Temple Ratcliffe's research while affiliated with University of Texas Health Science Center at San Antonio and other places

Publications (29)

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Background: COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown. Objective: To examine the effects of the in...
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Background: The internal medicine (IM) subinternship (also referred to as acting internship) plays a crucial part in preparing medical students for residency. The roles, responsibilities, and support provided to subinternship directors have not been described. Objective: We sought to describe the current role of IM subinternship directors with r...
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Objectives Uncertainty 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 fa...
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Background Situated 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 in...
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Background The 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 t...
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Background: Clinical reasoning is at the core of health professionals' practice. A mapping of what constitutes clinical reasoning could support the teaching, development, and assessment of clinical reasoning across the health professions. Methods: We conducted a scoping study to map the literature on clinical reasoning across health professions...
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Background: Interprofessional collaborative practice (IPCP) offers great potential to improve healthcare. Increases in IPCP will require educating learners in authentic IPCP settings and will generate opportunities and challenges. Methods: In January 2015, we implemented an IPCP model called Collaborative Care (CC) for hospitalized adult medical...
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Introduction Contextual factors (eg, diagnostic suggestion and burnout) can affect physician clinical reasoning performance, leading to diagnostic error. Yet, contextual factors have only recently been studied and none of that work focused on how physicians appraise (ie, evaluate) the clinical situation as they reason. The purpose of this qualitati...
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Background: In the rapidly changing landscape of undergraduate medical education (UME), the roles and responsibilities of clerkship directors (CDs) are not clear. Objective: To describe the current roles and responsibilities of Internal Medicine CDs. Design: National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey...
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Cognitive load is a key mediator of cognitive processing that may impact clinical reasoning performance. The purpose of this study was to gather biologic validity evidence for correlates of different types of self-reported cognitive load, and to explore the association of self-reported cognitive load and physiologic measures with clinical reasoning...
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Introduction: Clinical reasoning is considered to be at the core of health practice. Here, we report on the diversity and inferred meanings of the terms used to refer to clinical reasoning and consider implications for teaching and assessment. Methods: In the context of a Best Evidence Medical Education (BEME) review of 625 papers drawn from 18 hea...
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Purpose An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore th...
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Background A framework of clinical reasoning tasks used by physicians during clinical encounters was previously developed proposing that clinical reasoning is a complex process composed of 26 possible tasks. The aim of this paper was to analyze the verbalized clinical reasoning processes of medical students utilizing commonly encountered internal m...
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This Invited Commentary is written by coauthors working to implement and study new models of interprofessional practice and education in clinical learning environments. There are many definitions and models of collaborative care, but the essential element is a spirit of collaboration and shared learning among health professionals, patients, and fam...
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Introduction: Studies have shown that a physician's clinical reasoning performance can be influenced by contextual factors. We explored how the clinical reasoning performance of medical students was impacted by contextual factors in order to expand upon previous findings in resident and board certified physicians. Using situated cognition as the t...
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Background: Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds. Objective: To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables....
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Clinical reasoning is an essential component of a health professional's practice. Yet clinical reasoning research has produced a notably fragmented body of literature. In this article, the authors describe the pause-and-reflect exercise they undertook during the execution of a synthesis of the literature on clinical reasoning in the health professi...
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Background: The impact of context on the complex process of clinical reasoning is not well understood. Using situated cognition as the theoretical framework and videos to provide the same contextual "stimulus" to all participants, we examined the relationship between specific contextual factors on diagnostic and therapeutic reasoning accuracy in b...
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Introduction: Context specificity (CS) refers to the variability in clinical reasoning across different presentations of the same diagnosis. Cognitive load (CL) refers to limitations in working memory that may impact clinicians’ clinical reasoning. CL might be one of the factors that lead to CS. Although CL during clinical reasoning would be expect...
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Purpose: A framework of clinical reasoning tasks thought to occur in a clinical encounter was recently developed. It proposes that diagnostic and therapeutic reasoning comprise 24 tasks. The authors of this current study used this framework to investigate what internal medicine residents reason about when they approach straightforward clinical cas...
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Purpose: To compare the relative utility of open-book examinations (OBEs) and closed-book examinations (CBEs) given the rapid expansion and accessibility of knowledge. Method: A systematic review of peer-reviewed articles retrieved from MEDLINE, ERIC, Embase, and PsycINFO (through June 2013). In 2013-2014, articles that met inclusion criteria we...
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Sensemaking is the social act of assigning meaning to ambiguous events. It is recognized as a means to achieve high reliability. We sought to assess sensemaking in daily patient care through examining how inpatient teams round and discuss patients. Our purpose was to assess the association between inpatient physician team sensemaking and hospitaliz...
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Context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have...
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There is limited understanding of how clinical reasoning is developed, maintained, and objectively assessed. Using the theoretical lens of deliberate practice, we explored physicians' views on clinical reasoning. We compared responses from internists (faculty) and internal medicine interns, to identify potential qualitative and/or quantitative diff...
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Background: Effective written communication is a core competency for medical students, but it is unclear whether or how this skill is evaluated in clinical clerkships. Purpose: This study identifies current requirements and practices regarding required written work during internal medicine clerkships. Methods: In 2010, Clerkship Directors of I...
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Each year military medical students participate in a separate, military match culminating with the Joint Services Graduate Medical Education Selection Board (JSGMESB). Prior studies have explored postinterview communication that occurs during the National Resident Matching Program (NRMP), but not during the JSGMESB. We examined the frequency and na...

