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The role of patient involvement in the diagnostic process in internal medicine: A cognitive approach

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Abstract

Much cognitive and clinical research has addressed clinical reasoning, pointing out that physicians often have difficulties in following a linear course when making accurate diagnoses. Some authors suspect that physicians make mistakes because they unknowingly fail to observe the laws of formal logic and that their reasoning becomes influenced by contextual factors. In this paper, we introduce some basic principles of the cognitive approach to medical decision making and we describe the cognitive balanced model. Then we discuss the relationship between construction of mental models, cognitive biases and patient involvement by the use of a clinical vignette. Medical decisions may be considered fundamentally biased since the use of judgment heuristics and a combination of cognitive-related and system-related factors limit physicians' rationality. While traditional understanding of clinical reasoning has failed to consider contextual factors, most techniques designed to avoid biases seem to fail in promoting sound and safer medical practice. In particular, we argue that an unbiased process requires the use of a cognitive balanced model, in which analytical and intuitive mind skills should be properly integrated. In order to improve medical decision making and thereby lessen incidence of adverse events, it is fundamental to include the patient perspective in a balanced model. Physicians and patients should improve their collective intelligence by sharing mental models within a framework of distributed intelligence.
The role of patient involvement in the diagnostic process in
Internal Medicine: a cognitive approach
Claudio Lucchiari, Gabriella Pravettoni
Università degli Studi di Milano
This is a pre-print versione. To Cite this article:
LUCCHIARI, Claudio; PRAVETTONI, Gabriella. The role of
patient involvement in the diagnostic process in internal
medicine: a cognitive approach. European journal of internal
medicine, 2013, 24.5: 411-415.
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Abstract
Much cognitive and clinical research has addressed clinical
reasoning, pointing out that physicians often have difficulties in
following a linear course when making accurate diagnoses.
Some authors suspect that physicians make mistakes because
they unknowingly fail to observe the laws of formal logic and
that their reasoning becomes influenced by contextual factors.
In this paper, we introduce some basic principles of the
cognitive approach to medical decision making and we describe
the cognitive balanced model. Then we discuss the relationship
between construction of mental models, cognitive biases and
patient involvement by the use of a clinical vignette.
Medical decisions may be considered fundamentally biased
since the use of judgment heuristics and a combination of
cognitive-related and system-related factors limit physicians'
rationality.
While traditional understanding of clinical reasoning has failed
to consider contextual factors, most techniques designed to
avoid biases seem to fail in promoting sound and safer medical
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practice. In particular, we argue that an unbiased process
requires the use of a cognitive balanced model, in which
analytical and intuitive mind skills should be properly
integrated.
In order to improve medical decision making and thereby
lessen incidence of adverse events, it is fundamental to include
the patient perspective in a balanced model. Physicians and
patients should improve their collective intelligence by sharing
mental models within a framework of distributed intelligence.
Keywords: medical decision making; cognitive biases;
overconfidence; diagnostic errors;
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Introduction
The diagnostic process is probably the most relevant
component in medical decision making from a cognitive point
of view. In fact, physicians need to work like an information
processor, which collects data from the environment, infers
judgments and produces clinical scenarios. Much research has
been devoted to this important topic but most is superficial,
both when it succeeds and when it fails. Actually, diagnostic
error accounts for a substantial portion of all medical errors,
receiving increased attention in the last 30 years [1]. However,
it is astonishing that the error rate seems to remain constant
over time and space, as demonstrated in two studies (one in the
US and one in Germany) which indicate how the error rate has
not substantially changed over since 1980, remaining firmly
anchored in both countries at a rate of around 10%, although
alarmingly a recent systematic review reported a rate as high
as 24% [2].
Generally speaking, most errors are reported to occur
within the information analysis stage. Physicians declare
failures or delays in identifying significant clues and in
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prioritizing clinical information. In this stage, physicians, as
any other expert decision makers, need to gather data from the
environment and to organize them onto a so called mental
model. Indeed, the human mind works on well-structured data
that may be represented and cognitively processed, in order to
define a problem, highlights solutions and takes actions in a
cognitive loop (see figure 1). Thus, all the incoming
information needs to be weighted for relevance and tested for
reliability before being integrated in a mental model [3].
The activation of a first mental model starts with the
diagnostic process. In fact, using this mental structure based on
schemes stored in the long-term memory, a physician may
evaluate the consequences of each possible choice (diagnostic
or therapeutic interventions), in order to plan future actions,
choose scenarios, or even review the active mental model.
Figure 1 here
A number of studies have highlighted the complex nature of
making medical decisions, which cannot be considered a
cognitive exercise completely based on rational and technical
skills [4;5]. In particular, cognitive research has shown that the
clinical setting is influenced by heuristic processes, intuition
and a number of biases, or cognitive illusions, that can lead a
physician far from ideal clinical reasoning [6]. Recent studies
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showed that it is possible to understand and prevent errors in
internal medicine starting by the recognition of the interaction
between cognitive-related and system-related causes [7] and
learning to detect early warnings [8].
A Cognitive Balanced Model
In previous work [9], we have defined a cognitive balanced
model to describe how the clinical decision setting should be
represented by a functional balance between analysis and
intuition, that is, between the two basic components of the
human mind [10]. The cognitive balanced model is based on
the assumption that the use of concepts and logical reasoning
should be developed in medical education along with specific
training within the realm of intuitive skills. In particular, it
emphasizes the importance of developing specific awareness
about of the need for balance, since the lack of awareness will
inevitably expose physicians and patients to clinical hazards.
Indeed, an overconfidence in analytical skills or the
underestimation of the importance of implicit thought will
increase the likelihood of falling into cognitive traps [11], and
failure to understand the origin of many errors.
Of course, the development of analytical skills and intuition
follow different paths. To follow logical and analytical schemas
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it is necessary to learn general methods, specific concepts and
techniques as well as how to apply them in certain domains.
Intuition, in contrast, is developed with experience, essentially
during everyday activity and thus it is difficult to plan
training specifically aimed at develop intuitive skills. However,
it is possible to design education programs compatible with the
needs of the intuitive mind. Generally speaking, a strong
learning environment [12], characterized by consistency,
regularity, timely feedback and meta-cognitive moments can be
considered to be “pro-intuitive” [13].
Medical practitioners must learn to trust their intuition, but
also to know its limits. In particular, intuition is much more
powerful and reliable, when functioning within the specific
context in which it was developed. Doctors’ expert eye should
not be transferred automatically from one medical context to
another.
