scholarly journals Exploring the influence of contextual factors of the clinical encounter on clinical reasoning success : (unraveling context specificity)

2011 ◽  
Author(s):  
S.J. Durning
Keyword(s):  
Clinical Reasoning ◽  
Contextual Factors ◽  
Clinical Encounter ◽  
Context Specificity

scholarly journals Sequence matters: patterns in task-based clinical reasoning

Diagnosis ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. 281-289 ◽  
Author(s):  
Michael Soh ◽  
Abigail Konopasky ◽  
Steven J. Durning ◽  
Divya Ramani ◽  
Elexis McBee ◽  
...  
Keyword(s):  
Clinical Reasoning ◽  
Contextual Factors ◽  
Management Plan ◽  
Think Aloud ◽  
Context Specificity ◽  
Reasoning Task ◽  
General Sequence ◽  
Reasoning Process ◽  
Efficient Management ◽  
Reasoning Tasks

AbstractBackgroundThe cognitive pathways that lead to an accurate diagnosis and efficient management plan can touch on various clinical reasoning tasks (1). These tasks can be employed at any point during the clinical reasoning process and though the four distinct categories of framing, diagnosis, management, and reflection provide some insight into how these tasks map onto clinical reasoning, much is still unknown about the task-based clinical reasoning process. For example, when and how are these tasks typically used? And more importantly, do these clinical reasoning task processes evolve when patient encounters become complex and/or challenging (i.e. with contextual factors)?MethodsWe examine these questions through the lens of situated cognition, context specificity, and cognitive load theory. Sixty think-aloud transcripts from 30 physicians who participated in two separate cases – one with a contextual factor and one without – were coded for 26 clinical reasoning tasks (1). These tasks were organized temporally, i.e. when they emerged in their think-aloud process. Frequencies of each of the 26 tasks were aggregated, categorized, and visualized in order to analyze task category sequences.ResultsWe found that (a) as expected, clinical tasks follow a general sequence, (b) contextual factors can distort this emerging sequence, and (c) the presence of contextual factors prompts more experienced physicians to clinically reason similar to that of less experienced physicians.ConclusionsThese findings add to the existing literature on context specificity in clinical reasoning and can be used to strengthen teaching and assessment of clinical reasoning.

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

Diagnosis ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. 257-264 ◽  
Author(s):  
Abigail Konopasky ◽  
Anthony R. Artino ◽  
Alexis Battista ◽  
Megan Ohmer ◽  
Paul A. Hemmer ◽  
...  
Keyword(s):  
Cognitive Load ◽  
Clinical Reasoning ◽  
Contextual Factors ◽  
Diagnostic Error ◽  
Analysis Of Covariance ◽  
Context Specificity ◽  
Negative Effects ◽  
Significant Difference ◽  
Valid Evidence ◽  
Attending Physicians

AbstractBackgroundSituated 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.

Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process

Diagnosis ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. 299-305 ◽  
Author(s):  
Divya Ramani ◽  
Michael Soh ◽  
Jerusalem Merkebu ◽  
Steven J. Durning ◽  
Alexis Battista ◽  
...  
Keyword(s):  
Clinical Reasoning ◽  
Contextual Factors ◽  
Descriptive Analysis ◽  
Clinical Encounter ◽  
Reasoning Task ◽  
Reasoning Process ◽  
Linguistic Markers ◽  
Clinical Encounters ◽  
Reasoning Tasks ◽  
To Come

AbstractObjectivesUncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians’ clinical reasoning process.MethodsIn this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt’s clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.).ResultsThirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection.ConclusionsThese results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.

scholarly journals Challenges in mitigating context specificity in clinical reasoning: a report and reflection

Diagnosis ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. 291-297
Author(s):  
Abigail Konopasky ◽  
Steven J. Durning ◽  
Alexis Battista ◽  
Anthony R. Artino ◽  
Divya Ramani ◽  
...  
Keyword(s):  
Clinical Reasoning ◽  
Outcome Measure ◽  
Contextual Factors ◽  
Computer Training ◽  
Diagnostic Error ◽  
Descriptive Statistics ◽  
Analysis Of Covariance ◽  
Control Group ◽  
Context Specificity ◽  
Experimental Group

