Reasoning processes in clinical reasoning: from the perspective of cognitive psychology

Improving clinical reasoning and communication during handover: An intervention study of the BRIEF-C tool

BACKGROUND

Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers.

DESIGN

A pre-test post-test intervention study.

SETTING

Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital.

INTERVENTION

The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback.

MEASUREMENTS

Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods.

RESULTS

A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach's alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen's d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen's d=0.83).

CONCLUSION

This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.

Affective Prosody and Its Impact on the Neurology of Language, Depression, Memory and Emotions

Based on the seminal publications of Paul Broca and Carl Wernicke who established that aphasic syndromes (disorders of the verbal-linguistic aspects of communication) were predominantly the result of focal left-hemisphere lesions, "language" is traditionally viewed as a lateralized function of the left hemisphere. This, in turn, has diminished and delayed the acceptance that the right hemisphere also has a vital role in language, specifically in modulating affective prosody, which is essential for communication competency and psychosocial well-being. Focal lesions of the right hemisphere may result in disorders of affective prosody (aprosodic syndromes) that are functionally and anatomically analogous to the aphasic syndromes that occur following focal left-hemisphere lesions. This paper will review the deductive research published over the last four decades that has elucidated the neurology of affective prosody which, in turn, has led to a more complete and nuanced understanding of the neurology of language, depression, emotions and memory. In addition, the paper will also present the serendipitous clinical observations (inductive research) and fortuitous inter-disciplinary collaborations that were crucial in guiding and developing the deductive research processes that culminated in the concept that primary emotions and related display behaviors are a lateralized function of the right hemisphere and social emotions, and related display behaviors are a lateralized function of the left hemisphere.

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care

AIM

The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care.

BACKGROUND

The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role.

METHOD

A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data.

FINDINGS

Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty.

CONCLUSION

This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

Spine Biomechanics in the Work of Aristotle (384 - 322 BC)

Background: Spine biomechanics is a field of applied research aiming to unravel the biomechanical understanding of the spine and its disorders and to understand the implications of their interventional therapy to improve clinical practice, physical performance and daily living. Its scientific whereabouts can be traced in the work of Aristotle, who discussed physical and biological concepts of spine biomechanics in a series of treatises.Results: The authors searched the Thesaurus Linguae Graecae archive for original texts written in Greek and attributed to Aristotle and selected excerpts of medical and biological treatises that elaborate on spine biomechanics.Discussion: While many of his theories have become outdated, his methodology and rationale remain relevant for contemporary researchers and clinicians. Here, the relevant content of passages of the corpus aristotelicum related to spine biomechanics and discuss their practical implications are presented.

Making sense of complexity: A qualitative 'Framework' analysis of naturopathic case management and clinical reasoning

BACKGROUND AND PURPOSE

The clinical encounter is inherently complex and uncertain. Naturopathic clinical practice is shaped by a traditional philosophy and practice guiding principles, with a therapeutic framework that incorporates a complex inter-systems approach. It is possible that this foundation may orient naturopathic practitioners to manage clinical complexity and uncertainty in a distinct manner. The aim of this study is to explore the perceptions of experienced naturopathic practitioners to the management of clinical complexity within naturopathic care.

MATERIALS AND METHODS

Twenty experienced Australian naturopathic practitioners participated across four focus groups, responding to semi-structured questions regarding their clinical reasoning strategies and case management processes. The data were analysed using a seven step Framework analysis method.

RESULTS

Three primary themes were identified: i) patient is encountered as a whole entity, ii) clinical reasoning is ampliative and explicative, and iii) treatment reflects systems thinking. Participants perceived a focus on the connections between various case elements, building a comprehensive internalised schematic of each case. Participants saw treatments as meeting various needs including prevention, symptom alleviation, causal mitigation, and support of innate healing processes.

CONCLUSION

Naturopathic practitioners perceive they clinically embody the traditional holistic philosophy of naturopathy as a systems orientation, incorporating traditional and contemporary bioscience knowledge. This appears to shape a distinct naturopathic case management approach, oriented to working with patients in a complexity-informed manner.

Clinical reasoning in emergency medical technicians and its compliance with the illness script theory: A pilot study

BACKGROUND

Emergency medical technicians (EMTs) play a pivotal role in the management and treatment chain of emergency patients and their health outcomes. Knowing the clinical reasoning pattern in prehospital procedures is of particular importance that can help to develop a correct clinical decision-making process in this group. Therefore, this study aimed to clarify the clinical reasoning in EMTs and evaluate its compliance with the "illness script" theory.