The cognitive balanced model highlights how these meta-skills
should belong to the cognitive background of a doctor. Without
this background, error prevention protocols and techniques to
cut down biases will always be partial solutions [14]. The
cognitive balanced model also implies that doctors should be
properly supported in both their training, and in their clinical
everyday practice by specific decision aids. However, also
these support systems should be designed to balance the
strength of analytical methods with the need for intuitive
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evaluation. In contrast, most existing support systems have a
cognitive architecture mainly based on analytical algorithms
and static knowledge structures such as decision trees and
deterministic decision-making methods.
Furthermore, our perspective proposes use of general processes
that can be analyzed as a whole, instead of addressing simple
and elementary “mind bugs”. In particular, while agreeing with
the literature data [15] we argue that there are two general
conditions that often lead to an unbalanced decision-making
process and to potential adverse events: overconfidence bias
and premature closure.
Premature closure is the tendency to avoid considering other
possibilities after reaching a diagnosis, while overconfidence
bias is the tendency to overestimate one’s judgment ability.
Premature closure can lead to stopping the diagnostic process
even before a favoured diagnosis is actually confirmed by
appropriate clinical examination. It should derive from a strong
cognitive load which depends on several factors [personal,
inter-personal and contextual) and is time-dependent. More
specifically, premature closure may be the result of the
combination of an individual’s need for cognitive closure along
with certain contextual factors. It is obvious that intuitive
thinking is strongly associated with premature closure, even if
specific training could teach physician both to trust in their
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intuition and to activate subsequent meta-cognitive control on
it.
Also overconfidence is a consequence of a number of direct
and indirect drivers, including age and experience. In
particular, overconfidence bias seems to be particularly
significant for expert doctors, since they have developed sound
competences and confidence in them.
Interestingly, experienced physicians are as likely as novices to
exhibit premature closure and indeed senior physicians may be
particularly predisposed both to premature closure and
overconfidence, probably because of the development of age-
related cognitive constraints [16].
The special importance that overconfidence and premature
closure seem to play in the diagnostic process probably lies in
some basic mind processes. The overconfidence bias leads to
the creation of a conservative mental model, ready to use, and
the need for closure exerts pressure to confirm the same mental
model in order to avoid cognitive and emotional overloading. A
particular mental model, by itself, can also contain complex
analytical processes and procedures, incorporating both
intuitive and analytical knowledge. Nevertheless, a lack of
awareness about decision making mechanisms may lead to the
use of unbalanced models.
In order to avoid the cognitive pitfalls it would be desirable to
implement an unbiased process in which incoming data are
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organized in a mental model that highlights essential
information and leads to a safer diagnostic process.
However, we propose that a balanced process cannot really be
effective within a clinical context if it is built in isolation from
the context. The medical scenario includes different actors, in
particular physicians and patients. To avoid errors and to
strengthen the power of cognitive processes, mental structures
should be shared and the related intelligence distributed.
Patient involvement and error prevention
Although progress has been made in a number of specific areas
of prevention of errors, the patient's role in protecting and
promoting his or her own safety has long been neglected.
The scientific literature on this topic is scarce, despite some
positive cognitive studies which have suggested that this may
be a fruitful area to cut down errors. Indeed it has been
observed that patients seem to be quite efficient in detecting
errors and reporting risk situations.
Patient involvement in error detection and prevention has been
recommended, for example, by the US Institute of Medicine,
the American Hospital Association and by some clinical
experts [17;18;19]. In particular, the involvement of patients is
thought to be vital in avoiding errors in administration of
drugs, which cause many adverse events. Different studies in
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internal medicine departments showed that prescription-related
error are not rare and that in the last decades error rate did not
substantially change. In particular, errors are originated by
incomplete, duplicative, or contradictory orders or by the
failure to adjust dosages for comorbid conditions.
For instance, in a two-year prospective study on nurses [20],
141 drug administration errors were found on 4.752
hospitalizations. Forty one percent of these errors were errors
in planning (omission of the administration and measurement
checks), 21% were errors in writing or transcription of
prescriptions and 38% were errors in dispensing drugs (mainly
wrong dose or wrong medication). Most researchers suggest to
adopt corrective measures by the implementation of a
computerized physician order entry system that allow the
elimination of transcribing errors and permit the introduction of
alarm systems. However, we argue that an active patient
involvement is equally important.
Administration of medication in cancer patients is particularly
critical, given the narrow therapeutic window of cytotoxic
drugs. Patients undergoing cycles of chemotherapy may be able
to participate in error prevention, since being exposed to
similar procedures several times may enable them to adopt
clinical abilities.
These skills might be considered the result of the development
of clinical competences (knowledge of the therapy,
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pharmacodynamic principles, methods and procedures)
acquired by undergoing continuous clinical testing, inspections
and treatments. The repeated experiences over time, allow the
acquirement of a set of adaptive strategies for patients to take
control of their therapeutic journey [21;22]. If properly
informed and motivated, patients have the capability to play an
important role in the prevention or at least diminution of
adverse events. Yet little research has been undertaken on how
to effectively engage patients in this role of "watchful partner"
in their own healthcare [23;24].
In one study [25] doctors were asked to assess the perceived
effectiveness of fourteen recommended actions to prevent
errors. Results indicated that most actions were considered
effective. However, respondents also indicated that the
possibility to be involved in similar actions in their daily
activity were improbable. Having a greater self-efficacy of
being able to prevent medical errors is significantly correlated
with a higher probability to report and to be engaged in
preventive actions. For instance, feeling able to involve
patients in medical decision making and adverse event
prevention will increase the probability that a physician will
actually work to involve each subsequent patient in their
medical journey. To improve patients’ involvement, thus,
physicians need specific training to increase self-efficacy and
not just a general set of guidelines.
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Clearly, the desire for involvement and participation in the
healthcare process and shared medical decision making also
depends on certain characteristics of patients. Age, gender,
level of education and personality traits are all factors capable
of modulating the need for involvement and the ability to be a
pro-active patient. Generally speaking, younger patients tend to
report a greater desire for involvement than older patients.
Women seem to prefer a more active role than males, as do
patients with more time in higher education. Younger and more
educated patients have a greater ability to obtain and
understand health-related information and thus they will be
more likely to become involved in health-related decisions
[26].
Past experience and the specific disease characteristics are
other components to be considered in understanding a patient’s
ability to be involved [26]. For instance, patients who have had
a recent myocardial infarction, coronary angioplasty or bypass
surgery are more prone to seek involvement in medical
decisions, compared to those patients who have no history of
cardiovascular disease.