Citations

... Further studies will be needed to fully understand the impact on learners who experienced that loss in training. 12 There was also a significant shift towards online, asynchronous learning that has accelerated the discussion around essential in-person teaching activities in the preclerkship training period. Perhaps there is a rhythm to preclerkship education in the form of acquisition, consolidation, and application that may help inform how to best utilize our resources and focus on the value of application of knowledge over memorization of knowledge. ...
... 21 Uncertainty is expressed in situations with distracting contextual factors, most of all in diagnosis and least in reflection. 48 Nurses' perceptions of inconsistent practises and processes of care of individual anaesthesia providers were often compromised by prioritising relationships over best practices. 25 In the absence of clarity regarding the expectations and responsibilities in care structure, post-anaesthesia nurses tend to adapt their assessment priorities to the preferences of the anaesthesia provider. ...
... These findings are consistent with other research showing that more uncertainty is expressed during clinical reasoning inpatient cases where contextual distractions are present. 13,19 Physicians expressed the greatest uncertainty inpatient cases which contained contextual distractions that stemmed from either the patient (e.g., the complexity of presentation, English proficiency), the physician (e.g., fatigue, expertise, cognitive load), or the environment (e.g., length of consultation, the functionality of the electronic medical record). 13 In our study, we also found the highest number of statements expressing implicit uncertainty inpatient cases where contextual distractions arose from the patients' physical condition or misleading symptoms, i.e., patient 2 with iatrogenic opioid dependence, patient 3 with a history of unnecessary gallbladder removal, and patient 6 with vitamin B1 deficiency after gastric sleeve surgery. ...
... linearity) between diagnosis and management. 27,28 Clinical reasoning emerges, evolves and is dynamic and non-sequential and clinicans must be able to use strategies that assist in "feeling their way through a problem" when working within teams along a chaotic chain of handoffs and transitions of care often undermined by discontinuity. 2(p801), 29 Ilgen and colleagues have recently described clinical reasoning as a "creative and open-ended exploration of a problem that aims to develop an understanding of a situation". ...
... Clinical reasoning refers to repetitive and dynamic thinking processes in which nurses or doctors collect evidence, process information, understand patient problems, plan or apply treatment, evaluate results, and reflect the learning process (Kuiper, 2013). For this reason, it has been described as the main cognitive skill -the backbone-in terms of achieving the purpose of clinical practice, or in other words, the realization of the practice (Higgs et al., 2019;Mattingly, 1991;Young et al., 2020). Higgs (1993) counts clinical reasoning as the central component of clinical competence. ...
... 12 Varying composition of a team adversely affects the opportunity to develop a team identity with shared mental models and trust. 2 The challenge for members of inter-professional teams is to manage the team processes that occur in all teamwork while simultaneously managing their individual professional identities. 13 Other factors affecting team behaviours are related to the local organisational culture, including management of staff behaviour, variable case demands, team members' technical competence, perceptions regarding optimal interpersonal and team behaviours, and fitness of organisational structures and processes to support teamwork. 14 Military, aviation industry and orchestra are the examples where personnel possessing different knowledge and skill-sets are trained together and thus learn to work as a team. ...
... Such distracting contextual elements of the presentation have been shown to elicit emotions that could influence the process of clinical reasoning by inducing uncertainty. 20 For patient 5, a woman with a twisted ovarian cyst, and Patient 4, a man with chronic cholecystitis, the fewest attenuators of information were found. In these cases, the correct diagnosis is most frequently reported in the handovers. ...
... 8 Furthermore, more than one-third of CDs (34%) screened positively for burnout, an increase compared with 25% from the 2019 CDIM Annual Survey. 9 Moreover, almost half of CDs (47%) had considered resigning from their position which is higher compared with 35% in 2018 and 2019. 9 These findings are concerning and underscore the need to provide additional support to CDs, particularly during times of rapid curricular transformation. ...
... 21 Previous studies have also found moderate to strong associations between physiological measures and gold standard instruments (i.e., NASA-TLX and SURG-TLX), corroborating the concurrent validity of such metrics. 22 In a systematic review of physiological proxies for cognitive load, heart rate and heart rate variability (HRV) were the most used within cardiovascular measures. HRV refers to the time series analysis of the variations in an individual's interbeat intervals, 23 providing a noninvasive measurement of mental strain and cognitive load. ...
... Analytical skills refer to the ability to analyze and critically appraise information, present arguments, and examine things from different perspectives (Winston et al., 2012). In health professions education, analytical and problem-solving skills are needed in clinical reasoning and making decisions about patient care (Monteiro and Norman, 2013;Young et al., 2019;Cooper et al., 2021). ...