Clinical Decisionmaking: Opening the Black Box of Cognitive Reasoning

Washington University in St. Louis, San Luis, Missouri, United States
Annals of emergency medicine (Impact Factor: 4.68). 01/2007; 48(6):713-9. DOI: 10.1016/j.annemergmed.2006.03.011
Source: PubMed
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    • "When clinicians feel confident in their decision-making, they may be unaware of the correctness of their diagnosis and thus not open to using supports like clinical decision rules to change their decision [40]. In the case of minor head injuries, physicians may also employ the ‘rule out worst-case scenario’ strategy of decision making and order CTs for many patients to avoid missing a life-threatening diagnosis [41]. Fitting a clinical decision rule into the management of a clinical problem requires reflection on how clinicians make a diagnosis in a range of scenarios [38]. "
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    ABSTRACT: The Canadian CT Head Rule was prospectively derived and validated to assist clinicians with diagnostic decision-making regarding the use of computed tomography (CT) in adult patients with minor head injury. A recent intervention trial failed to demonstrate a decrease in the rate of head CTs following implementation of the rule in Canadian emergency departments. Yet, the same intervention, which included a one-hour educational session and reminders at the point of requisition, was successful in reducing cervical spine imaging rates in the same emergency departments. The reason for the varied effect of the intervention across these two behaviours is unclear. There is an increasing appreciation for the use of theory to conduct process evaluations to better understand how strategies are linked with outcomes in implementation trials. The Theoretical Domains Framework (TDF) has been used to explore health professional behaviour and to design behaviour change interventions but, to date, has not been used to guide a theory-based process evaluation. In this proof of concept study, we explored whether the TDF could be used to guide a retrospective process evaluation to better understand emergency physicians' responses to the interventions employed in the Canadian CT Head Rule trial. A semi-structured interview guide, based on the 12 domains from the TDF, was used to conduct telephone interviews with project leads and physician participants from the intervention sites in the Canadian CT Head Rule trial. Two reviewers independently coded the anonymised interview transcripts using the TDF as a coding framework. Relevant domains were identified by: the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour. Eight physicians from four of the intervention sites in the Canadian CT Head Rule trial participated in the interviews. Barriers likely to assist with understanding physicians' responses to the intervention in the trial were identified in six of the theoretical domains: beliefs about consequences; beliefs about capabilities; behavioural regulation; memory, attention and decision processes; environmental context and resources; and social influences. Despite knowledge that the Canadian CT Head Rule was highly sensitive and reliable for identifying clinically important brain injuries and strong beliefs about the benefits for using the rule, a number of barriers were identified that may have prevented physicians from consistently applying the rule. This proof of concept study demonstrates the use of the TDF as a guiding framework to design a retrospective theory-based process evaluation. There is a need for further development and testing of methods for using the TDF to guide theory-based process evaluations running alongside behaviour change intervention trials.
    Implementation Science 02/2013; 8(1):25. DOI:10.1186/1748-5908-8-25 · 4.12 Impact Factor
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    • "A major goal of undergraduate medical education is to somehow teach the skill of clinical reasoning. This remains a challenge, because our understanding of medical decision making and how one acquires expertise in this skill is still evolving (Elstein & Schwarz 2002; Norman 2005; Sandhu & Carpenter 2006) and educators have not agreed on the best ways to teach these skills to inexperienced students (Goss 1996; Bowen 2006). Deriving an appropriate differential diagnosis requires an extensive knowledge base, skills in gathering the patient's history and performing the physical examination, and the ability to synthesize all of this information effectively. "
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    ABSTRACT: Deriving an appropriate differential diagnosis is a key clinical competency, but there is little data available on how medical students learn this skill. Software resources designed to complement clinical reasoning might be asset in helping them in this task. The goals of this study were to identify the resources third year medical students use to solve a challenging diagnostic case, and specifically to evaluate the usefulness of Isabel, a second-generation electronic diagnosis support system. Third year medical students (n = 117) were presented a challenging case and asked to identify and prioritize their top 3 diagnoses, report the time devoted to the exercise, and list the resources they used and their relative usefulness. Students were randomized to receive (or not) free access, instruction, and encouragement to use to a web-based decision support system (Isabel). Students who identified the correct diagnosis as their first choice spent significantly more time on the case than did the other students (3.75 +/- 0.28 hours vs 2.88 +/- 0.15 hours, p < 0.05). Students used electronic resources extensively, in particular Google. Students who self-reported use of Isabel had greater success identifying the correct diagnosis (24/33 = 73% for users vs 45/84 = 53% for non-users) a difference of borderline statistical significance. These findings indicate that medical trainees use a wide range of electronic decision support products to solve challenging cases. Medical education needs to adapt to this reality, and address the need to teach future clinicians how to use these tools to advantage.
    Medical Teacher 06/2009; 31(6):522-7. DOI:10.1080/01421590802167436 · 1.68 Impact Factor

  • Annals of emergency medicine 01/2007; 48(6):720-2. DOI:10.1016/j.annemergmed.2006.03.030 · 4.68 Impact Factor
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