The relationship between patient involvement and
cognitive traps: an example.
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Patients can be critical to the efficiency of the diagnostic
process, as illustrated with the following example.
Mr. Smith went to the emergency department with a severe
abdominal pain. The pain arose suddenly, starting from the
solar plexus and spread though to his back, persisting for
several hours, before the decision to go to the nearest hospital.
Here, after a brief giving a complete history including careful
description of his pain, he had an electrocardiogram and blood
tests to rule out a myocardial infarction. This having been
ruled out by normal tests, he was given analgesic drugs and a
proton pump inhibitor, and discharged to the care of his
family doctor.
After a second acute episode, the family doctor referred Mr
Smith to have an esophagogastroduodenoscopy. The
endoscopic examination did not indicate the presence of
gastroesophageal reflux and also the histological results of
biopsies were negative. A diagnosis of moderate chronic
gastritis was made and he was recommended to continue with
the same therapy plus small fonts of Butylscopolamine as
required. The patient continued to suffer painful episodes
which became increasingly difficult to control with his
prescribed drugs so Mr. Smith decided to consult a specialist
in gastroenterology. After a brief history and description of
symptoms, the specialist read the report of the previous
endoscopy and then, having briefly examined the patient
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confirmed the diagnosis of chronic gastritis, agreed with the
existing medications and suggested some diet changes.
Despite good general health, Mr Smith continued to experience
episodes of acute pain, only partially controlled by
Butylscopolamine and began to lose weight, put down to the
results of the dietary restrictions and physical exercise.
Eventually, after four referrals to the emergency department in
eighteen months for acute pain, each time being recommended
the same painkiller and sedative treatments, and the refusal of
further investigation he was seen by a surgeon who suspected
that the pain might be due to biliary colic. A careful ultrasound
confirmed the existence of gallstones and after hospitalisation
he was found to have signs of hepatitis and pancreatitis. The
patient was subsequently operated for removal of his gall
bladder and stones, and discharged from hospital free of pain
for the first time in two years.
The case of Mr. Smith, is not uncommon and has various
interesting facets, most critically the total absence of
involvement of the patient in the diagnostic process. Mr. Smith
was considered by the many doctors who met him (his family
doctor, specialists, emergency department internists) as a mere
symptoms and signs carrier. It is obvious that after the first
diagnosis the mental model of the subsequent doctors was built
instantly on it (so-called anchoring process) [27].
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Indeed, the first question when encountering a patient coming
to the emergency department with a painful condition is often
“did you already suffered from stomach problems?”. A positive
response ("I have been diagnosed with gastritis") will
automatically elicit the activation of a mental model that will
guide the subsequent actions.
Once the pain goes away, the patient does not bring any more
information and thus may be discharged, in order to rapidly
close the case (in fact, the emergency department internist
won’t see the patient anymore). The patient will not be asked
for further information about his state of health (for example,
with respect to weight loss), nor will his request for further
investigation be heeded.
In practice, the use of a stand-alone mental scheme, not to be
shared with the patient, caused an overconfidence bias and
subsequently the need for a premature closure determined the
course, and the end of clinical reasoning among Mr Smith’s
caring professionals.
The last surgeon observed the patient without the filter of the
initial framing information, since his clinical history was
collected anew from the patient, independent of the previous fat
file of case note. In this way, the surgeon was guided only by
his cultural background and expertise that led him to build a
mental model specifically focused on the symptoms which he
ascribed to colic. We argue that greater patient involvement in
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medical decision-making would have allowed internists to
doubt their own mental model and share with the patient a
more flexible one. In this way, Mr. Smith would not have
suffered a two years delay in diagnosis.
Of course, this case could be construed as a classic case of
delayed diagnosis due to a biased mind process, however, it is
our opinion that it is essential to consider also the patient
involvement issues to improve our ability to appraise the whole
situation. In fact, the overconfidence bias and the premature
closure acted not only on the individual doctor, preventing a
balanced logical thought process, but also on the relationship
with others, in this case with the patient.
Lacking technical expertise and specific knowledge the patient
was overwhelmed by each physician’s confidence in their
decisions. Subsequently premature closure precluded the use
of, or the search for further data, such as marginal signs and
perpetuation of the patient’s complaints despite what should
have been appropriate medication.
A doctor/patient relationship model based on openness and
sharing would have allowed the patient to declare his doubts, to
better describe the characteristics of this pain (as well as his
other symptoms), and to have the confidence to make effective
requests for alternative management. In this way, Mr Smith’s
legion of doctors would have been able to observe their own
mental models from a different perspective and to assess more
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objectively the next steps to be performed. In this way, any of
them could have activated a balanced thought process, avoiding
the insidious cognitive traps, particularly the overconfidence
bias (see figure 2) into which the internists in our example
inevitably fell.
Figure 2 here
Conclusion
The paradigm of cognitive balanced model is not only a
theoretical framework that allows us to create a sort of
metaphorical description of clinical reasoning. but also, the
cognitive balanced model helps focus attention on all those
mechanisms (both at individual and social level) capable of
unbalancing the clinical reasoning in one way or another. A
lack of awareness about the functioning of the mind and the
failure to elicit a shared context give rise to double imbalance
in the diagnostic process, consequently doubly-dangerous.
The active involvement of the patient can be a powerful
mechanism to balance the cognitive course also within the
realm of the diagnostic process and not only in oncology or
chronic diseases. According to our model, the involvement of
the patient represents a solid anchor for clinical reasoning in
many clinical scenarios. However, this entails a change of
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paradigm, since the physician must be able to shift from the
construction of an individual (stand-alone) mental model (much
simpler to build and to manage) to a shared mental model,
according to the paradigm of distributed cognition [28]. The
patient and the doctor, in this way, would work as a small team,
sharing information, purpose and decisions [29]. The sharing
and the co-construction of mental models to be used during the
diagnostic journey is a mechanism for increasing the collective
intelligence (in this case the community is made up of the
doctor-patient duet), which acts as an error pre-emptive tool
[29;30;31]. However, building a distributed cognitive model is
much more complex and requires skills that many doctors did
not have the opportunity to develop in their education or
professional experience. It will therefore be a task of higher
education agencies to help clinicians in this direction, in order
to significantly contribute to reduce medical errors. Even if is
possible to plan the use of sophisticated decision support
systems to prevent misdiagnosis events (as the one we
described), we argue that the first step toward a safer diagnostic
path is the active involvement of patients. Any other devices
will be useful tools to be used within a paradigm of shared
cognition between patients and physicians within a balanced
cognitive model.
