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Authors’ reply: Comment on: Teaching metacognition in clinical decision-making using a novel mnemonic checklist: an exploratory study
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Background
Although a clinician may have the intention of carrying out strategies to reduce cognitive errors, this intention may not be realized especially under heavy workload situations or following a period of interruptions. Implementing strategies to reduce cognitive errors in clinical setting may be facilitated by a portable mnemonic in the form of a checklist. MethodsA 2-stage approach using both qualitative and quantitative methods was used in the development and evaluation of a mnemonic checklist. In the development stage, a focus-driven literature search and a face-to-face discussion with a content expert in cognitive errors were carried out. Categories of cognitive errors addressed and represented in the checklist were identified. In the judgment stage, the face and content validity of the categories of cognitive errors represented in the checklist were determined. This was accomplished through coding responses of a panel of experts in cognitive errors. ResultsFrom the development stage, a preliminary version of the checklist in the form of four questions represented by four specific letters was developed. The letter ‘T’ in the TWED checklist stands for ‘Threat’ (i.e., ‘is there any life or limb threat that I need to rule out in this patient?’), ‘W’ for ‘Wrong/What else’ (i.e., ‘What if I am wrong? What else could it be?’), ‘E’ for ‘evidences’ (i.e., ‘Do I have sufficient evidences to support or exclude this diagnosis?’), and ‘D’ for ‘dispositional factors’ (i.e., ‘is there any dispositional factor that influence my decision’). In the judgment stage, the content validity of most categories of cognitive errors addressed in the checklist was rated highly in terms of their relevance and representativeness (with modified kappa values ranging from 0.65 to 1.0). Based on the coding of responses from seven experts, this checklist was shown to be sufficiently comprehensive to activate the implementation intention of checking cognitive errors. Conclusion
The TWED checklist is a portable mnemonic checklist that can be used to activate implementation intentions for checking cognitive errors in clinical settings. While its mnemonic structure eases recall, its brevity makes it portable for quick application in every clinical case until it becomes habitual in daily clinical practice.
Introduction:
Metacognition is a cognitive debiasing strategy that clinicians can use to deliberately detach themselves from the immediate context of a clinical decision, in order to reflect upon the thinking process engaged. However, the use of cognitive debiasing strategies is often most needed in occasions where the clinician cannot afford the time to do so. A mnemonic checklist known as the TWED checklist (where T = Threat, W = What else, E = Evidence and D = Disposition influence) was recently created to facilitate metacognition. This study explores the hypothesis that the TWED checklist improves the ability of medical students to make better quality clinical decisions.
Methods:
Two groups of final year medical students from Universiti Sains Malaysia, Malaysia, were recruited for participation in this quasi-experimental study. The intervention group (n = 21) received educational intervention introducing the TWED checklist, while the control group (n = 19) received a tutorial on basic electrocardiography. Post-intervention, both groups received a similar assessment on clinical decision making based on five case scenarios.
Results:
The mean score of the students in the intervention group was significantly higher than that of students in the control group (18.50 ± 4.45 marks vs. 12.50 ± 2.84 marks, p < 0.001). Specifically, in three of the five case scenarios, the students in the intervention group obtained higher scores than the students in the control group.
Conclusion:
This results of this study supports the use of the TWED checklist to facilitate metacognition in clinical decision-making.
To describe the development of acronym use across five major medical specialties and to evaluate the technical and aesthetic quality of the acronyms.
Acronyms obtained through a literature search of Pubmed.gov followed by a standardised assessment of acronym quality (BEAUTY and CHEATING criteria).
Randomised controlled trials within psychiatry, rheumatology, pulmonary medicine, endocrinology, and cardiology published between 2000 and 2012.
Prevalence proportion of acronyms and composite quality score for acronyms over time.
14 965 publications were identified, of which 18.3% (n=2737) contained an acronym in the title. Acronym use was more common among cardiological studies than among the other four medical specialties (40% v 8-15% in 2012, P<0.001). Except for within cardiology, the prevalence of acronyms increased over time, with the average prevalence proportion among the remaining four specialties increasing from 4.0% to 12.4% from 2000 to 2012 (P<0.001). The median combined acronym quality score decreased significantly over the study period (P<0.001), from a median 9.25 in 2000 to 5.50 in 2012.
From 2000 to 2012 the prevalence of acronyms in trial reports increased, coinciding with a substantial decrease in the technical and aesthetic quality of the acronyms. Strict enforcement of current guidelines on acronym construction by journal editors is necessary to ensure the proper use of acronyms in the future.
© Pottegård et al 2014.
Checklists are common in some medical fields, including surgery, intensive care and emergency medicine. They can be an effective tool to improve care processes and reduce mortality and morbidity. Despite the seemingly rapid acceptance and dissemination of the checklist, there are few studies describing the actual process of developing and implementing such tools in health care. The aim of this study is to explore the experiences from checklist development and implementation in a group of non-medical, high reliability organisations (HROs).
A qualitative study based on key informant interviews and field visits followed by a Delphi approach. Eight informants, each with 10-30 years of checklist experience, were recruited from six different HROs.
The interviews generated 84 assertions and recommendations for checklist implementation. To achieve checklist acceptance and compliance, there must be a predefined need for which a checklist is considered a well suited solution. The end-users ("sharp-end") are the key stakeholders throughout the development and implementation process. Proximity and ownership must be assured through a thorough and wise process. All informants underlined the importance of short, self-developed, and operationally-suited checklists. Simulation is a valuable and widely used method for training, revision, and validation.
Checklists have been a cornerstone of safety management in HROs for nearly a century, and are becoming increasingly popular in medicine. Acceptance and compliance are crucial for checklist implementation in health care. Experiences from HROs may provide valuable input to checklist implementation in healthcare.