scholarly journals Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic

2022 ◽  
Author(s):  
Matteo Coen ◽  
Julia Sader ◽  
Noëlle Junod-Perron ◽  
Marie-Claude Audétat ◽  
Mathieu Nendaz
Keyword(s):  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Clinical Cases

Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Vita Jaspan ◽  
Verity Schaye ◽  
Andrew S. Parsons ◽  
David Kudlowitz
Keyword(s):  
Acute Pancreatitis ◽  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
First Episode ◽  
Gut Flora ◽  
Case Presentation ◽  
Early Hypothesis ◽  
Elevated Transaminases

Abstract Objectives Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. Case presentation This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1–2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. Conclusions Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

Becoming a teacher of clinical reasoning

Diagnosis ◽  
2018 ◽  
Vol 5 (1) ◽  
pp. 11-14 ◽  
Author(s):  
Robert L. Trowbridge ◽  
Andrew P.J. Olson
Keyword(s):  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Reasoning ◽  
Dual Process ◽  
Diagnostic Process ◽  
Clinical Experiences ◽  
Context Specificity ◽  
Clinician Educators ◽  
Medical Educators

AbstractDiagnostic reasoning is one of the most challenging and rewarding aspects of clinical practice. As a result, facility in teaching diagnostic reasoning is a core necessity for all medical educators. Clinician educators’ limited understanding of the diagnostic process and how expertise is developed may result in lost opportunities in nurturing the diagnostic abilities of themselves and their learners. In this perspective, the authors describe their journeys as clinician educators searching for a coherent means of teaching diagnostic reasoning. They discuss the initial appeal and immediate applicability of dual process theory and cognitive biases to their own clinical experiences and those of their trainees, followed by the eventual and somewhat belated recognition of the importance of context specificity. They conclude that there are no quick fixes in guiding learners to expertise of diagnostic reasoning, but rather the development of these abilities is best viewed as a long, somewhat frustrating, but always interesting journey. The role of the teacher of clinical reasoning is to guide the learners on this journey, recognizing true mastery may not be attained, but should remain a goal for teacher and learner alike.

scholarly journals Development and evaluation of a clinical reasoning curriculum as part of an Internal Medicine Residency Program

Diagnosis ◽  
2019 ◽  
Vol 6 (2) ◽  
pp. 115-119 ◽  
Author(s):  
Shwetha Iyer ◽  
Erin Goss ◽  
Casey Browder ◽  
Gerald Paccione ◽  
Julia Arnsten
Keyword(s):  
Internal Medicine ◽  
Clinical Reasoning ◽  
Residency Program ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Internal Medicine Residency ◽  
Case Vignette ◽  
Internal Medicine Residency Program ◽  
Reasoning Skills ◽  
Clinical Reasoning Skills

Abstract Background Errors in medicine are common and often tied to diagnosis. Educating physicians about the science of cognitive decision-making, especially during medical school and residency when trainees are still forming clinical habits, may enhance awareness of individual cognitive biases and has the potential to reduce diagnostic errors and improve patient safety. Methods The authors aimed to develop, implement and evaluate a clinical reasoning curriculum for Internal Medicine residents. The authors developed and delivered a clinical reasoning curriculum to 47 PGY2 residents in an Internal Medicine Residency Program at a large urban hospital. The clinical reasoning curriculum consists of six to seven sessions with the specific aims of: (1) educating residents on cognitive steps and reasoning strategies used in clinical reasoning; (2) acknowledging the pitfalls of clinical reasoning and learning how cognitive biases can lead to clinical errors; (3) expanding differential diagnostic ability and developing illness scripts that incorporate discrete clinical prediction rules; and (4) providing opportunities for residents to reflect on their own clinical reasoning (also known as metacognition). Results Forty-seven PGY2 residents participated in the curriculum (2013–2016). Self-assessed comfort in recognizing and applying clinical reasoning skills increased in 15 of 15 domains (p < 0.05 for each). Resident mean scores on the knowledge assessment improved from 58% pre-curriculum to 81% post curriculum (p = 0.002). Conclusions A case vignette-based clinical reasoning curriculum can effectively increase residents’ knowledge of clinical reasoning concepts and improve residents’ self-assessed comfort in recognizing and applying clinical reasoning skills.

scholarly journals Improving Resident Feedback on Diagnostic Reasoning after Handovers: The LOOP Project

2019 ◽  
Vol 14 (10) ◽  
pp. 622-625 ◽  
Author(s):  
Kathleen P Lane ◽  
Catherine Chia ◽  
Juan N Lessing ◽  
Julia Limes ◽  
Benji Mathews ◽  
...  
Keyword(s):  
Clinical Reasoning ◽  
Self Efficacy ◽  
Cognitive Biases ◽  
Night Shift ◽  
Transitions Of Care ◽  
Negative Effects ◽  
Secure Messaging ◽  
Educational Value ◽  
Diagnostic Changes

Appropriate calibration of clinical reasoning is critical to becoming a competent physician. Lack of follow-up after transitions of care can present a barrier to calibration. This study aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners’ self-efficacy. Trainees shared feedback via a structured form within their electronic health record’s secure messaging system. Forms were analyzed for diagnostic changes. Surveys evaluated comfort with sharing feedback, self-efficacy in identifying and mitigating cognitive biases’ negative effects, and perceived educational value of night admissions—all of which improved after implementation. Analysis of 544 forms revealed a 43.7% diagnostic change rate spanning the transition from night-shift to day-shift providers; of the changes made, 29% (12.7% of cases overall) were major changes. This study suggests that structured feedback on clinical reasoning for overnight admissions is a promising approach to improve residents’ diagnostic calibration, particularly given how often diagnostic changes occur.