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References
[1] Mamede S, Schmidt HG, Rikers R. Diagnostic errors and
reflective practice in medicine. J Ev Clin Pract 2007;13:138–45.
[2] de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ,
Boermeester MA. The incidence and nature of in-hospital adverse
events: a systematic review. Qual Saf Health Care 2008;17:216-23.
[3] Blendon RJ, DesRoches CM, Brodie M, et al. Views of
practicing physicians and the public on medical errors. N Engl J Med
2002;347:1933-40.
[4] Norman GR, Eva KW. Diagnostic error in clinical
reasoning. Med Educ 2010;44:94-100.
[5] Croskerry P. Achieving quality in clinical decision
making: cognitive strategies and detection of bias. Acad Emerg
Med 2002;9:1184-204.
[6] Croskerry P. A universal model of diagnostic reasoning.
Acad med 2009;84:1022-8.
[7] Graber ML, Franklin N, Gordon R. Diagnostic error in
internal medicine. Arch Intern Med 2005;165:1493-9.
[8] Balla J, Heneghan C, Goyder C, Thompson M. Identifying
20
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
39
40
early warning signs for diagnostic errors in primary care: a qualitative
study. BMJ open 2012;2.
[9] Lucchiari C, Pravettoni G. Cognitive balanced model: a
conceptual scheme of diagnostic decision making. J Eval Clin
Pract 2012;18:82-8.
[10] Stanovich K. Who Is Rational: Studies of Individual
Differences in Reasoning. Mahwah, N.J.: Lawrence Erlbaum
Associates, 1999.
[11] Klein JG. Five pitfalls in decisions about diagnosis and
prescribing. BMJ 2005;330-81
[12] Hogarth R M. Educating intuition. Chicago: University
of Chicago Press, 2001.
[13] Klein G. Naturalistic decision making. Human factors.
2008;50:456-60
[14] Normann G. Dual processing and diagnostic errors. Adv in
Health Sci Educ 2009;14:37–49
[15] Berner ES, Graber ML. Overconfidence as a cause of
diagnostic error in medicine. Am J Med 2008;121:22-3.
[16] Choudhry NK, Fletcher RH, Soumerai SB. Systematic
review: the relationship between clinical experience and quality
of health care. Ann Int Med 2005;142:260-73.
[17] Schwappach DLB, Wernli M. Medication errors in
chemotherapy: incidence, types and involvement of patients in
prevention. A review of the literature. Eur j Cancer Care
2010;19:285-92.
21
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
41
42
[18] Coulter A. Patient safety: what role can patients play?
Health Expect 2006;9:205-6.
[19] Vincent C A, Coulter A. Patient safety: what about the
patient? Qual Saf Health Care 2002;11:76-80.
[20] Ford CD, Killebrew J, Fugitt P, Jacobsen J, Prystas E
M. Study of medication errors on a community hospital
oncology ward. J Oncol Pract 2006;2:149-54.
[21] Franneby U, Sandblom G, Nyren O, Nordin P,
Gunnarsson U. Self-reported adverse events after groin hernia
repair, a study based on a national register. Value Health
2008;11:927-32.
[22] Schwappach DL. "Against the silence": development
and first results of a patient survey to assess experiences of
safety-related events in hospital. BMC health services research
2008;8:59.
[23] Weissman JS, Schneider EC, Weingart SN, Epstein
AM, David-Kasdan J, Feibelmann S, et al. Comparing patient-
reported hospital adverse events with medical record review: do
patients know something that hospitals do not? Ann Intern Med
2008;149:100-8.
[24] Unruh KT, Pratt W. Patients as actors: the patient's role
in detecting, preventing, and recovering from medical errors.
International journal of medical informatics 2007;76 Suppl
1:S236-44.
22
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
43
44
[25] Hibbard JH, Peters E, Slovic P, Tusler M. Can patients
be part of the solution? Views on their role in preventing
medical errors. MCRR 2005;62:601-16.
[26] Davis RE, Jacklin R, Sevdalis N, Vincent CA. Patient
involvement in patient safety: what factors influence patient
participation and engagement? Health Expect 2007;10:259-67.
[27] Rottenstreich Y, Tversky A. Unpacking, repacking, and
anchoring: advances in support theory. Psychol Rev
1997;104:406-15.
[28] Perry M. Distributed Cognition. In J.M. Carroll (Ed.)
HCI Models, Theories, and Frameworks: Toward an
Interdisciplinary Science. Burligton: Morgan Kaufmann, 2003
[29] Woolf S H. Shared decision-making: the case for
letting patients which choice is best. J Fam Pract 2005; 45:205-
18.
[30] Epstein RM. Whole mind and shared mind in clinical
decision-making. Pat Edu Couns 2012. Epub 2012/08/14.
[31] Cote S, Lopes PN, Salovey P, Miners CTH. Emotional
intelligence and leadership emergence in small groups.
Leadership Quart 2010;21:496-08.
23
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
45
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... Information from former doctors should be verified, without prejudice, as in cases 1 and 2. The correction of cognition bias by Availability is needed. It is important to include the patient perspective [23] and for patients to be "co-producers" in making a safer diagnostic process [23]. Previous studies showed that a semi-structured interview and the use of positive criteria are effective [24]. ...
... Information from former doctors should be verified, without prejudice, as in cases 1 and 2. The correction of cognition bias by Availability is needed. It is important to include the patient perspective [23] and for patients to be "co-producers" in making a safer diagnostic process [23]. Previous studies showed that a semi-structured interview and the use of positive criteria are effective [24]. ...
Article
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Background Non-organic lesions or diseases of unknown origin are sometimes misdiagnosed as “psychogenic” disorders or “psychosomatic” diseases. For the quality of life and safety of patients, recent attention has focused on diagnostic error. The aim of this study was to clarify the factors that affected misdiagnoses in psychosomatic medicine by examining typical cases and to explore strategies that reduce diagnostic errors. Case presentation The study period was from January 2001 to August 2017. The data of patients who had visited the Department of Psychosomatic Medicine, Kindai University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic, were collected. All patients were aged 16 years or over. Multiple factors, such as age, sex, presenting symptoms, initial diagnosis, final diagnosis, sources of re-diagnosis and types of diagnostic errors were retrospectively analyzed from the medical charts of 20 patients. Among them, four typical cases can be described as follows. Case 1; a 79-year-old woman, initially diagnosed with psychogenic vomiting due to depression that was changed to gastric torsion as the final diagnosis. Case 2; a 24-year-old man, diagnosed with an eating disorder that was later changed to esophageal achalasia. Case 10; a 60-year-old woman’s diagnosis changed from conversion disorder to localized muscle atrophy. Case 19; a 68-year-old man, appetite loss from depression due to cancer changed to secondary adrenal insufficiency, isolated ACTH deficiency (IAD). Conclusion This study showed that multiple factors related to misdiagnoses were combined and had a mutual influence. However, they can be summarized into two important clinical observations, diagnostic system-related problems and provider issues. Provider issues contain mainly cognitive biases such as Anchoring, Availability, Confirmation bias, Delayed diagnosis, and Representativeness. In order to avoid diagnostic errors, both a diagnostic system approach and the reduction of cognitive biases are needed. Psychosomatic medicine doctors should pay more attention to physical symptoms and systemic examination and can play an important role in accepting a perception of patients based on a good, non prejudicial patient/physician relationship.
