AUC: 0.71; 95% CI: 0.67, 0.76; sensitivity = 60%; specificity = 74%). Moreover, the pediatric asthma risk score is not linearly related to asthma risk, and at any given pediatric asthma risk score value, different combinations of its pediatric asthma risk score clinical variables differentially predict asthma risk. CONCLUSION Conditional inference tree-based decision rules could be a useful childhood asthma prognostic tool, providing an alternative way to identify unique subgroups of at-risk children, and insights into associations and effect mechanisms that are suggestive of appropriate tailored preventive interventions. However, the feasibility and effectiveness of such decision rules in clinical practice is warranted.
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Affiliation(s)
- Arthur H Owora
- Department of Epidemiology and Biostatistics, School of Public Health, Bloomington, IN, USA.,Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Robert S Tepper
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Clare D Ramsey
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Allan B Becker
- Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
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Pretorius D, Couper ID, Mlambo MG. Sexual history taking: Doctors' clinical decision-making in primary care in the North West province, South Africa. Afr J Prim Health Care Fam Med 2021; 13:e1-e9. [PMID: 34636612 PMCID: PMC8517797 DOI: 10.4102/phcfm.v13i1.2985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Clinical reasoning is an important aspect of making a diagnosis for providing patient care. Sexual dysfunction can be as a result of cardiovascular or neurological complications of patients with chronic illness, and if a patient does not raise a sexual challenge, then the doctor should know that there is a possibility that one exists and enquire. AIM The aim of this research study was to assess doctors' clinical decision-making process with regards to the risk of sexual dysfunction and management of patients with chronic illness in primary care facilities of the North West province based on two hypothetical patient scenarios. SETTING This research study was carried out in 10 primary care facilities in Dr Kenneth Kaunda health district, North West province, a rural health district. METHODS This vignette study using two hypothetical patient scenarios formed part of a broader grounded theory study to determine whether sexual dysfunction as comorbidity formed part of the doctors' clinical reasoning and decision-making. After coding the answers, quantitative content analysis was performed. The questions and answers were then compared with standard answers of a reference group. RESULTS One of the doctors (5%) considered sexual dysfunction, but failed to follow through without considering further exploration, investigations or management. For the scenario of a female patient with diabetes, the reference group considered cervical health questions (p = 0.001) and compliance questions (p = 0.004) as standard enquiries, which the doctors from the North West province failed to consider. For the scenario of a male patient with hypertension and an ex-smoker, the reference group differed significantly by expecting screening for mental health and vision (both p = 0.001), as well as for HIV (p 0.001). The participating doctors did not meet the expectations of the reference group. CONCLUSION Good clinical reasoning and decision-making are not only based on knowledge, intuition and experience but also based on an awareness of human well-being as complex and multidimensional, to include sexual well-being.
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Affiliation(s)
- Deidré Pretorius
- Division of Family Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg.
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Ritz C, Sader J, Cairo Notari S, Lanier C, Caire Fon N, Nendaz M, Audétat MC. Multimorbidity and clinical reasoning through the eyes of GPs: a qualitative study. Fam Med Community Health 2021; 9:fmch-2020-000798. [PMID: 34556495 PMCID: PMC8461689 DOI: 10.1136/fmch-2020-000798] [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] [Indexed: 11/05/2022] Open
Abstract
Objectives Despite the high prevalence of patients suffering from multimorbidity, the clinical reasoning processes involved during the longitudinal management are still sparse. This study aimed to investigate what are the different characteristics of the clinical reasoning process clinicians use with patients suffering from multimorbidity, and to what extent this clinical reasoning differs from diagnostic reasoning. Design Given the exploratory nature of this study and the difficulty general practitioners (GPs) have in expressing their reasoning, a qualitative methodology was therefore, chosen. The Clinical reasoning Model described by Charlin et al was used as a framework to describe the multifaceted processes of the clinical reasoning. Setting Semistructured interviews were conducted with nine GPs working in an ambulatory setting in June to September 2018, in Geneva, Switzerland. Participants Participants were GPs who came from public hospital or private practice. The interviews were transcribed verbatim and a thematic analysis was conducted. Results The results highlighted how some cognitive processes seem to be more specific to the management reasoning. Thus, the main goal is not to reach a diagnosis, but rather to consider several possibilities in order to maintain a balance between the evidence-based care options, patient’s priorities and maintaining quality of life. The initial representation of the current problem seems to be more related to the importance of establishing links between the different pre-existing diseases, identifying opportunities for actions and trying to integrate the new elements from the patient’s context, rather than identifying the signs and symptoms that can lead to generating new clinical hypotheses. The multiplicity of options to resolve problems is often perceived as difficult by GPs. Furthermore, longitudinal management does not allow them to achieve a final resolution of problems and that requires continuous review and an ongoing prioritisation process. Conclusion This study contributes to a better understanding of the clinical reasoning processes of GPs in the longitudinal management of patients suffering from multimorbidity. Through a practical and accessible model, this qualitative study offers new perspectives for identifying the components of management reasoning. These results open the path to new research projects.