MATERIALS AND METHODS

This descriptive-analytical study was conducted in 2021 at Hormozgan University of Medical Sciences (HUMS) by involving EMTs in two groups of experts and novices. To collect and analyze participants' mental script-based information, the "think aloud" method was used. In the content analysis of extracted protocols, two main steps were considered: 1) preparing a suitable map to compare the protocol with the base pattern and 2) quantifying the relationship between the protocol and the base pattern. Statistical Package for the Social Sciences (SPSS)-21 software, the Shapiro-Wilk test, and the independent t-test were used for analyzing quantitative data.

RESULTS

After exploring the concordance of the clinical reasoning of EMTs with the base pattern, results showed that the components of Enabling condition and Management were consistent with the illness script strategy. Pathophysiology and Diagnosis components did not conform to the base pattern. Regarding Signs and Symptoms, these were significantly different from the classic pattern of illness script. A new component called Contextual insight was suggested for this pattern. Generally, on comparing the clinical script content of experts and novices, only two components of Pathophysiology and Diagnosis did not show any significant difference (P > 0.05) between these two groups.

CONCLUSION

Results of evaluating the clinical reasoning of the under-study groups showed that in some components of the pattern, they practiced as in other medical groups, but in relation to some components, this was not the case. It is due to the different nature of the prehospital conditions. Also, there is a need to add new components to the base model, which should be considered in distinguishing between expert and novice EMTs.

Reasoning like a doctor or like a nurse? A systematic integrative review

When physicians and nurses are looking at the same patient, they may not see the same picture. If assuming that the clinical reasoning of both professions is alike and ignoring possible differences, aspects essential for care can be overlooked. Understanding the multifaceted concept of clinical reasoning of both professions may provide insight into the nature and purpose of their practices and benefit patient care, education and research. We aimed to identify, compare and contrast the documented features of clinical reasoning of physicians and nurses through the lens of layered analysis and to conduct a simultaneous concept analysis. The protocol of this systematic integrative review was published doi: 10.1136/bmjopen-2021-049862. A comprehensive search was performed in four databases (PubMed, CINAHL, Psychinfo, and Web of Science) from 30th March 2020 to 27th May 2020. A total of 69 Empirical and theoretical journal articles about clinical reasoning of practitioners were included: 27 nursing, 37 medical, and five combining both perspectives. Two reviewers screened the identified papers for eligibility and assessed the quality of the methodologically diverse articles. We used an onion model, based on three layers: Philosophy, Principles, and Techniques to extract and organize the data. Commonalities and differences were identified on professional paradigms, theories, intentions, content, antecedents, attributes, outcomes, and contextual factors. The detected philosophical differences were located on a care-cure and subjective-objective continuum. We observed four principle contrasts: a broad or narrow focus, consideration of the patient as such or of the patient and his relatives, hypotheses to explain or to understand, and argumentation based on causality or association. In the technical layer a difference in the professional concepts of diagnosis and the degree of patient involvement in the reasoning process were perceived. Clinical reasoning can be analysed by breaking it down into layers, and the onion model resulted in detailed features. Subsequently insight was obtained in the differences between nursing and medical reasoning. The origin of these differences is in the philosophical layer (professional paradigms, intentions). This review can be used as a first step toward gaining a better understanding and collaboration in patient care, education and research across the nursing and medical professions.

Prueba de concordancia de guiones para entrenar el razonamiento clínico en estudiantes de fonoaudiología

La prueba de concordancia de guiones (PCG) ha sido utilizada en el entrenamiento y evaluación del razonamiento clínico (RC) como una estrategia innovadora en la formación de profesionales. Sin embargo, no se dispone de evidencia de su aplicación en el pregrado de fonoaudiología. El objetivo de esta investigación fue analizar el desempeño y la percepción de estudiantes de fonoaudiología con respecto al uso de scripts. Se diseñó un piloto pre-experimental y multicéntrico, complementado con tres grupos focales. Las variables cuantitativas continuas fueron resumidas a través de medias y desviación estándar. La comparación entre grupos se ejecutó con Anova one way y la prueba post hoc de Bonferroni, considerando un nivel de significancia p<.05. La fase cualitativa incorporó un análisis de contenido mediante la codificación abierta de textos y la identificación e interpretación de familias de significado emergentes. El rendimiento promedio de los estudiantes fue de 4.03 (DS= 0.35), observándose un incremento en el rendimiento de RC durante el semestre (p= 0.03). La percepción de los estudiantes resulto positiva y se identificó cuatro familias de significado relacionadas con: razonamiento clínico, oportunidades de mejora implementación de la estrategia y retroalimentación docente. A modo de conclusión, la incorporación de scripts en estudiantes de pregrado de fonoaudiología es factible, incrementa el rendimiento y apoya el desarrollo del RC.