... 8 The rationale against routinely testing for, or recording, alcohol presence in patients in the ED, especially patients with altered levels of consciousness, primarily stems from the potential to bias clinical decision making or prematurely ruling out differential diagnoses due to a presumption that the patient's condition is due to acute alcohol consumption. 9 Blood ethanol, the most frequently used biomarker of alcohol use, may not always accurately reflect the patient's ethanol exposure. Due to its relatively short half-life in blood, it is only a snapshot of the blood alcohol level at that moment in time. ...
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Introduction Alcohol use in patients presenting to the emergency department (ED) is a significant problem in many countries. There is a need for valid and reliable surveillance of the prevalence of alcohol use in patients presenting to the ED, to provide a more complete picture of the risk factors and inform targeted public health interventions. This PACE study will use two biomarkers, blood ethanol and phosphatidylethanol (PEth), to determine the patterns, presence and level of alcohol use in patients presenting to an Australian ED. Methods and analysis This is an observational prevalence study involving the secondary use of routinely collected blood samples from patients presenting to the Royal Brisbane and Women’s Hospital (RBWH) Emergency and Trauma Centre (ETC). Samples will be tested for acute and medium-term alcohol intake using the two biomarkers blood ethanol and PEth respectively, over one collection period of 10–12 days. Descriptive statistics such as frequencies, percentages, means, SD, medians and IQRs, will be used to describe the prevalence, pattern and distribution of acute and medium-term alcohol intake in the study sample. The correlation between acute and medium-term alcohol intake levels will also be examined. Ethics and dissemination This study has been approved by the RBWH Human Research Ethics Committee (reference, LNR/2019/QRBW/56859). Findings will be disseminated to key stakeholders such as RBWH ETC, Australasian College for Emergency Medicine, Royal Australasian College of Surgeons, Statewide Clinical Networks, and used to inform clinicians and hospital services. Findings will be submitted for publication in peer-reviewed journals and presentation at appropriate conferences.
... Social exclusion: Psychological approaches to understanding and reducing its impact (pp. [9][10][11][12][13][14][15]. New York, NY: Springer. ...
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People usually prefer to appear with an inclusive and positive attitude to others’ eyes. For this reason, the self-report scales assessing social exclusion intentions are often biased by social desirability. In this work, we present an innovative graphical tool, named Social Exclusion Bench Tool (SEBT), for assessing social exclusion not influenced by social desirability. The tool is based on the consistency between social distance and physical distance evaluation. The results showed that in two samples of adults from Italy (N = 252) and the UK (N = 254), the SEBT positively correlated with self-report measures of social exclusion, but not with the social desirability measure. The tool has been preliminarily evaluated in the context of social exclusion toward migrant people, but it appears a promising instrument for assessing social exclusion intentions toward different social groups. • The self-report scales assessing social exclusion intentions are often biased by social desirability. • The Social Exclusion Bench Tool (SEBT) is an innovative visual instrument for assessing social exclusion that seems not to be influenced by social desirability. • The tool appears a promising instrument for assessing social exclusion intentions toward different social groups.
... It is often perceived as singularly the clinician's role to make a diagnosis, but this process can lack transparency for patients due to a high level of medical knowledge needed to understand it and because patients may not be privy to most of the decision making. Indeed, poor shared understanding between clinicians and patients may adversely affect diagnostic decision making [15], highlighting that communication and listening are key parts of the diagnostic process [16,17]. However, mixed evidence (possibly reflecting an evolution towards shared decision making) shows that how clinician express uncertainty may positively or negatively impact patient satisfaction and decision making [18,19]. ...
Article
Objective Uncertainty occurs throughout the diagnostic process and must be managed to facilitate accurate, timely diagnoses and treatments. Better characterization of uncertainty can inform strategies to manage it more effectively in clinical practice. We provide a comprehensive overview of current literature on diagnosis-related uncertainty describing 1) where patients and clinicians experience uncertainty within the diagnostic process, 2) how uncertainty affects the diagnostic process, 3) roots of uncertainty related to probability/risk, ambiguity, or complexity, and 4) strategies to manage uncertainty. Discussion Each diagnostic process step involves uncertainty, including patient engagement with the healthcare system; information gathering, interpretation, and integration; formulating working diagnoses; and communicating diagnoses to patients. General management strategies include acknowledging uncertainty, obtaining more contextual information from patients (e.g., gathering occupations and family histories), creating diagnostic safety nets (e.g., informing patients what red flags to look for), engaging in worst case/best case scenario planning, and communicating diagnostic uncertainty to patients, families, and colleagues. Potential strategies tailored to various aspects of diagnostic uncertainty are also outlined. Conclusion Scientific knowledge on diagnostic uncertainty, while previously elusive, is now getting better defined. Next steps include research to evaluate relationships between management and communication of diagnostic uncertainty and improved patient outcomes.
... Biases can influence the DM process in chronic illness (Gorini and Pravettoni, 2011;Lucchiari and Pravettoni, 2013). Some cognitive biases in chronic illness could enhance attention to and the salience of symptoms which tend to be perceived as uncontrollable and incurable (Moss- Morris and Petrie, 2003), so that they negatively influence the patients' decisions regarding treatment and health management. ...