AbstractObjectivesDiagnostic error is a growing concern in U.S. healthcare. There is mounting evidence that errors may not always be due to knowledge gaps, but also to context specificity: a physician seeing two identical patient presentations from a content perspective (e.g., history, labs) yet arriving at two distinct diagnoses. This study used the lens of situated cognition theory – which views clinical reasoning as interconnected with surrounding contextual factors – to design and test an instructional module to mitigate the negative effects of context specificity. We hypothesized that experimental participants would perform better on the outcome measure than those in the control group.MethodsThis study divided 39 resident and attending physicians into an experimental group receiving an interactive computer training and “think-aloud” exercise and a control group, comparing their clinical reasoning. Clinical reasoning performance in a simulated unstable angina case with contextual factors (i.e., diagnostic suggestion) was determined using performance on a post-encounter form (PEF) as the outcome measure. The participants who received the training and did the reflection were compared to those who did not using descriptive statistics and a multivariate analysis of covariance (MANCOVA).ResultsDescriptive statistics suggested slightly better performance for the experimental group, but MANCOVA results revealed no statistically significant differences (Pillai’s Trace=0.20, F=1.9, df=[4, 29], p=0.15).ConclusionsWhile differences were not statistically significant, this study suggests the potential utility of strategies that provide education and awareness of contextual factors and space for reflective practice.

scholarly journals A situated cognition model for clinical reasoning performance assessment: a narrative review

Diagnosis ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. 227-240 ◽  
Author(s):  
Joseph Rencic ◽  
Lambert W.T. Schuwirth ◽  
Larry D. Gruppen ◽  
Steven J. Durning
Keyword(s):  
Performance Assessment ◽  
Conceptual Model ◽  
Clinical Reasoning ◽  
Social Cognitive ◽  
Contextual Factors ◽  
Situated Cognition ◽  
Context Specificity ◽  
Cognitive Theories ◽  
Social Cognitive Theories ◽  
The Impact

AbstractBackgroundClinical reasoning performance assessment is challenging because it is a complex, multi-dimensional construct. In addition, clinical reasoning performance can be impacted by contextual factors, leading to significant variation in performance. This phenomenon called context specificity has been described by social cognitive theories. Situated cognition theory, one of the social cognitive theories, posits that cognition emerges from the complex interplay of human beings with each other and the environment. It has been used as a valuable conceptual framework to explore context specificity in clinical reasoning and its assessment. We developed a conceptual model of clinical reasoning performance assessment based on situated cognition theory. In this paper, we use situated cognition theory and the conceptual model to explore how this lens alters the interpretation of articles or provides additional insights into the interactions between the assessee, patient, rater, environment, assessment method, and task.MethodsWe culled 17 articles from a systematic literature search of clinical reasoning performance assessment that explicitly or implicitly demonstrated a situated cognition perspective to provide an “enriched” sample with which to explore how contextual factors impact clinical reasoning performance assessment.ResultsWe found evidence for dyadic, triadic, and quadratic interactions between different contextual factors, some of which led to dramatic changes in the assessment of clinical reasoning performance, even when knowledge requirements were not significantly different.ConclusionsThe analysis of the selected articles highlighted the value of a situated cognition perspective in understanding variations in clinical reasoning performance assessment. Prospective studies that evaluate the impact of modifying various contextual factors, while holding others constant, can provide deeper insights into the mechanisms by which context impacts clinical reasoning performance assessment.

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.

Consequences of contextual factors on clinical reasoning in resident physicians

2015 ◽  
Vol 20 (5) ◽  
pp. 1225-1236 ◽  
Author(s):  
Elexis McBee ◽  
Temple Ratcliffe ◽  
Katherine Picho ◽  
Anthony R. Artino ◽  
Lambert Schuwirth ◽  
...  
Keyword(s):  
Clinical Reasoning ◽  
Contextual Factors ◽  
Resident Physicians

scholarly journals 196 The effect of affect: what we teach our learners about the role of patient induced emotion in clinical reasoning in the ED and why?

2020 ◽  
Vol 37 (12) ◽  
pp. 839.2-840
Author(s):  
Susie Roy ◽  
Janet Skinner ◽  
Alan Jaap
Keyword(s):  
Clinical Reasoning ◽  
Empirical Studies ◽  
Management Strategies ◽  
Clinical Encounter ◽  
Structured Interviews ◽  
Difficult Patients ◽  
Formal Curriculum ◽  
Frequent Attendance ◽  
Ethical Approval ◽  
Impact Patient Care

