Understanding Clinical Reasoning from Multiple Perspectives: A Conceptual and Theoretical Overview

Cate, Olle ten; Durning, Steven J.

doi:10.1007/978-3-319-64828-6_3

Cited by 27 publications

(12 citation statements)

References 40 publications

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“…Therefore, the external validity of the results is quite limited. This limited external validity is especially important if one considers the well-known challenges associated with case specificity (ten Cate and Durning 2018; Wimmers and Fung 2008). Therefore, it is important to replicate this study across contexts, content, samples, and clinical tasks to corroborate the consistency of the results.…”

Section: Discussionmentioning

confidence: 99%

First-year medical students’ calibration bias and accuracy across clinical reasoning activities

Cleary

Konopasky

Rochelle

et al. 2019

Adv in Health Sci Educ

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To be safe and effective practitioners and learners, medical professionals must be able to accurately assess their own performance to know when they need additional help. This study explored the metacognitive judgments of 157 first-year medical students; in particular, the study examined students’ self-assessments or calibration as they engaged in a virtual-patient simulation targeting clinical reasoning practices. Examining two key subtasks of a patient encounter, history (Hx) and physical exam (PE), the authors assessed the level of variation in students’ behavioral performance (i.e., effectiveness and efficiency) and judgments of performance (i.e., calibration bias and accuracy) across the two subtasks. Paired t tests revealed that the Hx subtask was deemed to be more challenging than the PE subtask when viewed in terms of both actual and perceived performance. In addition to students performing worse on the Hx subtask than PE, they also perceived that they performed less well for Hx. Interestingly, across both subtasks, the majority of participants overestimated their performance (98% of participants for Hx and 95% for PE). Correlation analyses revealed that the participants’ overall level of accuracy in metacognitive judgments was moderately stable across the Hx and PE subtasks. Taken together, findings underscore the importance of assessing medical students’ metacognitive judgments at different points during a clinical encounter.

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Section: Discussionmentioning

confidence: 99%

First-year medical students’ calibration bias and accuracy across clinical reasoning activities

Cleary

Konopasky

Rochelle

et al. 2019

Adv in Health Sci Educ

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“…evidence a physician offers for a given diagnosis) in which these decisions are grounded. Other recent work has taken up a socially situated theoretical model to better understand context specificity, but it has been exploratory and, as such, was conducted with no control group and relatively few participants [7,14,[32][33][34][35].…”

Section: Introductionmentioning

confidence: 99%

Understanding context specificity: the effect of contextual factors on clinical reasoning

et al. 2020

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BackgroundSituated cognition theory argues that thinking is inextricably situated in a context. In clinical reasoning, this can lead to context specificity: a physician arriving at two different diagnoses for two patients with the same symptoms, findings, and diagnosis but different contextual factors (something beyond case content potentially influencing reasoning). This paper experimentally investigates the presence of and mechanisms behind context specificity by measuring differences in clinical reasoning performance in cases with and without contextual factors.MethodsAn experimental study was conducted in 2018–2019 with 39 resident and attending physicians in internal medicine. Participants viewed two outpatient clinic video cases (unstable angina and diabetes mellitus), one with distracting contextual factors and one without. After viewing each case, participants responded to six open-ended diagnostic items (e.g. problem list, leading diagnosis) and rated their cognitive load.ResultsMultivariate analysis of covariance (MANCOVA) results revealed significant differences in angina case performance with and without contextual factors [Pillai’s trace = 0.72, F = 12.4, df =(6, 29), p < 0.001, $\eta _{\rm p}^2 = 0.72$], with follow-up univariate analyses indicating that participants performed statistically significantly worse in cases with contextual factors on five of six items. There were no significant differences in diabetes cases between conditions. There was no statistically significant difference in cognitive load between conditions.ConclusionsUsing typical presentations of common diagnoses, and contextual factors typical for clinical practice, we provide ecologically valid evidence for the theoretically predicted negative effects of context specificity (i.e. for the angina case), with large effect sizes, offering insight into the persistence of diagnostic error.

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“…Contextual presence is viewed as a negative influence outside of the traditional clinical domain, exerting its power as an external force on the GP [ 35 , 60 ]. It has been described as “something other than the essential content (that) is driving the physician’s clinical reasoning” [ 81 ]. For example, several studies have focused on guidelines adherence as outcomes.…”

Section: Discussionmentioning

confidence: 99%

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

2021

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Background How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. Method The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. Results Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. Conclusion Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

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Understanding Clinical Reasoning from Multiple Perspectives: A Conceptual and Theoretical Overview

Cited by 27 publications

References 40 publications

First-year medical students’ calibration bias and accuracy across clinical reasoning activities

First-year medical students’ calibration bias and accuracy across clinical reasoning activities

Understanding context specificity: the effect of contextual factors on clinical reasoning

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

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