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This opinion article provides a synthetic overview of biases of reasoning and decision making in chronic illness management, ranging from the cognitive biases related to information processing (attentional bias, interpretation bias, and recall bias) to distortions in self-perception and social groups’ influence. Secondarily, the manuscript addresses the hypothesis that biases in chronic illness do not only impact quality of life, but also patients’ commitment to their own health management. Specifically, the systematic, repeated influence of cognitive biases may be associated with a “vicious circle” that reduces patients’ motivation to recognize and address the same mental health issues that influence their decision making. This idea is briefly discussed, suggesting that future research considers the relationship between biases in decision making and factors relevant to patient engagement. This information could be relevant to the development of psychological support interventions for chronic patients that focus on cognitive components of their healthcare journey. https://www.frontiersin.org/articles/10.3389/fpsyg.2020.579455/full
... AI confirms that a cognitive approach represents the primary method for improving the reliability of making a diagnosis, and, as a corollary, provides a monitoring system to test the appropriateness of decisions, thus helping health personnel as well as health organizations to learn by experience and to adapt when new demands emerge. By using these technologies, it is possible to avoid some of the most serious cognitive traps and biases that undermine the daily work of health personnel, such as premature closure and overconfidence (Lucchiari and Pravettoni 2013). AI also makes it possible to keep track of each step, to analyze the entire process backwards when things go wrong (e.g., due to a violation) and to find the origin of possible adverse events. ...
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Research suggests that doctors are failing to make use of technologies designed to optimize their decision making skills in daily clinical activities, despite a proliferation of electronic tools with the potential for decreasing risks of medical and diagnostic errors. This paper addresses this issue by exploring the cognitive basis of medical decision making and its psychosocial context in relation to technology. We then discuss how cognitive-led technologies-in particular, decision support systems and artificial neural networks-may be applied in clinical contexts to improve medical decision making without becoming a substitute for the doctor's judgment. We identify critical issues and make suggestions regarding future developments.
... In order to support CDSS, the identification of the information in EHRs is a labor-intensive task and depends strongly on the availability of structured information [18,19]. Due to fact that medical history consists of mostly unstructured data type, the clues for diagnosis in medical history are often lost in the physician-patient communication or the physicians simply do not appreciate the patient's perspective fully [20][21][22]. Therefore, diagnostic support is needed for diseases due to a lack of experience with these disease and even many sub-specialties. ...
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Electronic health records (EHRs) can improve physicians' performance and health care quality by describing the medical information of patients such as patient's symptoms, medical history, results of clinical examination and tests, laboratory results, and prescribed medicines. The interpretation of the medical information about a patient's status and a patient's medical history often offers important clues for the pre-diagnostic process. However, nowadays the medical history information is the most abundant unstructured data type in the EHRs and still in free text. The data arrangement and retrieval of such free text parts become difficult to analyse computationally. This study offers a methodology to analyse free texts in Turkish EHRs to diagnose diseases by using text-mining (TM) and natural language processing (NLP) methods because TM and NLP methods are able to extract useful knowledge from unstructured free texts. Proposed method (bi-gram based word associations) was tested for neuromuscular disease reports and the results achieved for selected performance metrics were compared with Naive Bayes method results. Accuracy for the proposed method and Naive Bayes method are 73.33% and 58%; sensitivity/recall values are 0.78 and 0.76; specificity values are 0.80 and 0.55; precision values are 0.82 and 0.66; and f1-score values are 0.60 and 0.81, respectively. Consequently, TM and NLP with a good accuracy rate of classification of neuromuscular diseases to be predicted from free text of medical history can integrate into EHRs as a diagnostic tool to improve clinical decision support system (CDDS) on the pre-diagnostic time period.
... In order to support CDSS, the identification of the information in EHRs is a labor-intensive task and depends strongly on the availability of structured information [18,19]. Due to fact that medical history consists of mostly unstructured data type, the clues for diagnosis in medical history are often lost in the physician-patient communication or the physicians simply do not appreciate the patient's perspective fully [20][21][22]. Therefore, diagnostic support is needed for diseases due to a lack of experience with these disease and even many sub-specialties. ...
Conference Paper
Full-text available
Electronic health records (EHRs) can improve physicians' performance and health care quality by describing the medical information of patients such as patient's symptoms, medical history, results of clinical examination and tests, laboratory results, and prescribed medicines. The interpretation of the medical information about a patient’s status and a patient’s medical history often offers important clues for the pre-diagnostic process. However, nowadays the medical history information is the most abundant unstructured data type in the EHRs and still in free text. The data arrangement and retrieval of such free text parts become difficult to analyze computationally. This study offers a methodology to analyze free texts in Turkish EHRs to diagnose diseases by using text-mining (TM) and natural language processing (NLP) methods because TM and NLP methods are able to extract useful knowledge from unstructured free texts. Proposed method (bi-gram based word associations) was tested for neuromuscular disease reports and the results achieved for selected performance metrics were compared with Naive Bayes method results. Accuracy for the proposed method and Naive Bayes method are 73.33% and 58%; sensitivity/recall values are 0.78 and 0.76; specificity values are 0.80 and 0.55; and precision values are 0.82 and 0.66, respectively. Consequently, TM and NLP with a good accuracy rate of classification of neuromuscular diseases to be predicted from free text of medical history can integrate into EHRs as a diagnostic tool to improve clinical decision support system (CDDS) on the pre-diagnostic time period.
... Psychological support in this scenario strives for improving patients' decreased quality of life starting from the personal needs. In this sense, the treatment phase of disease needs a personalized approach [25,26]: the main aim of health professionals is that of enabling patients to participate and guide their own healthcare, increasing their autonomy and self-determination. Studies assessing patients' wishes within a personalized medicine framework have underlined their need to have adequate information and permission to participate in decisions which affect them, as well as the request for receiving such information with empathy, dignity and respect, taking into account their preferences and their personal social characteristics [25]. ...
Chapter
The discovery of an insidious disease such as breast cancer most of the time is experienced like a life interruption creating a large gap between the life before and after the diagnosis. The main goal in women’s life, together with fighting the disease, is therefore that of re-establishing the natural life balance or, in other words, repairing the biographic rift. This process of reconstruction is not exempt from psychological and emotional suffering. Women’s quality of life could be damaged, and scientific evidence has stressed that adopting an interdisciplinary approach is the best way to re-establish it again. In this perspective, a biopsychosocial model appears to be the best option for caring, where the patient is considered as a complex system characterized by physical, psychological and social aspects and where constant changes and adaptation to the physical, relational and cultural environment are required. Adhering to this model means to empower patients in the disease management, actively involving them and their family when needed, in treatment decision-making, in order to promote decisions that are consistent with their values, preferences and daily life management. This personalized approach, by means of an increase in patients’ autonomy and self-determination, results to positively affect clinical outcomes.