Aims/Objectives/BackgroundFew empirical studies explore the contribution of non-clinical factors to perceptions of patient difficulty in EM. Fewer have investigated what students placed in EDs learn about ‘difficult’ patients or what, if anything, clinicians teach about the topic. We looked to address this. Considering these questions is imperative: patients perceived as frustrating report lower satisfaction with their clinical encounter, experience worse health outcomes and seem to be at risk of medical error secondary to faulty clinical reasoning.Methods/DesignWith ethical approval, we undertook three interrelated, qualitative studies to conduct a case study of the undergraduate EM module delivered at Edinburgh University. In the first two, focus groups were used as the method of data collection; five clinician (n=25) and four medical student (n=21) groups were facilitated. In the third, semi-structured interviews with clinicians (n=12) were conducted. All groups/interviews were audio-recorded and transcribed. The data were analysed inductively using reflexive thematic analysis.Results/ConclusionsFrequent attendance, demands, pre-existing relationships and unrealistic expectations contributed to perceived patient difficulty. These were modified by personal and circumstantial factors. Although rarely told, students were aware who these ‘difficult’ patients were through observing behaviours. Critically, clinicians and students alike believed frustration adversely impacted aspects of clinical reasoning. Students struggled when witnessing what they considered ‘bad’ behaviour as it contradicted their previously held ideals of how physicians should act.It seems we teach students to try to internalise emotion yet that it is acceptable to let it negatively impact patient care. To combat this, students sought greater emotional transparency from physicians as well as advice on self-management strategies. Clinicians recognised the benefits of being candid but were afraid of being so. Contributing to this is the culture in medicine being one that mistrusts emotion. Further, both groups desired a formal curriculum addressing emotion in clinical reasoning thus suggesting one is needed.

Physiotherapists as detectives: investigating clues and plots in the clinical encounter

2017 ◽  
Vol 44 (1) ◽  
pp. 40-45 ◽  
Author(s):  
Birgitte Ahlsen ◽  
Anne Marit Mengshoel ◽  
Hilde Bondevik ◽  
Eivind Engebretsen
Keyword(s):  
Clinical Reasoning ◽  
Muscle Pain ◽  
Clinical Encounter ◽  
Narrative Approach ◽  
Reasoning Process ◽  
Chronic Muscle Pain ◽  
First Session

This article investigates the clinical reasoning process of physiotherapists working with patients with chronic muscle pain. The article demonstrates how physiotherapists work with clues and weigh up different plots as they seek to build consistent stories about their patient’s illness. The material consists of interviews with 10 Norwegian physiotherapists performed after the first clinical encounter with a patient. Using a narrative approach and Lonergan’s theory of interpretation, the study highlights how, like detectives, the therapists work with clues by asking a number of interpretive questions of their data. They interrogate what they have observed and heard during the first session, they also question how the patient’s story was told, including the contextual and relation aspects of clue production, and they ask why the patient’s story was told to them in this particular way at this particular time. The article shows how the therapists configure clues into various plots on the basis of their experience of working with similar cases and how their detective work is pushed forward by uncertainty and persistent questioning of the data.

scholarly journals The Linguistic Effects of Context Specificity: Exploring Affect, Cognitive Processing, and Agency in Physicians’ Think-Aloud Reflections

Diagnosis ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. 273-280 ◽  
Author(s):  
Abigail Konopasky ◽  
Steven J. Durning ◽  
Anthony R. Artino ◽  
Divya Ramani ◽  
Alexis Battista
Keyword(s):  
Cognitive Processing ◽  
Cognitive Processes ◽  
Repeated Measures ◽  
Contextual Factors ◽  
Situated Cognition ◽  
Descriptive Analysis ◽  
Think Aloud ◽  
Context Specificity ◽  
Linguistic Markers ◽  
Third Person

AbstractBackgroundThe literature suggests that affect, higher-level cognitive processes (e.g. decision-making), and agency (the capacity to produce an effect) are important for reasoning; however, we do not know how these factors respond to context. Using situated cognition theory as a framework, and linguistic tools as a method, we explored the effects of context specificity [a physician seeing two patients with identical presentations (symptoms and findings), but coming to two different diagnoses], hypothesizing more linguistic markers of cognitive load in the presence of contextual factors (e.g. incorrect diagnostic suggestion).MethodsIn this comparative and exploratory study, 64 physicians each completed one case with contextual factors and one without. Transcribed think-aloud reflections were coded by Linguistic Inquiry and Word Count (LIWC) software for markers of affect, cognitive processes, and first-person pronouns. A repeated-measures multivariate analysis of variance was used to inferentially compare these LIWC categories between cases with and without contextual factors. This was followed by exploratory descriptive analysis of subcategories.ResultsAs hypothesized, participants used more affective and cognitive process markers in cases with contextual factors and more I/me pronouns in cases without. These differences were statistically significant for cognitive processing words but not affective and pronominal words. Exploratory analysis revealed more negative emotions, cognitive processes of insight, and third-person pronouns in cases with contextual factors.ConclusionsThis study exposes linguistic differences arising from context specificity. These results demonstrate the value of a situated cognition view of patient encounters and reveal the utility of linguistic tools for examining clinical reasoning.

Sign in / Sign up

Export Citation Format

Share Document