A Novel Deep Framework for English Communication Based on Educational Psychology Perspective

The impact of verbal reading practices on learning is examined from the perspective of educational psychology, using the motivation theory and the schema theory. This research intends to enhance learner's English communication abilities in response to the needs for national economic growth and scientific and technological development. To motivate students to improve their English, the research may address the issue of inadequate opportunities by adding an artificial intelligence (AI) conversation mechanism to the students speaking English exercise. First, cognitive psychology is analyzed in detail, and a model based on cognitive psychology is implemented to solve the problems existing in student's English communication. In addition, various measures are presented and used to increase student's oral English communication abilities. We used sixty students from North China University of Water Resources and Electric Power are separated into two classes: Class A and Class B. The experimental group is called Class A, while the control group is called Class B. Following a comparison of the outcomes obtained before and after training. The experimental group's reading comprehension, responding to questions, situational conversation, and subject description scores rose by 13.33, 15.19, 17.39, and 28.3 %, respectively. The overall average score of the class climbed by 17.75 %, whereas the scores of pupils in Class B improved just an undersized. The results reveal that following the vocalized reading exercise, the student's English grades, self-efficacy, and topic knowledge increased considerably in the experimental group. Moreover, the proposed model, employs computer simulation in the English communication teaching system and AI, which can aid in the creation of an interactive learning environment for students to improve their spoken English and English communication abilities.

Effects of Problem-Based Learning on the Problem-Solving Ability and Self-Efficacy of Students Majoring in Dental Hygiene

This study developed a problem-based learning (PBL) module to improve integrated thinking and problem-solving ability in students of dental hygiene. After applying PBL, the study tested the improvement in the problem-solving ability and self-efficacy of students. The subjects were 31 fourth-year students of the Department of Dental Hygiene at G University. The PBL process was applied to three topics for 15 weeks, and the tools for evaluating problem-solving ability and self-efficacy were reconstructed and used before and after the application to examine the effects of the module. The result indicates that the mean of problem-solving ability (32 detailed items) increased from 3.37 to 3.65 (an increase of 0.28) after classes (p < 0.001). Alternatively, the average for self-efficacy (22 detailed questions) increased from 0.21 to 2.89 (p < 0.05; an increase of 2.67). The study also confirmed the correlation between problem-solving ability and the total posttest score for self-efficacy (p < 0.001). Thus, the problem-solving ability and self-efficacy of learners were improved in the class to which PBL was applied. These improvements exerted a significant effect on the improvement of problem-solving ability. This finding confirmed the effect of the PBL method on dental hygiene education.

The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles

RATIONALE

Traditional whole systems of medicine, such as naturopathy, are founded upon holism; a philosophical paradigm consistent with contemporary complexity science. Naturopathic case management is predicated upon the understanding of an intimately interconnected internal physiological and external context of the human organism-potentially indicating a worldview aligned with a complexity perspective. In this study we investigate naturopathic clinical reasoning using a complexity lens with the aim of ascertaining the extent of correspondence between the two.

METHOD

Mind maps depicting case presentations were sought from Australian degree qualified naturopaths. A network mapping was undertaken, which was then analysed in accordance with a complexity science framework using exploratory data analysis and network analysis processes and tools.

RESULTS

Naturopathic case schematics, in the form of mind maps (n = 70), were collected, network mapped, and analysed. A total of 739 unique elements and 2724 links were identified across the network. Integral elements across the network were: stress, fatigue, general anxiety, systemic inflammation, gut dysbiosis, and diet. A modularity algorithm detected 11 communities, the primary ones of these representing the nervous system and mood; the gastrointestinal tract, liver, and nutrition; immune function and the immune system; and diet and nutrients.

CONCLUSIONS

Naturopathic case management is holistic and based on a perspective of an integrated physiology and external context of the human organism. The traditional concept of holism, when subjected to a complexity lens, leads to the emergence of a contemporary holistic paradigm cognisant of the human organism being a complex system. The application of complexity science to investigate naturopathic case management as employed in this study, demonstrates that it is possible to investigate traditional philosophies and principles in a scientific and critical manner. A complexity science research approach may offer a suitable scientific paradigm to develop our understanding of traditional whole systems of medicine.