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This study is multidisciplinary, in which a relationship among relational persuasion, cognitive involvement and management support have been analyzed. This study will focused to analyze the effect of rational persuasion on management support in the presence of cognitive involvement. In this study deductive research approach is used which is based on survey method for data collection. In this study adopted questionnaire is used to collect data from respondents. Population is the whole universe of the study. In this study target population of this study is health sector in Pakistan. While the sample is the subset of population and in this study total 200 employees from health sector has been taken as sample through random sampling technique. In this study SPSS 21 is used to analyze data for correlation and regression analysis to prove hypothesis. By the implementation of this study in banking sector in Pakistan. Organizational performance can be enhanced through process oriented organizational design which can never do before this study.
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The goal of this study was to determine the relative contribution of system-related and cognitive components to diagnostic error and to develop a comprehensive working taxonomy. One hundred cases of diagnostic error involving internists were identified through autopsy discrepancies, quality assurance activities, and voluntary reports. Each case was evaluated to identify system-related and cognitive factors underlying error using record reviews and, if possible, provider interviews. Ninety cases involved injury, including 33 deaths. The underlying contributions to error fell into 3 natural categories: "no fault," system-related, and cognitive. Seven cases reflected no-fault errors alone. In the remaining 93 cases, we identified 548 different system-related or cognitive factors (5.9 per case). System-related factors contributed to the diagnostic error in 65% of the cases and cognitive factors in 74%. The most common system-related factors involved problems with policies and procedures, inefficient processes, teamwork, and communication. The most common cognitive problems involved faulty synthesis. Premature closure, ie, the failure to continue considering reasonable alternatives after an initial diagnosis was reached, was the single most common cause. Other common causes included faulty context generation, misjudging the salience of findings, faulty perception, and errors arising from the use of heuristics. Faulty or inadequate knowledge was uncommon. Diagnostic error is commonly multifactorial in origin, typically involving both system-related and cognitive factors. The results identify the dominant problems that should be targeted for additional research and early reduction; they also further the development of a comprehensive taxonomy for classifying diagnostic errors.
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Distributed cognition (DCog) extends the traditional notion of cognition using a similar theoretical framework and ontological basis for describing human activity. The most developed framework of distributed cognition uses the same computational basis to understand human behavior as cognitive psychology and applies the same notions of information representations and representational transformations. Analysis of systems using distributed cognition permits the inclusion of all of the significant features in the environment that contribute toward the accomplishment of tasks. The DCog framework allows researchers to consider all of the factors relevant to the task, bringing together the people, the problem, and the tools used into a single unit of analysis. It is therefore an ideal method to use to discover the artifactual, social, and cultural dimensions of work.
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This article describes the origins and contributions of the naturalistic decision making (NDM) research approach. NDM research emerged in the 1980s to study how people make decisions in real-world settings. Method: The findings and methods used by NDM researchers are presented along with their implications. The NDM framework emphasizes the role of experience in enabling people to rapidly categorize situations to make effective decisions. The NDM focus on field settings and its interest in complex conditions provide insights for human factors practitioners about ways to improve performance. The NDM approach has been used to improve performance through revisions of military doctrine, training that is focused on decision requirements, and the development of information technologies to support decision making and related cognitive functions.
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This is an important book. It addresses the question: Are human beings systematically irrational? They would be so if they were "hard-wired" to reason badly on certain types of tasks. Even if they could discover on reflection that the reasoning was bad, the unreflective tendency to reason badly would be a systematic irrationality. According to Stanovich, psychologists have shown that "people assess probabilities incorrectly, they display confirmation bias, they test hypotheses inefficiently, they violate the axioms of utility theory, they do not properly calibrate degrees of belief, they overproject their own opinions onto others, they allow prior knowledge to become implicated in deductive reasoning, they systematically underweight information about nonoccurrence when evaluat-ing covariation, and they display numerous other information-processing bi-ases." (1-2) Such cognitive psychologists as Nisbett and Ross (1980) and Kahneman, Slovic and Tversky (1982) interpret this apparently dismal typical performance as evidence of hard-wired "heuristics and biases" (whose pres-ence can be given an evolutionary explanation) which are sometimes irra-tional. Critics have proposed four alternative explanations. (1) Are the deficiencies just unsystematic performance errors of basically competent subjects due to such temporary psychological malfunctions as in-attention or memory lapses? Stanovich and West (1998a) administered to the same subjects four types of reasoning tests: syllogistic reasoning, selection, statistical reasoning, argument evaluation. They assumed that, ifmistakes were random performance errors, there would no significant correlation between scores on the different types of tests. In fact, they found modest but statisti-cally very significant correlations (at the .001 level) between all pairs of scores except those on statistical reasoning and argument evaluation. Hence, they concluded, not all mistakes on such reasoning tasks are random performance errors.
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We investigate the mechanisms of diagnostic error in primary care consultations to detect warning signs for possible error. We aim to identify places in the diagnostic reasoning process associated with major risk indicators. A qualitative study using semistructured interviews with open-ended questions. A 2-month study in primary care conducted in Oxfordshire, UK. We approached about 25 experienced general practitioners by email or word of mouth, 15 volunteered for the interviews and were available at a convenient time. Interview transcripts provided 45 cases of error. Three researchers searched these independently for underlying themes in relation to our conceptual framework. Locating steps in the diagnostic reasoning process associated with major risk of error and detecting warning signs that can alert clinicians to increased risk of error. Initiation and closure of the cognitive process are most exposed to risk of error. Cognitive biases developed early in the process lead to errors at the end. These warning signs can be used to alert clinicians to the increased risk of diagnostic error. Ignoring red flags or critical cues was related to processes being biased through the initial frame, but equally well, it could be explained by knowledge gaps. Cognitive biases developed at the initial framing of the problem relate to errors at the end of the process. We refer to these biases as warning signs that can alert clinicians to the increased risk of diagnostic error. We conclude that lack of knowledge is likely to be an important factor in diagnostic error. Reducing diagnostic errors in primary care should focus on early and systematic recognition of errors including near misses, and a continuing professional development environment that promotes reflection in action to highlight possible causes of process bias and of knowledge gaps.