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Affiliation(s)
- Claire Ritz
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland
| | - Julia Sader
- Faculty of Medicine, (UDREM), University of Geneva, Geneva, Switzerland
| | | | - Cedric Lanier
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland
| | | | - Mathieu Nendaz
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- Faculty of Medicine (IuMFE), University of Geneva, Geneva, Switzerland .,Faculty of Medicine, (UDREM), University of Geneva, Geneva, Switzerland.,Faculty of Medicine, Université de Montreal, Montreal, Quebec, Canada
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Guedj R, Marini M, Kossowsky J, Berde C, Mateo C, Fleegler EW. Explicit and implicit bias based on race, ethnicity, and weight among pediatric emergency physicians. Acad Emerg Med 2021; 28:1073-1076. [PMID: 34032346 DOI: 10.1111/acem.14301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Romain Guedj
- Department of Anesthesiology, Critical Care, and Pain Medicine Boston Children’s Hospital Boston Massachusetts USA
- Department of Pediatric Emergency Medicine Trousseau HospitalAssistance Publique des Hôpitaux de ParisSorbonne Université Paris France
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé) Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS) Inserm UMR1153Paris Descartes University Paris France
| | - Maddalena Marini
- Center for Translational Neurophysiology of Speech and Communication Istituto Italiano di Tecnologia (IIT Ferrara FE Italy)
| | - Joe Kossowsky
- Department of Anesthesiology, Critical Care, and Pain Medicine Boston Children’s Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Division of Clinical Psychology and Psychotherapy University of Basel Basel Switzerland
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain Medicine Boston Children’s Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
| | - Camila Mateo
- Harvard Medical School Boston Massachusetts USA
- Division of General Pediatrics Boston Children’s Hospital Boston Massachusetts USA
| | - Eric W. Fleegler
- Harvard Medical School Boston Massachusetts USA
- Division of Emergency Medicine Boston Children’s Hospital Boston Massachusetts USA
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Cairo Notari S, Sader J, Caire Fon N, Sommer JM, Pereira Miozzari AC, Janjic D, Nendaz M, Audétat MC. Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research. Int J Clin Pract 2021; 75:e14187. [PMID: 33783098 PMCID: PMC8459259 DOI: 10.1111/ijcp.14187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term. METHODS A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. RESULTS A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient. CONCLUSIONS Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.
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Affiliation(s)
- Sarah Cairo Notari
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
| | - Julia Sader
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nathalie Caire Fon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Johanna Maria Sommer
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Danilo Janjic
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
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LoGiudice AB, Sherbino J, Norman G, Monteiro S, Sibbald M. Intuitive and deliberative approaches for diagnosing 'well' versus 'unwell': evidence from eye tracking, and potential implications for training. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:811-825. [PMID: 33423154 DOI: 10.1007/s10459-020-10023-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 12/21/2020] [Indexed: 06/12/2023]
Abstract
Rapidly assessing how ill a patient is based on their immediate presentation-colloquially termed 'eyeballing' in practice-serves a vital role in acute care settings. Yet surprisingly little is known about how this diagnostic skill is learned or how it should be taught. Some authors have pointed to a dual-process model, suggesting that assessments of illness severity are driven by two distinct types of processing: an intuitive, fast, pattern recognition-like process (Type 1) that depends on many prior patient encounters and outcomes being stored in memory; and a deliberate, slow, analytic process (Type 2) characterized by additional data gathering, data scrutiny, or recollection of rules. But prior studies have supported a dual-process model for the assessment of illness severity only insofar as experienced clinicians chiefly displayed what was presumed to be Type 1 processing. Here we further explored a dual-process model by examining whether less experienced clinicians displayed both types of processing when assessing illness severity across a series of cases. Consistent with the model, a dissociation between Type 1 and Type 2 processing was observed through resident reports of deliberation, response times, and three eye tracking metrics associated with diagnostic expertise. We conclude by discussing potential implications for the training of this enigmatic diagnostic skill.
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Affiliation(s)
- Andrew B LoGiudice
- MacPherson Institute for Leadership, Innovation, and Excellence in Teaching, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), Hamilton, Canada.
| | - Jonathan Sherbino
- Department of Medicine, McMaster University, Hamilton, Canada
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), Hamilton, Canada
| | - Geoffrey Norman
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), Hamilton, Canada
| | - Sandra Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), Hamilton, Canada
| | - Matthew Sibbald
- Department of Medicine, McMaster University, Hamilton, Canada
- McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), Hamilton, Canada
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