Teaching and Assessing Critical Thinking and Clinical Reasoning Skills in Medical Education

2019 ◽  
pp. 213-233
Author(s):  
Md. Anwarul Azim Majumder ◽  
Bidyadhar Sa ◽  
Fahad Abdullah Alateeq ◽  
Sayeeda Rahman
Keyword(s):  
Medical Education ◽  
Critical Thinking ◽  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Higher Order Thinking ◽  
Recent Trends ◽  
Reasoning Skills ◽  
Clinical Reasoning Skills ◽  
And Training

In recent years, there has been more emphasis on developing higher order thinking (e.g., critical thinking and clinical reasoning) processes to tackle the recent trends and challenges in medical education. Critical thinking and clinical reasoning are considered to be the cornerstones for teaching and training tomorrow's doctors. Lack of training of critical thinking and clinical reasoning in medical curricula causes medical students and physicians to use cognitive biases in problem solving which ultimately leads to diagnostic errors later in their professional practice. Moreover, there is no consensus on the most effective teaching model to teach the critical thinking and clinical reasoning skills and even the skill is not effectively tested in medical schools. This chapter will focus on concepts, contemporary theories, implications, issues and challenges, characteristics, various steps, teaching models and strategies, measuring and intervention tools, and assessment modalities of critical thinking and clinical reasoning in medical education settings.

scholarly journals Self-learning Courses EaD to qualify clinical practice

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
A Fassa ◽  
E J Fantinel ◽  
D C Soares ◽  
M L V Carret ◽  
R Linhares ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Distance Learning ◽  
Formative Assessment ◽  
Clinical Reasoning ◽  
Health Professionals ◽  
Evaluation Studies ◽  
Remote Areas ◽  
The Subject ◽  
Self Learning ◽  
Clinical Cases

Abstract Background Health service evaluation studies point to the low quality of care, however the permanent education of health professionals is a major challenge. Within the scope of the Open University for the Unified Health System (SUS), the Department of Social Medicine of the Federal University of Pelotas produced open access self-learning courses, for primary health care, based on interactive clinical cases, through distance learning. Methods The courses, with 45 hours, provides interactive clinical cases, medical calculators and textual materials for use by the professional or with the community. The cases are presented and followed by multiple choice questions, focusing diagnosis and treatment. The feedback is automatic. An expanded theoretical content ('learn more') that privileges the use of illustrations, images, infographics and flowcharts useful for professional practice can be accessed. Bibliographical references on the subject are also available. The courses are available in a responsive web client app, for various types of devices, providing control of progress and automatic certification. The app allows the work offline, enabling the permanent education of professionals working in remote areas. Results Six courses were produced for doctors, nurses and dentists, more than 30,000 users were certified. Conclusions This problem-based learning initiative allows the student to have a menu of cases, providing a choice of the subject, decision on the time allocated to the activity, repetition according to its need, access to a large bibliography and reading in the quantity and depth chosen by the student. In addition, the format is challenging and develops clinical reasoning. The proposition of questions promotes the reflection of the student in relation to his knowledge on the subject. Automatic feedback, 'learn more' and selected bibliographies provide formative assessment and subsidize students to define their study needs in each subject. Key messages Distance learning expands the possibility of qualifying the clinical practice of health professionals, especially those in remote areas. Interactive clinical cases provide the development of clinical reasoning, content review and promote formative assessment.

Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and “picking at the air”

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Charles D. Magee ◽  
Andrew S. Parsons ◽  
Alexander S. Millard ◽  
Dario Torre
Keyword(s):  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Human Cognition ◽  
Case Presentation ◽  
Fishbone Diagram ◽  
Major Factors ◽  
Medication Changes ◽  
Incision Drainage

Abstract Objectives Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. Case presentation A 43-year-old female was brought to the emergency department with 4–5 days of confusion, disequilibrium resulting in several falls, and hallucinations. Further investigation revealed tachycardia, diaphoresis, mydriatic pupils, incomprehensible speech and she was seen picking at the air. Given multiple recent medication changes, there was initial concern for serotonin syndrome vs. an anticholinergic toxidrome. She then developed a fever, marked leukocytosis, and worsening encephalopathy. She underwent lumbar puncture and aspiration of an identified left ankle effusion. Methicillin sensitive staph aureus (MSSA) grew from blood, joint, and cerebrospinal fluid cultures within 18 h. She improved with antibiotics and incision, drainage, and washout of her ankle by orthopedic surgery. Conclusions Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores how multiple cognitive biases can cascade sequentially, skewing clinical reasoning toward erroneous conclusions and driving potentially inappropriate testing and treatment. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of structured reflection, a tool to promote metacognitive analysis, and the application of knowledge organization tools such as illness scripts to navigate these cognitive biases.

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