Article
Background: Hospitals routinely survey patients about the quality of care they receive, but little is known about whether patient interviews can detect adverse events that medical record reviews do not. Objective: To compare adverse events reported in postdischarge patient interviews with adverse events detected by medical record review. Design: Random sample survey. Setting: Massachusetts, 2003. Patients: Recently hospitalized adults. Measurements: By using parallel methods, physicians reviewed postdischarge interviews and medical records to classify hospital adverse events. Results: Among 998 study patients, 23% had at least 1 adverse event detected by an interview and 11% had at least 1 adverse event identified by record review. The K statistic showed relatively poor agreement between interviews and medical records for occurrence of any type of adverse event (K= 0.20 [95% Cl, 0.03 to 0.27]) and somewhat better agreement between interviews and medical records for life-threatening or serious events (K= = 0.33 [Cl, 0.20 to 0.45]). Record review identified 11 serious, preventable events (1.1% of patients). Interviews identified an additional 21 serious and preventable events that were not documented in the medical record, including 12 predischarge events and 9 postdischarge events, in which symptoms occurred after the patient left the hospital. Limitations: Patients had to be healthy enough to be interviewed. Delay in reaching patients (6 to 12 months after discharge) may have resulted in poor recall of events during the hospital stay. Conclusion: Patients report many events that are not documented in the medical record; some are serious and preventable. Hospitals should consider monitoring patient safety by adding questions about adverse events to postdischarge interviews.
Article
We searched MEDLINE (Ovid Technologies, 1966 to June 2004; English language) for terms describing physician experience (keywords: physician age, clinician age, physician experience, clinician experience), physician demographic characteristics (keywords: physician characteristics, clinician characteristics), practice variation (subject heading: physician's practice patterns), and performance in various domains (subject headings: clinical competence, health knowledge, attitudes and practice, outcomes assessment[health care]; keywords: knowledge, guideline adherence, appropriateness, outcomes). We retrieved potentially relevant articles and reviewed their reference lists to identify studies that our search strategy may have missed (Figure 1). We also searched our personal archives to identify additional studies. We included studies if they 1) were original reports providing empirical results; 2) measured knowledge, guideline adherence, mortality, or some other quality-of-care process or outcome; and 3) included years since graduation from medical school, years since certification, or physician age as a potential explanatory variable. We excluded studies if they described practice variation that is not known to affect quality of care (for example, assessed test-ordering behavior in clinical situations where optimal practice is unknown) or evaluated the performance of fewer than 20 physicians. For studies that examined several different end points, we included only those outcomes that are linked to knowledge or quality of care. We used a standardized data extraction form to obtain data on study design and relevant results. We categorized studies into 4 groups on the basis of whether they evaluated knowledge (for example, knowledge of indications for blood transfusion), adherence to standards of care for diagnosis, screening, or prevention (for example, adherence to preventive care guidelines), adherence to standards of care for therapy (for example, appropriate prescribing), or health outcomes (for example, mortality). We classified the results of each study into 6 groups on the basis of the nature of the association between length of time in practice or age and performance: consistently negative, partially negative, no effect, mixed effect, partially positive, and consistently positive. “Consistently negative” studies were those for which all reported outcomes demonstrated a statistically significant decrease in performance with increasing years in practice or age. “Partially negative” studies showed decreasing performance with increasing experience for some outcomes and no association for others. We used similar definitions for “consistently positive” and “partially positive” studies. “Concave” studies found performance to initially improve with years in practice or age, then peak, and subsequently decrease.
Article
Objective: To review the theory, research evidence and ethical implications regarding "whole mind" and "shared mind" in clinical practice in the context of chronic and serious illnesses. Methods: Selective critical review of the intersection of classical and naturalistic decision-making theories, cognitive neuroscience, communication research and ethics as they apply to decision-making and autonomy. Results: Decision-making involves analytic thinking as well as affect and intuition ("whole mind") and sharing cognitive and affective schemas of two or more individuals ("shared mind"). Social relationships can help processing of complex information that otherwise would overwhelm individuals' cognitive capacities. Conclusions: Medical decision-making research, teaching and practice should consider both analytic and non-analytic cognitive processes. Further, research should consider that decisions emerge not only from the individual perspectives of patients, their families and clinicians, but also the perspectives that emerge from the interactions among them. Social interactions have the potential to enhance individual autonomy, as well as to promote relational autonomy based on shared frames of reference. Practice implications: Shared mind has the potential to result in wiser decisions, greater autonomy and self-determination; yet, clinicians and patients should be vigilant for the potential of hierarchical relationships to foster coercion or silencing of the patient's voice.
Article
Objectives: In most clinics, follow-up after inguinal hernia surgery is not a routine procedure and complications may pass unnoticed, thus impairing quality assessment. The aim of this study was to investigate the frequency, spectrum, and risk factors of short-term adverse events after groin hernia repair. Methods: All patients aged 15 years or older with a primary unilateral inguinal or femoral hernia repair recorded in the Swedish Hernia Register (SHR) between November 1 and December 31, 2002 were sent a questionnaire asking about complications within the first 30 postoperative days. Results: Of the 1643 recorded patients, 1448 (88.1%) responded: 1341 (92.6%) were men and 107 (7.4%) women, mean age 59 years. There were 195 (11.9%) nonresponders. Postoperative complications reported in the questionnaire were hematoma in 203 (14.0%) patients, severe pain in 168 (11.6%), testicular pain in 120 (8.3%), and infection in 105 (7.3%). Adverse events were reported in the questionnaire by 391 (23.8%) patients, whereas only 85 (5.2%) were affected according to the SHR. Risk factors for postoperative complications were age below the median (59 years) among the studied hernia patients (OR 1.36; 95% CI 1.06-1.74) and laparoscopic repair (OR 2.66; 95% CI 1.17-6.05). Conclusion: Questionnaires provide valuable additional information concerning postoperative complications. We recommend that they become an integrated part of routine postoperative assessment.
Article
SCHWAPPACH D.L.B. & WERNLI M. (2010) European Journal of Cancer Care19, 285–292 Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature Medication errors in chemotherapy occur frequently and have a high potential to cause considerable harm. The objective of this article is to review the literature of medication errors in chemotherapy, their incidences and characteristics, and to report on the growing evidence on involvement of patients in error prevention. Among all medication errors and adverse drug events, administration errors are common. Current developments in oncology, namely, increased outpatient treatment at ambulatory infusion units and the diffusion of oral chemotherapy to the outpatient setting, are likely to increase hazards since the process of preparing and administering the drug is often delegated to patients or their caregivers. While professional activities to error incidence reduction are effective and important, it has been increasingly acknowledged that patients often observe errors in the administration of drugs and can thus be a valuable resource in error prevention. However, patients need appropriate information, motivation and encouragement to act as ‘vigilant partners’. Examples of simple strategies to involve patients in their safety are presented. Evidence indicates that high self-efficacy and perceived effectiveness of the specific preventive actions increase likelihood of participation in error prevention. Clinicians play a crucial role in supporting and enabling the chemotherapy patient in approaching errors.