Cognitive elements in clinical decision-making

Abstract

Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for ambiguity, state-trait anxiety and metacognitive awareness were assessed for obstetricians (n = 12) who provided intra-partum care to 4,149 women. Outcome measures included delivery mode and intrapartum asphyxia. Analysis was carried out using logistic regression and tree-based classification. Obstetricians with high RC scores were more likely to perform a caesarean section (OR 1.59, p < 0.0001), less likely undertake a mid-forceps or low forceps delivery (OR 0.41, p < 0.0001; OR 0.49, p < 0.0001), and more likely to supervise a spontaneous vaginal delivery (OR 1.17, p = 0.08). Obstetricians with high NFC scores were more likely to perform a caesarean section (OR 1.53, p = 0.03), more likely to undertake a vacuum delivery (OR 5.8, p = 0.001), less likely undertake a mid-forceps delivery (OR 0.45, p = 0.02) and less likely to supervise a spontaneous vaginal delivery (OR 0.47, p < 0.0001). Obstetricians high in trait anxiety were more likely to perform a mid forceps delivery (OR 2.49, p = 0.01) or a vacuum delivery (OR 5.08, p = 0.003), and less likely to supervise a spontaneous vaginal delivery (OR 0.38, p < 0.0001). NFC was negatively associated (OR 0.10, p < 0.001) and trait anxiety was positively associated with intrapartum asphyxia (p < 0.05, rho = 0.582). In summary, physician cognitive processes and affect have a significant impact on patient outcomes, particularly in situations where there is a higher level of clinical unpredictability.

Medical student changes in self-regulated learning during the transition to the clinical environment

“…Studies suggest that metacognition has a positive association with academic performance [35] and surgical skills acquisition [70], a negative association with procrastination [4] and depression [9], and is important for clinical reasoning, decision making [71, 72] and the continuous process of life-long learning [73, 74]. Furthermore, positive metacognitive abilities have been associated with a decreased level of perceived stress [75].…”

Relationship between obstetricians’ cognitive and affective traits and delivery outcomes among women with a prior cesarean

“…These scales were chosen on the basis of use in prior work, their high construct validity, and the theoretical basis of these traits' relationships to medical decision making. 13,14 Details of each instrument can be found in Table 1.…”

“…[9][10][11][12] Provider emotional influences and affective traits, or predisposition toward types of emotional responses, have additionally been proposed to affect clinical decisions. [9][10][11][12] In a small study of 12 obstetricians, Dunphy et al 13 found that physicians with better coping skills and lower trait anxiety were more likely to care for women who achieved spontaneous vaginal deliveries. In previous work, our group studied the relationship between obstetrician cognitive traits and delivery outcomes for nulliparas, finding decreased risk of operative vaginal delivery for patients delivered by providers who evidenced more adaptive decision making.…”

Reducing Cognitive Skill Decay and Diagnostic Error: Theory-Based Practices for Continuing Education in Health Care

“…49−51 It is also important to note that Type 2 processes are not triggered by conditions of unconscious incompetence or overconfidence (ie, "we don't know we don't know"). 56 Metacognitive processes have been shown to be related to clinical decision making 57 and sensitive to educational intervention. 53−55 Metacognition has been defined in terms of "thinking about thinking"; that is, cognitive processes deliberately concentrated on reflection and selfregulation of one's own cognitive processes.…”

“…Dunphy; 57 Klein 81 Target communication and other teamwork competencies to mitigate system-oriented causes of diagnostic error. These rules, propositions, and search strategies were conceptualized as domain independent.…”