Cognitive Structure of College Students and Teaching Strategies of Ideological and Political Education Under Educational Psychology

The ideological and political education (IPE) situation is constantly developing and changing. In modern globalization, the ideological education of college students has received great attention. The purpose is to strengthen morality and cultivate people as the basic point of a college education. The principles of educational psychology are adopted to integrate IPE into the whole process of college teaching and help students develop healthily for a long time. First, IPE psychology's concept and subject attribute under educational psychology are expounded. Next, the concept and development of cognitive structure theory are introduced. Moreover, educational constructivist measures are analyzed. Furthermore, the cognitive structure of college students' self-cognition and IPE is interpreted and analyzed using cognitive psychology. Then, a questionnaire is designed to study the influencing factors of political education strategies in colleges. Finally, the questionnaire is collected to summarize the influencing factors and put forward optimization strategies. The results show that using the principles of educational psychology and cognitive psychology to investigate can accurately understand modern college students' self-cognitive structure and ideological and political cognitive structure. The opportunity factor greatly impacts the IPE strategy of college students. More than 97% think that it has an impact, of which more than 51% think that it has a great impact and more than 21% think that it is the decisive factor. Challenge factors greatly impact college students' IPE strategies. More than 97% think they have an impact, of which more than 55% think they have a great impact, and more than 24% think they are decisive factors. It shows that educational psychology is conducive to the progress of political education in colleges and the improvement of college students' ideological and political levels. This exploration provides a new direction for educational psychology research in ideological and political work.

Enhancing clinical judgement in virtual care for complex chronic disease

The COVID-19 pandemic has transformed traditional in-person care into a new reality of virtual care for patients with complex chronic disease (CCD), but how has this transformation impacted clinical judgement? I argue that virtual specialist-patient interaction challenges clinical reasoning and clinical judgement (clinical reasoning combined with statistical reasoning). However, clinical reasoning can improve by recognising the abductive, deductive, and inductive methods that the clinician employs. Abductive reasoning leading to an inference to the best explanation or invention of an explanatory hypothesis is the default response to unfamiliar or confusing situations. Deductive reasoning supports a previously established goal, but deductive accuracy requires sound premises leading to a valid conclusion. Inductive reasoning uses efficient data sorting, data interpretation, and plan creation without a previously established goal, and allows assessing inferential accuracy over time. In all cases, communication remains the backbone of the clinical encounter. Virtual care for CCD challenges clinical judgement by reducing available information, so even experienced specialists who use induction might default to deduction or abduction. The visit might shorten, decreasing narrative competence and in-turn management quality. Clinical judgement in virtual encounters can be enhanced by allowing sufficient time, employing allied health staff, using an advance script, avoiding dogmatic commitment to either virtual or in-person encounters, special training in virtual care, and conscious awareness of abductive, deductive, and inductive reasoning processes. Clinical judgement in virtual encounters especially calls for Gestalt cognition to assess a situational pattern irreducible to its parts and independent of its particulars, so that efficient data interpretation and self-reflection are enabled. Gestalt cognition integrates abduction, deduction, and induction, appropriately divides the time and effort spent on each, and can compensate for reduced available information. Evaluating one's clinical judgement for those components especially vulnerable to compromise can help optimize the delivery of virtual care for patients with CCD.

The Relationship between Self-Directed Learning and Problem-Solving Ability: The Mediating Role of Academic Self-Efficacy and Self-Regulated Learning among Nursing Students

Problem-solving ability is necessary for the clinical reasoning and decision-making of nurses to solve patients' health problems. This study aims to investigate the association between self-directed learning and problem-solving ability using the multiple mediation model to identify strategies to enhance problem-solving ability in nursing students. This is a descriptive survey study of 193 nursing students from two universities in South Korea. Data about self-directed learning, self-regulated learning, academic self-efficacy, and problem-solving ability were collected using structured questionnaires between 5 March and 17 June 2018, and were analyzed using serial multiple mediation analysis. The direct effect of self-directed learning on problem-solving ability was statistically significant. The serial multiple mediation technique predicting problem-solving ability from self-directed learning, academic self-efficacy, and self-regulated learning was significant, explaining 40% of the variance in problem-solving ability. The relationship between self-directed learning and problem-solving ability was partially mediated by academic self-efficacy and self-regulated learning. This study suggests the suitability of considering academic self-efficacy and self-regulated learning together when conducting self-directed learning to improve nursing students' problem-solving ability.

Early Years Research Elective: Changing Perspectives and Dealing with Uncertainty

Uncertainty is ever-present within the medical profession. To effectively manage uncertainty, future doctors must develop key competencies including resilience, creativity and adaptability along with the capacity for collaboration and embracing multiculturalism. The authors believe that attending an overseas clinical research placement as a junior medical student can benefit medical education by offering an early opportunity to develop these qualities. These views are supported by reflections on a clinical research module and placement in Guangzhou, China completed by the authors during the second year of medical school and aims to highlight key learning opportunities.