Teaching Problem-Solving — How Are We Doing?

Kassirer, Jerome P.

doi:10.1056/nejm199506013322210

Cited by 33 publications

(16 citation statements)

References 45 publications

(3 reference statements)

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“…He considers that ‘despite substantial advances in our understanding of human cognition during the last few decades, our teaching methods are still based largely on expert opinion’. There is a consensus among experts that clinical reasoning can and must be taught during medical studies (52, 53). …”

Section: Discussionmentioning

confidence: 99%

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

Pelaccia¹,

Tardif

Triby

et al. 2011

Medical Education Online

278

235

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Context: Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physician's most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward. Purpose: This paper aims at exploring a comprehensive approach: the ''dual-process theory'', a model developed by cognitive psychologists over the last few years. Discussion: After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians' intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed.

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Section: Discussionmentioning

confidence: 99%

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

Pelaccia¹,

Tardif

Triby

et al. 2011

Medical Education Online

278

235

View full text Add to dashboard Cite

show abstract

“…They should recognize that these critical cognitive skills constitute a specific body of knowledge and should find imaginative ways of teaching them. 3 The problem that faces us involves thinking about the ways we think. We need to develop more awareness of, and insight into, the cognitive pro- Croskerry • HOW WE THINK cesses involved in decision making.…”

mentioning

confidence: 99%

The Cognitive Imperative Thinking about How We Think

Croskerry

2000

Academic Emergency Medicine

201

128

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Abstract. There are three domains of expertise required for consistently effective performance in emergency medicine (EM): procedural, affective, and cognitive. Most of the activity is performed in the cognitive domain. Studies in the cognitive sciences have focused on a number of common and predictable biases in the thinking process, many of which are relevant to the practice of EM. It is important to understand these biases and how they might influence clinical decision-making behavior. Among the specialities, EM provides a unique clinical milieu of inconstancy, uncertainty, variety, and complexity. Injury and illness are seen within narrow time windows, often under pressured ambient conditions. These operating characteristics force practitioners to adopt a distinctive blend of thinking strategies. Principal among them is the use of heuristics, a form of abbreviated thinking that often leads to successful outcomes but that occasionally may result in error. A number of opportunities exist to overcome interdisciplinary, linguistic, and other historical obstacles to develop a sound approach to understanding how we think in EM. This will lead to a better awareness of our cognitive processes, an improved capacity to teach effectively about cognitive strategies, and, ultimately, the minimization or avoidance of clinical error. Key words: emergency medicine; cognition; errors; decision making; heuristics. ACADEMIC EMERGENCY MEDICINE 2000; 7:1223-1231 T HERE are three major skill sets in the performance repertoire of emergency physicians (EPs): procedural, affective, and cognitive.1 It may appear to outside observers, as well as to many within the profession, that emergency medicine (EM) is predominantly action-oriented and that procedural skills are, therefore, the most important of the three. Indeed, during training, a considerable emphasis is directed at the acquisition and retention of skills such as intubation, wound repair, the insertion of chest tubes and central lines, diagnostic peritoneal lavage, lumbar puncture, and cast application. This procedural skill set is tangible, well defined and teachable. While procedural skills are important and integral to an effective performance in the emergency department (ED), they comprise a relatively small part of the overall activity of EPs. Most of our time, in fact, is engaged in cognitive behavior; it is the preponder- ant substance of EM. Surprisingly, it has attracted relatively little attention, perhaps because of an undervalued regard for the importance of exactly how we think. In a recent report, medical educators concluded that EM health care workers were often ''. . . not consciously aware of how they evaluate evidence and cope with decision complexity. '' 2 Proficiency in the cognitive domain, compared with that in procedural skills, is less easily defined, involves a much broader range of possibilities, and would appear to be less easily taught. Kassirer, in 1995, recognized the problem very clearly:Research in the cognitive aspects of clinical problems...

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“…Fortunately, errors can convey information that helps physicians revise their diagnostic hypotheses. [5][6][7] They are thus a source of learning and experience in clinical reasoning. According to one account, the most memorable experiences are acquired when events run counter to expectations, and the most experienced persons are those who can integrate and retain the information revealed in the process.…”

Section: Discussionmentioning

confidence: 99%

Seeking an Expert Interpretation

Berkwits

Gluckman²

1997

N Engl J Med

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A 32-year-old woman had been evaluated one month earlier for low-grade fevers and malaise. Her temperature at that time was 37.9°C (100.2°F), but her history and physical examination were otherwise unremarkable. She was told that she probably had a viral syndrome, and she was treated supportively. She returned one week later with the same symptoms, and on the basis of a distant history of sinus problems, she was given a one-week course of amoxicillin for possible sinusitis. Her fever persisted.This patient has a subacute febrile illness. Initially she was told she had two conditions: a viral syndrome and sinusitis. Both disorders are often ill documented and self-limiting. There is little evidence of a viral syndrome; the patient certainly does not have many symptoms characteristic of a viral infection. Sinusitis is often diagnosed in patients with respiratory symptoms, yet it is uncommon for patients to have respiratory symptoms and documentable sinus disease. It does not surprise me that her nonspecific illness did not get better.The patient reported a history of childhood asthma and occasional exercise-induced cough. She had received a course of antibiotics six months earlier for uncomplicated cystitis. She uses oral contraceptives and takes acetaminophen for occasional joint pains that she attributes to exercise. She had no relevant travel history and no risk factors for human immunodeficiency virus (HIV) infection or tuberculosis, and she used no other medications. Her blood pressure was 90/60 mm Hg, with a temperature of 38.4°C (101.2°F) and a pulse of 112. The remainder of her examination was unremarkable. The patient was admitted to the hospital.The history of joint pains is intriguing but nonspecific. If she had had overt arthritis I would be interested in examining her for rheumatic diseases. With respect to HIV, it is important to remember that because the traditional risk factors do not necessarily hold true anymore, anyone who has had sexual exposure could be at risk. The most salient feature of her history so far is her hypotension and tachycardia. The most common cause of these findings is dehydration or hypovolemia, though she has no history of fluid losses or physical findings to suggest volume depletion. I am always concerned about adrenal insufficiency in patients with a chronic illness and unexplained hypotension. At this point, though, I would still want to see the results of basic laboratory tests before ordering more specific tests.The patient's blood pressure returned to normal, but she continued to be febrile and had occasional temperatures as high as 38.8°C (102°F). Urinalysis was normal. The white-cell count was 10,300 per cubic millimeter with a predominance of lymphocytes. The hematocrit was 36 percent, and a peripheral-blood smear showed no abnormal cellular forms. Electrolyte levels were normal. Liver-function tests revealed an aspartate aminotransferase level of 54 U per liter, an alanine aminotransferase level of 45 U per liter, an alkaline phosphatase level of 118 U per liter, an...

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Teaching Problem-Solving — How Are We Doing?

Cited by 33 publications

References 45 publications

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

The Cognitive Imperative Thinking about How We Think

Seeking an Expert Interpretation

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